Sinus Pain

For some infections we’re sold that antibiotics help. UTIs, kidney infections, and skin infections are a few examples. People with these frequently get better over hours. I myself had a MRSA cellulitis back in 2005. Keflex failed, Clindamycin failed. Bactrim knocked it out in 24-48 hours. I became a believer in the right drug for bug.

Then there are infections where we struggle to determine whether the problem is viral or bacterial. And even if bacterial, we’re still not certain whether an antibiotic will actually help. Ear infections, coughs, sore throats and sinus pain are all in that same camp. When it comes to sinus pain, knowing the buzzwords can be very helpful.

Red Flags:

• Prolonged fevers
• Diabetes
• Past sinus surgeries
• Congenital sinus abnormalities
• Smoker
• Associated vision problems
• Associated skin infection

Happy Words

• “I just had a cold and I’ve been sniffling for a week.”
• “My doctor always gives me antibiotics, but I don’t really know if they help.”
• “I feel better sitting up or after a long hot shower.”
• “My neti pot makes me feel better.”
• “The pain goes away with ibuprofen.”

I’m often asked when best to start antibiotics for suspected sinusitis. Honestly, I still don’t know. But I can tell you all my own colds have a very consistent pattern, which invariably go through a phase with miserable sinus pain. (Sore throat… fever… achy… a little better… ridiculous nasal congestion… sniffling… pounding headache… sinus pain… lingering cough… done.) So sinus pain alone isn’t my trigger to prescribe an antibiotic.

For patients with sinus pain, I usually try to buy time; 24-48 hours even. I often suggest ibuprofen with food (6-800 mg 2-3 times a day for adults). I suggest Sudafed to open the pipes and promote drainage. If they have a Neti pot, I give a thumbs up. I’m also a fan of long hot showers to decongest, followed by sleep with head elevated by pillows or a Lazyboy. I also recommend steering clear of antihistamines, which can turn a river of snot into an ooze of concrete. Afrin too is my friend, but only for 2-3 days. For me it helps mainly to get to sleep. You may also try simple saline spray. Flonase is OTC now and worth a try too.

When all else fails and patients are convinced it’s time for antibiotics, I frequently crumble. But I try to make it clear that the risks may not outweigh the benefits. When I say “risks,” I mean more than the rare anaphylaxis, “Stevens Johnson Syndrome” or “Toxic Epidermal Necrolysis.” There’s also C. difficile overgrowth in the gut, stomach aches, diarrhea, photosensitivity. And then there is the time and money wasted chasing down prescriptions at the pharmacy… not to mention what they may pay me for the Rx.

In summary, sinus pain or “sinusitis,” like otitis media, is really more of a plumbing topic. When the air spaces in the skull become inflamed or packed with fluid, the pain can be immense. The goal is to facilitate drainage and to limit inflammation and pressure.

If antibiotics do not suffice, an ENT may next in line along with a CT. Surgery or stents may be offered to those who suffer chronic sinus infections, which is a curse for many.

Read more here Acute Sinusitis by Mayo Clinic.
… and slightly related, for those of you who like internet rabbit holes, Google “Empty Nose Syndrome.” If ENS is your problem, sadly, I fear a call to Pre-R may disappoint.

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