by Nancy Gahles, DC, CCH, RSHom(NA)
Antibiotics are not the best approach to patients suffering with rhinosinusitis, even if a patient reports that symptoms have persisted for longer than 7-10 days, according to a study published in The Lancet, March 15, 2008.
“Primary-care physicians continue to overprescribe antibiotics for acute rhinosinusitis because distinction between viral and bacterial sinus infection is difficult”, writes Jim Young, PhD, from Basel Institute for Clinical Epidemiology, University Hospital Basel in Basel, Switzerland.” (Medscape.com by Charles Vega, MD and Brande Nicole Martin).
Rhinosinusitis is a term for a combination of signs and symptoms associated with the nose and sinuses. It is an inflammation of the mucous membrane which lines the nose and sinuses that is characterized by nasal obstruction, nasal discharge, sneezing, facial pain and pressure or a combination of these. Some people present with a purulent (greenish associated with pus) or bloody discharge which upgrades the diagnosis to “infection” under some conditions.
Authors of this meta-analysis conclude that even in the presence of this type of discharge, while it may take longer to cure, antibiotics are only slightly more effective than no treatment and does not justify their use. NOTE: the presence of high fever, swelling around the eye, redness of the skin or intense facial pain DOES require prompt intervention with antibiotics.
The highlight of the study was to conclude that no symptom or constellation of symptoms of acute rhinosinusitis were significantly able to predict a best case scenario response to antibiotics. There was, in fact, a high cure rate associated with no treatment, which led the authors to recommend against routine prescription of uncomplicated acute rhinosinusitis.
Which brings us back to the repeating conundrum of the primary care physician wherein so many of the pharmaceuticals that used to be prescribed for the “common acutes” in everyday practice have either been recalled or are reported as no longer effective and not recommended for use. How do we treat in this case?
Keywords in this dilemma are the opening ones that Dr. Young notes. That is that antibiotics are overprescribed because it is difficult to distinguish if these symptoms are viral or bacterial. If they are bacterial, we have antibiotics. If they are viral, we have nothing. Patients do not want “nothing” when they are suffering. So, as Hippocrates said, at least do no harm, and many physicians feel that a course of antibiotics may help IF it’s an infection and if it isn’t, the virus will have run its course by the end of the treatment.
The larger issue to address is the fact that there are OTHER ways to address rhinosinusitis in its acute presentation. The significant others are diet and lifestyle factors, stresses that depress the immune system, co-morbid conditions, inherent genetics and the environment. The symptoms of rhinosinusitis are also the symptoms of allergies. A thorough case needs to be taken for each individual and a treatment plan should be based on the totality of the symptoms as well as their lifestyle assessment. Here is where the concept of INTEGRATIVE HEALTHCARE comes in. Primary care physicians are trained in one or possibly two modalities of treatment. When one is taken away, such as antibiotics, what do you have left to treat with? We, as providers, keep current with studies such as this one so that we can change with the times and treat according to the latest findings. We do know that there are treatments for viral syndromes in the world outside of allopathic medicine but we may not know how to use them ourselves, which ones are effective, the side effects or drug interactions. It is usually not practical to consider embarking on the learning adventure of a whole other field of study. It IS, however, incumbent upon us to inform ourselves about the relevant therapies and to advise our patients where they might find a certified or licensed practitioner to consult with or where they might find information themselves. Examples of practitioners to consult are Doctors of Chiropractic (American Chiropractic Association http://www.acatoday.org/), Certified Classical Homeopaths (National Center for Homeopathy www.nationalcenterforhomeopathy.org), acupuncturists (American Association of Oriental Medicine www.aaaomonline.org) and naturopaths (American Association of Naturopathic Physicians www.naturopathic.org). Ideally, look in your own community for these specialists and establish a referral network that works for the good of the patient and the caregiver as well. This is what integrative healthcare is all about.
We can also empower our patients to positive, responsible self care.
Self-limiting conditions such as uncomplicated rhinosinusitis can be safely treated with saline irrigation from a neti pot; simple saline nasal spray throughout the day; showering before bed to rid the skin, hair, eyelashes and eyebrows of pollen or other airborne allergens and using a humidifier or HEPA filter in the home.
Dietary corrections can made to EXCLUDE dairy and other mucous producing foods and the “whites” that are bereft of nutrition and stress the immune system, that is, white sugar, white flour and processed foods. Anything that lists a shelf life of 2-3 years CANNOT be life enhancing. These foods along with red meats are known to cause inflammation.
Personally, I love the immune enhancing effects of a good night sleep, love and laughter in your life and forgiveness of long held grievances. Less esoterically, I like quercetin, a bioflavinoid, for its histamine stabilizing properties, hence decrease in mucous secretions. This coupled with Bromelain for its anti-inflammatory enzyme action, Vit. C and zinc lozenges decrease duration and severity of a virus. I like turmeric for its powerful anti-inflammatory action as well as the Omega-3 fish oils. Echinacea is wonderful for its anti-viral and anti-bacterial action. Probiotics stabilize the gut flora and improve immunity and can be used in all age groups from infancy on.
Structure dictates function and cranial-facial therapy improves drainage and flow of the head and sinuses. Recent studies show that regular chiropractic adjustments increase immune function. I recommend chiropractic adjustments at the change of every season for optimal health benefit.
Homeopathically, I use a nasal spray, Euphorbium; Allium Cepa for nasal discharges that run like a faucet; Kali Bichromicum for obstructed nose with thick, ropy yellow mucous; Causticum for constant mucous sensation with a desire to clear the throat along with hoarseness. This is a short list as selection of an appropriate homeopathic remedy requires a bit of study and individualization to each case but it is possible and with the tutelage of a professional homeopath one can come to understand their own predisposition to illness and make a determination as to whether their symptoms are a virus, an allergy or a bacterial infection. Encourage your patients to discuss their issues with their provider. Self-knowledge is the key. Sharing information with your primary care doctor can eliminate the need for an unnecessary prescription and encourage co-creation in your health care as well as facilitating an integrative healthcare network in your community.
I always tell my patients that I look forward to answering any questions you may have about complementary and alternative healthcare and am more than happy to discuss your case with your primary care physician as an “integrator”.
With allergy season upon us and rhinosinusitis representing one third of upper respiratory infections, the ubiquitous question of whether this is an allergy or a cold will surface once again. Let’s all be a part of that discussion. Let us all be open to working together to find solutions that, at least do no harm and, at best, heal.
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