WhiteCoat

Got A Sinus Infection? Take A Sugar Pill.

Didn’t see this study when it first came out in JAMA, but happened to read a synopsis of the study in another medical journal.

First the study participants needed to meet two of four criteria to actually be diagnosed as having sinusitis (pus coming out of the nose, pus coming out of both sides of the nose, pus on inspection inside the nose, and localized pain to one side of the face).

Then the study randomized patients to get antibiotics, nasal steroids, both antibiotics and steroids, or sugar pills.
Participants kept a journal of their symptoms, including ratings on variables such as pain in the face, pain in the head, nasal blockage, nasal discharge, general well-being. They turned in the journal at the end of the study.
A “cure” was defined as having either no or very little problems with all indicators.

Results? People taking steroids and people taking antibiotics took just as long to get well as did those taking sugar pills.

There were some minor differences in symptom improvement, but these differences were not felt to be more likely than chance.

I think this study shows a few important points:

  1. A little pressure in your face does not necessarily mean that you have a sinus infection.
  2. Even if you have pressure in your face and pus coming out of your nose, antibiotics aren’t going to help a lot more than sugar pills will.
  3. Nasal steroids are expensive and are also of little help in improving symptoms of sinusitis.

A few days of nasal decongestants (Afrin/NeoSynephrine or store brand equivalents) coupled with nasal washes have always worked for me.

UPDATE MARCH 5, 2008

OK, Ian busted me in the comments about posting my anecdotal experience with nasal washes and nasal decongestants without backing up my personal preferences with medical studies. They exist, I just should have posted them. So here goes:

Practical Approach to the Patient With Sinusitis – “Saline irrigation may help remove mucus, as well as irritating eosinophilic proteins in the nasal mucus, and may help decrease the risk of crusting near the sinus ostia.” “Time-limited use of topical decongestants (eg, phenylephrine and oxymetazoline) may improve sinus drainage but may cause additional problems, such as rebound nasal congestion, if used longer than 3-5 days.”

Acute Bacterial Rhinosinusitis in Adults: Part II. Treatment – “Decongestants often are recommended, and there is some evidence to support their use, although topical decongestants should not be used for more than three days to avoid rebound congestion.” “Nasal irrigation with hypertonic and normal saline has been beneficial in chronic sinusitis and has no serious adverse effects.”

Pediatric Sinusitis – “Adjunctive measures include saline irrigation, steam inhalation, nasal and systemic steroids, mucolytics, and decongestants.”

US News Article on Nasal Wash – Nasal saline wash of the nose can be one of the most helpful treatments for both acute and chronic sinus problems.

Cochrane Review From 2007 – “Saline irrigations are well tolerated. Although minor side effects are common, the beneficial effect of saline appears to outweigh these drawbacks for the majority of patients. The use of topical saline could be included as a treatment adjunct for the symptoms of chronic rhinosinusitis.”

Finally, here’s a good sampling of the different nasal wash products on the market.

Oh, and here’s another study concluding that “Antibiotics and inhaled nasal corticosteroids are being used more often than their published efficacies would encourage.”

Now am I off the hook?

14 Responses to “Got A Sinus Infection? Take A Sugar Pill.”

  1. Ian Furst says:

    Hey — you talk about how it proves that steroids are just as good as placebo then finish with you’re own anecdotal junk. Stick to you’re guns.

    Wait! Let me ‘splain!
    Actually I typed the last sentence as I was getting ready to leave for work. Here’s my thought process in adding the sentence:
    I was initially going to leave the last sentence out. Then I thought about all the people who will do an internet search on sinus infections, who might see my post, and who then might be left wondering what to do. One of my goals in writing this blog is to help people out. If you check out previous posts about lice and snowblowers, I try not just to create controversy, but I want people who don’t have access to physicians to have a little self-help. So I added the sentence.
    I happen to like one brand of nasal washes. Initially I was going to link to that brand’s site which has several journal articles about the effectiveness of this particular product. Then I didn’t want to appear biased. So I linked to a Wikipedia article instead.
    The decongestants admittedly are my anecdotal experience, but there is literature to back it up.
    I changed the post to reflect that.
    I actually did an anonymous interview about this blog not too long ago. One of the quotes the journalist liked was that I likened the blog to having a “grand rounds” on my web site every day. I like it when people call me on things. Thanks for the peer review!

  2. Ed Chung says:

    Yeah – sort of what Ian said. That last sentence sticks out a lot from the rest of the post and your usual style. Removing it makes the post a lot stronger.

  3. SeaSpray says:

    I appreciate those nasal washes and am glad you mentioned them before because I had never heard of them. I vaguely remember someone talking about a home remedy for doing that to help keep you from getting sick but I never paid attention to it.

    I have an URI now…again and find they help. :)

  4. C. says:

    LOVE the nasal washes. I get sinus infections a few times a year and never take an antibiotic. Washing out all that junk a few times a day does the trick and for me a lot quicker with no nasty side effects.

  5. scalpel says:

    All these studies seem to use low dose amoxicillin, which is lame. Where are the studies using Levaquin or Zithromax? We only use amoxicillin as a placebo these days anyway, so those results are not surprising.

    That is an interesting point I never considered. Strep, H. flu, and M. catarrhalis cause most cases of bacterial sinusitis, and the resistance rates to amoxicillin in these organisms are significant (probably because so many docs use amoxicillin as a placebo). I see studies on PubMed about sinus penetration of macrolides, but nothing about macrolides vs placebo/amoxicillin.

  6. TK says:

    I agree with Scalpel. I never give Amox alone for what I think is true sinusitis (and I RARELY diagnose bacterial sinusitis). I usually give Biaxin, Doxy, or Augmentin. But your point is right, just like OM and pharyngitis, most sinusitis needs no ABx treatment.

  7. tabitharuth says:

    OK, dumb question here. Nasal washes sound extremely painful, like getting water up your nose in the pool. Do they hurt?

    It takes a little getting used to. Definitely not painful. Use room-temperature water. Don’t use straight water – it will burn like the chlorine pool water sensation you describe. You need to add some type of saline to the mixture to get it about the same concentration as the mucous membranes in your nostrils.
    The idea of the nasal wash is to use high volume. You don’t have to jam the fluid up there as fast as it will go, but you want to get your nasal passages full of saline and then blow the saline out in the sink along with the mucous. Don’t sniff the saline up your nose, either.
    I usually tell people to do an experiment – blow your nose with a tissue until nothing more comes out. Then use the sinus rinse and see how much more crud you can get out of your nose.
    It sounds disgusting, but – again my personal experience – I have found that it helps more than medications in a vast majority of patients. Even if it doesn’t work, you’ve lost what – $10 for the kit?

  8. Ms. H says:

    I spent the majority of the schoolday in a classroom full of teenagers taking a state-mandated test….many of whom were sniffling and snorting all the while.

    Oh, if only we could have them do a sinus-rinse before they enter the room to start their test!!!

    No more Snot Symphony!!

    Question: I had heard you shouldn’t do the sinus rinse when you have a diagnosed sinus infection (for fear it would make things worse, I guess)…but that seems like the exact time you should ABSOLUTELY do it. What do you think?

  9. Amy says:

    I didn’t treat my sinus infection, because my dork of a husband insisted that I go on a trip instead of to urgent care. It turned into pneumonia and then I went to urgent care. At one point I had pus coming out of my eye. When I laid down I could feel trapped tiny bubbles of air zip up to the top of my forehead sinus (sorry don’t know proper term for it). It was a freaky feeling. I also felt like someone was jumping on my head.

    Where does one get this sinus washing kit incase I get another whopper of a sinus infection?

  10. SeaSpray says:

    Amy, my husband got mine at Walmart. I would think any pharmacy or store with a pharmacy section.

  11. Ian Furst says:

    That’s what I’m talking about! Sorry just saw the post:-).
    Here one more randomized but I give.

    Ian.

  12. Terri E says:

    Sinus survivor here. Nasal irrigators (water pik and special adapter) are awesome. I can’t imagine how much worse off I would be without them. I have had two surgeries. They were the only thing plus a few months of antibiotics that have helped. You can even add stuff to them to treat fungus or bugs. You don’t have to have green stuff anywhere to have a sinus infection. Mine just get inflamed and then shut off. They can hurt just as much and make you sick all over.

    I think sinuses are a mystery to most ENTs. They just play at treating them. It took me six years to find my dr.

  13. [...] phlegm and sinus pain may be signs of sinusitis or they may not. But even if you have a true “sinus infection”, antibiotics are not proven to help. Bust out the nasal decongestants and nasal [...]

  14. patti says:

    I like you folks are a sinus suffer when I( get flu or heavey cold it turns to infection not fun at all …have tried every thing herbal rinses (which do help) but in the end I end up on antibotic have flu now 3 weeks used antibotic did not help me still doing sinus rinses with salt baking soda which burns my nose any suggestion …. feel defeated patti

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