I found the following article on

www.medscape.com

I saved it to my hard drive, but I don't still have the URL to point to.
Since the article is not so long, I will post the whole article below.

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Approach to the Patient With Chronic Sinusitis

First, it is imperative to take a careful history and review past medical
records, with special attention to treatment options that have been used in
the past, including antibiotic and corticosteroid use, past sinus surgeries,
history of nasal or facial trauma, and past subspecialty consultation (eg,
allergy and otolaryngology). Next, a thorough physical examination is
important, and baseline fiberoptic rhinoscopy can be very helpful to
delineate the patient's anatomy. In addition, a baseline limited sinus CT
scan will help document the extent of disease and clarify any other anatomic
abnormalities, such as a deviated nasal septum. An allergy evaluation is
also very important, since a failure to adequately address allergen triggers
may cause a relapse of the disease after initial treatment. The patient
should also be evaluated for associated asthma, since a significant portion
of patients with chronic sinusitis may have associated asthma. Finally, a
baseline absolute eosinophil count may be helpful, since persistence of
eosinophilia despite medical treatment portends a less favorable response to
more aggressive measures such as surgical intervention.

If there is suspicion of immune deficiency (eg, history of recurring otitis
media, bronchitis, pneumonia, or recurring infections with encapsulated
organisms), then humoral immunity may be evaluated with IgG (total and
subclasses), IgA, IgM, or specific immune responses. If there is suspicion
of allergic fungal sinusitis (by CT scan or clinical presentation), then
appropriate referral to a specialist for that evaluation should be done.

Once the disease has been adequately staged, as noted above, the patient
should receive "intensive medical therapy." This would consist of an
antibiotic for 30 days, simultaneously started with prednisone for 8 to 10
days (see dosages below), nasal saline irrigations, intranasal steroid spray
twice a day, and an (optional) oral decongestant (assuming no
contraindications exist for these medications). The patient should then be
re-evaluated and restaged in 1 month.

Antibiotic choices should be guided by sinus cultures whenever possible, and
the use of broader single antibiotic agents should be considered with or
without the addition of anaerobic coverage with clindamycin or
metronidazole. Antibiotic therapy should usually be given for 7 days after
sinusitis symptoms have completely resolved. This may take 4 to 8 weeks. If
symptoms recur soon after treatment is stopped, or fail to resolve with the
above program, then an alternative antibiotic may be needed. Treatment
failures occur more commonly in chronic sinusitis, compared with acute
sinusitis. In general, patients who fail a prolonged course of combined
prednisone and broad-spectrum antibiotics should be referred to an
otolaryngologist for surgical consultation.

There are only limited data to guide the treating physician on proper dosage
of prednisone (used in conjunction with antibiotics) for the treatment of
chronic sinusitis. A number of the symposium participants indicated that
they had used different dosage schedules in this setting. One possible
dosage regimen was suggested as follows: prednisone 20 mg orally twice a day
for 4 days, followed by 20 mg orally every day for 4 days, then stop. It
should be noted that the addition of oral corticosteroids to an antibiotic
regimen for treatment of chronic sinusitis is a significantly different
approach than those used in the past. Preliminary data suggest that it may
be a very useful adjunct in this setting. However, patients and physicians
alike need to be aware of the possible side effects of systemic
corticosteroids. These must be weighed by the possible adverse consequences
of chronic unresolved infection, risks of sinus surgery, etc. These
judgments can only be made after close consultation between the treating
physician and the patient, while taking all these factors into account.

Topical intranasal steroids are also recommended, especially if the patient
has a history of nasal polyposis. Intranasal steroids have been shown in
several double-blind, placebo-controlled trials to improve nasal congestion
and reduce the size or rate of growth of nasal polyps. Postoperatively, they
have also been shown to help prevent the recurrence of nasal polyps after
surgical polypectomy.

Summary

Management of chronic sinusitis presents a number of challenges to the
treating physician. It is now becoming clear that, in addition to infection,
inflammation may play a key role in the persistence of chronic sinusitis. If
the inflammation that leads to mucosal thickening and sinus ostial occlusion
is not addressed, it is much more difficult to successfully treat this
condition. Further studies are needed to better clarify the role and proper
dosage of both systemic and topical corticosteroids, when used alone or in
combination with antibiotic therapy, in the management of chronic sinusitis.
It is critical to identify allergen triggers to minimize the chance of
future infections through effective allergen avoidance, etc. If patients
fail to improve while on an intensive medical program, then referral to an
otolaryngologist for surgical consultation may be indicated.

References

 1.. Hamilos DL. Resistant sinusitis: what to look for when usual measures
fail. Program and abstracts of the American Academy of Allergy, Asthma and
Immunology 60th Anniversary Meeting; March 7-12, 2003; Denver, Colorado.
 2.. Slavin RG. Resistant sinusitis: What to look for when usual measures
fail. Program and abstracts of the American Academy of Allergy, Asthma and
Immunology 60th Anniversary Meeting; March 7-12, 2003; Denver, Colorado.
 3.. Berrettini S, Carabelli A, Sellari-Franceschini S, et al. Perennial
allergic rhinitis and chronic sinusitis: correlation with rhinologic risk
factors. Allergy. 1999;54:242-248. Abstract
 4.. Emanuel IA, Shaw SB. Chronic rhinosinusitis: allergy and sinus
computed tomography relationships. Otolaryngol Head Neck Surg.
2000;123:687-691. Abstract
 5.. Sinus and Allergy Health Partnership. Antimicrobial treatment
guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg.
2000;123:S1-S32.
 6.. Kaliner MA, Osguthorpe JD, Fireman P, et al. Sinusitis: bench to
bedside. Current findings, future directions. J Allergy Clin Immunol.
1997;99:S829-S848. Abstract

Copyright ? 2003 Medscape.