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"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 was 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, 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 MEDICINE 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 with whom to consult with or where they might find information themselves. Examples of practitioners to consult are Doctors of Chiropractic (American Chiropractic Association), Certified Classical Homeopaths (www. nationalcenterforhomeopathy. org) and acupuncturists (NYS Acupuncture Society). 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 airborn allergens and using a humidifier or HEPA filter in the home. Dietary corrections can be 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's 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. Echinacea is wonderful for its anti-viral and anti-bacterial action. Homeopathically, I use a nasal spray, Euphorbium; Allium Cepa for nasal discharges that run like a faucet; Kali Bichromicum for an 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 one's own predisposition to illness and make a determination as to whether one's symptoms are a virus, an allergy or a bacterial infection. Self knowledge is the key. Sharing this 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. Change starts the minute you decide to take an active role in your healthcare. I look forward to answering any questions you 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 approaching 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.
May The Blessings Be!
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