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Azerbaycan Saytlari

 »  Home  »  Endodontic Articles 2  »  Endodontic implications of the maxillary sinus: a review
Endodontic implications of the maxillary sinus: a review
Antibiotics, decongestants and analgesics in the management of sinusitis.



At least 70% of bacterial complications of acute sinusitis are caused by Streptococcus pneumoniae and Haemophilus influenzae , of which some 20–30% produce -lactamase (Yonkers 1992). Several other bacterial species, including Moraxella (Branhamella) catarrhalis , Streptococcus pyogenes , Staphylococcus aureus , and -streptococci, account for a proportion of cases. Approximately 10% of cases of acute sinusitis in adults arise from dental infections containing a mixture of anaerobic species (Gwaltney 1995). Antibiotics are a fundamental part of management in acute suppurative sinusitis. Pinheiro et al . (1998) recommended amoxycillin as a first-line empiric therapy aimed at covering both Gram-positive and Gram-negative organisms. Amoxycillin and its derivatives also cover Gram-negative encapsulated organisms such as H. influenzae and S. pneumoniae , making it particularly useful in the medical management of sinus disease. Other acceptable and inexpensive choices for first line therapy would be a combination of erythromycin and a sulphonamide or a second generation cephalosporin and a sulphonamide. However, patients with true hypersensitivity reactions to penicillin should not be given cephalosporins owing to cross-reactivity in approximately 10% of the population. In these patients, cotrimoxazole or clarithromycin may be suitable alternatives.
Synthetic penicillin antibiotics with a -lactamase inhibitor (e.g. amoxycillin-clavulanate) have a broader spectrum of activity against -lactamase producing strains of Haemophilus influenza and Moraxella catarrhalis , but they may not be effective against penicillin resistant pneumococcus. Second generation cephalosporins also cover -lactamase producing organisms. Individuals who have failed prior antibiotic treatment or with a history of frequent episodes recalcitrant to amoxycillin treatment may require a different antibiotic or a combination of antibiotics before a more invasive option is explored.
Intravenous antibiotics may be indicated in individuals with severe infections involving other sites, such as the orbit or intracranial spread. Either second or third generation cephalosporins or ampicillin sulbactam are good choices owing to excellent penetration of the blood–brain barrier in addition to covering the relevant organisms. Anaerobic coverage can be provided by metronidazole, which also has good penetration of cerebrospinal fluid.
Clinical improvement usually occurs within 48–72 h of initiation of antimicrobial therapy. The antibiotictherapy should be continued for a minimum period of 7 days after the symptoms have disappeared. Treatment for lesser periods of time may cause relapse or the disease may progress to chronic sinusitis. Smith & Browning (2000) suggested that general dental practitioners should not prescribe antibiotics for uncomplicated acute sinusitis. For patients presenting with symptoms of maxillary toothache, dental practitioners are best placed to examine the oral cavity for prompt treatment of dental disease. Cases that do not resolve should be referred once dental disease has been excluded as a source of infection.
The combination of allergic disease and infectious sinusitis has been considered the most difficult form of sinus disease to treat (Shin & Bellenir 1998). The patient with uncontrolled nasal allergies frequently experiences marked congestion, swelling, excess secretions and discomfort in the sinus area. These patients need to follow an allergy care programme to alleviate sinusitis.
In addition to destroying the involved organisms, it is important to decrease oedema around the ostia to facilitate drainage and allow sinus oxygenation (Pinheiro et al . 1998). Topical and systemic decongestants are beneficial and facilitate oxygenation and sinus drainage of pus by decreasing the ostial mucosal oedema. This is one of the few instances in which topical decongestants, drops or sprays are advocated and are beneficial, provided that their use is not extended beyond 3–5 days as a result of significant rebound effect.
Analgesics, such as paracetamol and nonsteroidal anti inflammatory drugs, are important for the control of pain. However, in severe sinus pain cases, a narcotic analgesic may be indicated.