Adult Chronic Sinusitis and Its Complications

By G. Douglas Campbell Jr., MD, FCCP

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Medical Management in Special Situations

Cystic Fibrosis

Sinus involvement in patients with cystic fibrosis is common (up to 10% of patients) and may cause exacerbations in the lower respiratory tract. Chronic purulent drainage and nasal congestion are frequent complaints, and most patients present with polyposis, often bilateral and occasionally significant in size. The spectrum of pathogens recovered from the sinuses is similar to those recovered from the lower respiratory tract. As the disease progresses, more virulent organisms are recovered from both the lower and upper respiratory tract, including P aeruginosa and S aureus (including methicillin-resistant S aureus), and these pathogens frequently are resistant to common antimicrobial agents.

Although presently there are no guidelines for management of chronic rhinosinusitis in cystic fibrosis patients, many physicians start with aggressive medical management, including decongestants and prolonged use of topical steroids, antihistamines, and antimicrobial agents. Because chronic rhinosinusitis disease and lower respiratory tract exacerbations frequently occur in tandem, antimicrobial choices are often based upon results of a sputum culture. Therapy is of prolonged duration (often 3 weeks or more), usually with two or more agents, when resistant and virulent pathogens are recovered. Early surgical intervention, proposed by the authors of one preliminary study, may reduce morbidity, improve exercise tolerance, and delay progressive respiratory failure.⁴⁶ Considerations for surgical management include a significant decrease in pulmonary function as a result of rhinosinusitis, chronic symptoms unrelieved by medical management, or the presence of a mucocele. Sinus surgery should be entertained in all such patients prior to undergoing lung transplantation.

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