Tuesday, May 31, 2011

I Think I Have a Sinus Infection, I Need a Z-pak!

I walked into see my next patient in the clinic.  She was a 30ish year old mother with two small children in tow. 
“HI, I’m Sharon, I’m a physician assistant, how can I help you?”
“I have a sinus infection, and I need a z-pak.”
“I see, well why don’t you start by telling me what your symptoms are?”
“I’ve got sinus congestion with yellow drainage.”
“Okay, well how about any coughing, sore throat, fevers or ear congestion?”
“No fevers, my throat’s a little scratchy, some cough and my ears feel full.”
“How about teeth pain?”
“No, none of that.”
“How long have you been sick?”
“About 4-5 days.  I caught it from my two year old son who had it last week and I took him to his pediatrician’s office who said he had an ear infection and gave him amoxil with some sort of nasal decongestant prescription.”
“Hmm, well what color are you coughing up?”
“The same yellow stuff that’s coming from my nose.”
“Looking at your medical chart, I see that you don’t have any medication allergies and you’re not on any prescription medications, is that still correct?”
“Alright, well let me exam you and then I’ll explain what can be done.”
The patient’s physical exam showed what I expected, some ear congestion, sinus congestion,  a slightly red throat, with clear respirations heard from her lungs.
“Okay, well why don’t you sit down here in this chair and I’ll explain everything to you.”
Over the next 10 minutes I reviewed with the patient the difference between an actual bacterial sinus infection, for which an antibiotic would work (i.e. amoxil, omnicef) and sinus congestion caused by a virus which is what she had.  And as usual, she kept insisting that the z-pak was the only thing that would clear up her sinus problems. 
I have come across this same scenario too many times in my many years of working in medicine.  So if you are like this patient and believe that sinus congestion equals to an acute bacterial sinus infection for which you need an antibiotic, please read on. 
Viral Related Sinus Congestion
Virus’ can cause you to have sinus congestion, some sinus discomfort, and low grade fevers up to 101.  You can have yellow to green sinus drainage, productive cough and a sore throat.  Your ears can feel full or be congested.  You might have some dullness in hearing due to the ear congestion.  Your low grade fevers are related to your viral infection, which typically is an adenovirus or rhinovirus.   Now compare that to a patient who has a bacterial related sinus infection.  They will have acute facial pain, sinus congestion, fevers generally in the range of 101-102 F, green to bloody drainage from sinus’, a sore throat, ear congestion and teeth pain.  I believe you can see the differences between the two. 
So in an effort to help my patients understand the differences between sinus congestion and an actual bacterial sinus infection which requires antibiotics I came up with the following chart which many of my patients have told me really helps them understand what to do. 
Sinus Allergies
Sinus Congestion
Sinus Infection
type of drainage
amount of pain
facial pain
due to
presence of fever
mild up to 100-101 F
usually over 101 F
ear symptoms
sometimes feels full
popping, feels congested
congested, can be painful
can be irritated, dry
teeth pain
no to minimal
head movement
no relationship
can be uncomfortable
pain with head movement
sinus tenderness to palpation
Yes! (typically acute pain over involved sinus)
Treatment of Above:

steroid spray
generally no
anti-viral medication
yes, if due to the flu virus
antibiotic (amoxil, omnicef, etc)
Frequently Asked Questions:

What is an antihistamine?
It is a medication which dries up your sinus drainage, and blocks the histamines which are released due to the presence of an allergen
What is a decongestant?
It is a medication which breaks the mucus free of the sinus membranes and opens your sinus passageways up so as relieve pressure
What is a steroid spray?
It is a medication which decreases the inflammation in the sinus’ passageways
What does mucinex do?
It thins out the secretions and allows drainage of the mucus
What is a virus?
A single stranded RNA particle which can infect cells and then replicate
What is a bacteria?
It is a living cell, which can invade your system and causes a bacterial infection
What is an antibiotic?
It a medication which is geared towards killing bacterial living cells.  It is incapable of killing viral particles. 

Progression of Sinus Symptoms
Sinus problems generally start in a patient who has a history of sinus allergies.  Their allergies begin to kick in and cause clear drainage.  Patients at this stage typically do very well taking over the counter antihistamines.   Then in some patients , sinus drainage and inflammation increases and they become congested with limited ability to drain the mucoid-like fluid.  It’s at this point in time that the patient’s sinus’ become infected with a virus (usually one of the virus’ that cause the common cold or a flu virus).  Once the virus has set up house, the  patient begins to have problems with yellow-to-green drainage, sinus congestion, sinus discomfort and possible low grade fevers.  It’s at this point that the patient has sinus congestion due to a viral infection. 
If the viral infection is left alone, then typically the patient will over time come down with an acute bacterial infection.  It’s at this stage that antibiotics will work to get rid of the bacterial culprit.  Patients will complain of fevers generally in the range of 101-102, acute facial pain over one or more of the sinus’, teeth pain, green/bloody drainage, productive cough, and a sore throat. 
But as a patient there are things you can do to address your sinus congestion to prevent the sinus’ becoming infected with a bacteria and your needing an antibiotic.  You can take ‘real’ Sudafed (from behind the pharmacy counter), you can take some mucinex, you can begin or increase your saline nasal washes.  All of this will help to address your sinus congestion and should prevent  it from progressing onto a bacterial infection. 
If your sinus problem is truly an acute bacterial sinus infection then you need the attention of your primary care physician or an ENT physician.  They can give you an antibiotic prescription and advise you to take guaifenesin, with a decongestant and/or the saline nasal washes. 
Symptoms Relief
One of the major ways to relieve your sinus symptoms and to address the sinus congestion (either from sinus congestion or an acute bacterial sinus infection) is to flush the sinus’ out of it’s mucus.  This is best done with either the saline nasal washes, guaifenesin, a decongestant  or all three.  Using an antihistamine in this scenario is just going to dry up the mucus and not allow it to drain which is what you need.    
Using saline nasal washes are very handy, easy to do.  And the most important part about them is that they do work to decrease your sinus problems by as much as 72%.  If you are going to do saline nasal washes I advise my patients to use a nasal bulb for ease of getting the saline wash into the sinus’.  It is also advisable to do the saline nasal washes at least 3-4 times a day to make them effective. 
Saline Washes:
Saline rinses of your sinus’ may reduce sinus symptoms by as much as 72 percent and even cut the number of infections for those with chronic sinus problems, researchers from England’s Royal National Throat, Nose and Ear Hospital concluded after reviewing a series of studies.  This ancient remedy softens and removes crusty mucus, thins nasal secretions, and helps wash away viral particles, bacteria and irritating immune system compounds. 
You can purchase a sinus rinsing tool called a neti pot at a natural foods store, get a special attachment for electric water-jet irrigators (like Water Pik), use a squeeze-bottle sinus rinse (such as NeilMed rinse), use a nasal bulb, or simply cup your hand to deliver the saline solution to your nose. 
The mixture:  ½ tsp non-ionized salt plus 1 pinch of baking soda with 8 ozs of warm water.  Another mixture you can use is ¼ tsp of salt, ¼ tsp of baking soda with 8 ozs of warm water. 
Rinsing directions:  Lean over the sink with your head down (some neti-pot instructions advise tilting your head to the side slightly).  Gently squirt the saline into each nostril (or inhale one nostril at a time, from your palm).  Breathe through your mouth at the same time will help keep the solution from entering your mouth (if it does spit it out).  Gently blow your nose.  Repeat until you’ve used the 8 ozs of salt water. 
Repeat as often during the day as needed. 
Using the over the counter medications generally doesn’t work.  These over the counter medications have ‘pretend sudafed’ in them, an antihistamine, or both.  They also have other unnecessary meds in them such as tylenol, ibuprofen, dexomethorphan, etc.  The ‘real’ sudafed which decongests your sinus’ is behind the pharmacy counter and you have to show your photo identification to acquire it. 
Precaution for Those Patients Who Have Hypertension
If you are a patient who has hypertension and is currently being treated for it, before you take an antihistamine or Sudafed (decongestant) please discuss it with your primary care provider.  Both Sudafed and any antihistamine are known to cause an increase in your blood pressure.  Your physician may tell you its okay to take them for the short duration you will need them to address your sinus congestion or they may tell you to address is with saline nasal washes and a steroid spray, so discuss this with them.   
So in the future if you think you have a sinus infection, please review the table and address your symptoms based on which column you fall in.   


  1. Wow, very detailed account - thanks for that!!

  2. What if your mucus is yellow, your sinuses/face are extremely painful, no fever, ears hurt and congested, teeth hurt, no sore throat, and it's January, not time for typical allergens.

  3. Thanks. I've been treating mself with a Z-pac, but it seem I have more of a sinus congestion issue vs infection. Being in clincal micrbiology (Medical technologist), I assumed yellow/brown mucus must be infection. Thanks for the knowledge!

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  5. What a nice chart--thank you for the detailed information. I just did this yesterday and got a Z-pak from a doctor I went to because the regular one was away. (He wanted to give me Bioxin and I declined, as it's given me a bad stomach ache). Now, though, it looks as if I don't truly need an a/b. Should I discontinue the Z-pak?

  6. Sinusitis is a common infection therefore everyone should know at least how to get a basic sinus infection treatment at home before you can reach a doctor. This knowledge could be useful in many situations, including the ones when you are away from home, on an expedition or somewhere else where you cannot get medical help. See more here http://survival-mastery.com/med/health/sinus-infection-treatment.html

  7. I'm still confused since my symptoms do not fit that chart. No colorful mucus or fever, but some congestion, ear pain, lower molar pain, feel shaky, painful lymph node, pain is so bad I can't sleep more then an hour or two at a time and my jaw is popping. I went to the dentist thinking I needed a root canal for a dental abscess. He said no the lump was a swollen lymph node and gave me a Z-pack for a sinus infection. It doesn't feel like a sinus infection to me but my dental x-ray was clean and I already take Allegra and Nasocort on a regular basis due to terrible allergies and a deviated septum.

  8. Bull...tired of this new non antibiotic movement. Its just so we can pay u twice bcz we wind up coming back for one anyway while u let ppl get sicker. Ur not doing anyone any favors. Oh..but offer steroids instead to suppress the immune system! Makes so much sense..smh

  9. JoHanna- Fine, just take the zpak like its water! And when the time comes when you DO actually need to take an antibiotic it will no longer work since you've become immune to it. I'm annoyed by people who assume medicine is fast food, you can't have it your way!

  10. Actually, if you want to know whether you have a bacterial or viral (BTW, the plural of virus is viruses, not virus') infection is to culture a mucus sample that you have taken from the sinus with a long q-tip. All of that other stuff is more than 50% likely to be true, but not definitive.

  11. Cold and sinus infections are the infections that are very closely linked and to determine those is important so as to get proper medications and treatment according
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  12. Cold and sinus infections are the infections that are very closely linked and to determine those is important so as to get proper medications and treatment according
    to the infection that you are suffering. Both Cold and Sinus have very similar symptoms but one can notice the difference between the two only by some of the minor
    differences. Determining the health issue that you are suffering with can be only done if you Know the Difference between Cold and Sinus.

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