What are the current treatment guidelines for sinusitis?

From the Guidelines

The current treatment guidelines for sinusitis prioritize symptom management and judicious use of antibiotics, with a focus on distinguishing between viral and bacterial causes to minimize unnecessary antibiotic use and promote appropriate treatment. For acute viral sinusitis, which represents most cases, treatment includes saline nasal irrigation, intranasal corticosteroids (such as fluticasone 50mcg 1-2 sprays per nostril daily or mometasone 50mcg 2 sprays per nostril daily), and analgesics like acetaminophen or NSAIDs for pain relief 1.

Key Considerations for Treatment

• Antibiotics should be reserved for bacterial sinusitis, typically diagnosed when symptoms persist beyond 10 days, worsen after initial improvement, or are severe from onset with high fever and purulent discharge.
• First-line antibiotic therapy is amoxicillin-clavulanate (875/125mg twice daily for 5-7 days) rather than amoxicillin alone due to increasing bacterial resistance 1.
• For penicillin-allergic patients, doxycycline (100mg twice daily) or a respiratory fluoroquinolone like levofloxacin (750mg daily) may be used.
• Chronic sinusitis treatment includes longer courses of intranasal corticosteroids, saline irrigation, and possibly a 2-3 week course of antibiotics if bacterial infection is suspected.
• For patients with nasal polyps, oral corticosteroids like prednisone (20mg daily for 5-7 days) may be added.
• Immunotherapy or biologics like dupilumab may be considered for cases with allergic or eosinophilic components.

Surgical Intervention

Surgery becomes an option when medical management fails after 3-6 months of appropriate treatment, especially in cases with anatomic obstructions, recurrent or persistent infectious sinusitis, or complications such as nasal polyps obstructing sinus drainage 1.

Evaluation and Management

Evaluation should include coronal sinus CT with extra cuts through the ostiomeatal complex to clarify the extent of disease and specific location or locations. Nasal-sinus biopsy may be considered in suspected cases of neoplasia, fungal disease, granulomatous disease, or for evaluating ciliary structures and function 1. Every effort should be made to maximize medical treatment for underlying rhinitis before proceeding with surgical intervention. Contemporary surgical therapy involves chiefly functional endoscopic sinus surgery, with most patients benefiting from continued individualized medical therapy after surgery.

From the FDA Drug Label

The 250 mg/125 mg amoxicillin and clavulanate potassium tablets should not be used until the child weighs at least 40 kg, due to the different amoxicillin to clavulanic acid ratios in the 250 mg/125 mg amoxicillin and clavulanate potassium tablets (250/125) versus the 250 mg/62.5 mg amoxicillin and clavulanate potassium tablets (Chewable). Table 1: Dosing in Patients Aged 12 weeks (3 months) and Older INFECTIONDOSING REGIMEN Every 12 hoursEvery 12 hours 200 mg/5 mL or 400 mg/5 mL oral suspension a125 mg/5 mL or 250 mg/5 mL oral suspension a Otitis media b, sinusitis, lower respiratory tract infections, and more severe infections45 mg/kg/day every 12 hours40 mg/kg/day every 8 hours Less severe infections25 mg/kg/day every 12 hours20 mg/kg/day every 8 hours

The current treatment guidelines for sinusitis recommend the following dosing regimens for amoxicillin-clavulanate:

• For patients aged 12 weeks (3 months) and older:
  • 45 mg/kg/day every 12 hours or 40 mg/kg/day every 8 hours for more severe infections
  • 25 mg/kg/day every 12 hours or 20 mg/kg/day every 8 hours for less severe infections
• For patients weighing 40 kg or more, dosing should be according to adult recommendations 2

From the Research

Current Treatment Guidelines for Sinusitis

The current treatment guidelines for sinusitis involve a combination of medical and surgical approaches.

• For acute sinusitis, treatment typically involves symptomatic relief with analgesics, topical or systemic decongestants, and steam inhalation 3.
• If indicated, antibiotics should be given for an adequate period of time 3, 4.
• For chronic sinusitis, treatment aims to control rhinitis and improve ventilation and function of the sinuses 3.
• Rhinitis may be controlled with the long-term use of topical corticosteroids, mast cell stabilizers, or antihistamines, either alone or in combination 3.
• Secretions may be cleared with steam inhalation and/or saline nasal douching 3, 5.
• Failure to control chronic sinusitis with medical treatment may indicate surgery 3, 5.
• The aim of surgery is to improve ventilation and facilitate drainage of the sinuses, allowing the restoration of normal function 3, 5.

Medical Management of Sinusitis

Medical management of sinusitis involves drainage of the congested sinuses and elimination of the pathogenic bacteria.

• Drainage can be accomplished medically by opening the sinus ostia through the use of decongestants and topical corticosteroids 5.
• Bacteria are effectively eliminated by washing the sinuses with saline and through the use of appropriate antibiotics 5.
• Systemic corticosteroids have been shown to be effective in relieving symptoms of acute sinusitis, particularly when used as an adjunctive therapy to oral antibiotics 6.

Surgical Management of Sinusitis

Surgical management of sinusitis is reserved for patients who have failed medical treatment or have complications such as intraorbital or intracranial sepsis.

• Surgery aims to improve ventilation and facilitate drainage of the sinuses, allowing the restoration of normal function 3, 5.
• Procedures such as removal of nasal polyps, reduction of inferior turbinates, or septal straightening may be performed to improve sinus drainage 3.
• Endoscopic ethmoidectomy and middle meatal antrostomy may also be necessary to improve ventilation and drainage of the sinuses 3.