What are the treatment options for sinusitis?

Treatment Options for Sinusitis

The primary treatment for acute bacterial sinusitis is antibiotics, with amoxicillin being the first-line therapy for both children and adults, supplemented by supportive measures including nasal corticosteroids, saline irrigation, and comfort measures. 1

Types of Sinusitis and Initial Approach

Acute Sinusitis (symptoms < 4 weeks)

• First-line antibiotic: Amoxicillin for 10-14 days 1
• For penicillin allergy: Trimethoprim-sulfamethoxazole (adults), cephalosporins, macrolides, or quinolones 1
• For treatment failure: Switch to high-dose amoxicillin-clavulanate after 3-5 days if no improvement 1, 2

Chronic Sinusitis (symptoms ≥ 8 weeks)

• Medical therapy:
  • Nasal corticosteroids (e.g., fluticasone) 1, 3
  • Saline irrigation 1, 4
  • Longer antibiotic courses with possible anaerobic coverage 1
• Surgical options: Consider when medical therapy fails for 12+ weeks 4
  • Balloon sinuplasty for chronic sinusitis without polyps 4
  • Functional endoscopic sinus surgery 1

Antibiotic Selection Algorithm

1. Initial therapy: Amoxicillin (standard dose) 1, 2
2. If no improvement in 3-5 days OR high resistance area:
   • High-dose amoxicillin-clavulanate (90 mg/kg amoxicillin and 6.4 mg/kg clavulanate, not exceeding 2g every 12 hours) 1
   • Alternative options: cefuroxime, cefpodoxime, cefprozil, or cefdinir 1, 2, 5
3. For penicillin allergy:
   • Adults: Trimethoprim-sulfamethoxazole 1
   • Alternatives: macrolides (clarithromycin, azithromycin) or quinolones 1, 2
4. For treatment failure after 21-28 days:
   • Broader-spectrum antibiotics with possible anaerobic coverage (clindamycin or metronidazole) 1

Adjunctive Therapies

Nasal Corticosteroids

• Beneficial for both acute and chronic sinusitis 1, 3
• May provide relief starting from the first day of use 3
• Can be used for up to 6 months in patients ≥12 years old 3
• Not associated with rebound effects like decongestants 3

Supportive Measures

• Adequate hydration
• Analgesics for pain relief
• Warm facial packs
• Steamy showers
• Sleeping with head elevated 1
• Saline nasal irrigation 1, 4

Oral Corticosteroids

• Consider short-term use for:
  • Treatment failure
  • Presence of nasal polyps
  • Marked mucosal edema 1
  • Chronic hyperplastic (non-infectious) sinusitis 1

Special Considerations

Recurrent Sinusitis

• Evaluate for underlying conditions:
  • Allergic rhinitis
  • Non-allergic rhinitis
  • Immunodeficiency
  • Anatomical abnormalities 1
• Consider referral to allergist-immunologist or otolaryngologist 1

Sinusitis with Allergic Rhinitis

• Evaluate for IgE sensitization to allergens
• Add environmental control measures
• Consider allergen immunotherapy in selected patients 1, 6

When to Refer to Specialists

• Refractory to usual antibiotic treatment
• Recurrent sinusitis (≥3 episodes per year)
• Unusual or opportunistic infections
• Significant impact on quality of life
• Concomitant conditions (asthma, nasal polyps, immunodeficiencies) 1
• Failed medical therapy for >12 weeks (consider surgical evaluation) 4

Common Pitfalls to Avoid

1. Overdiagnosis and unnecessary antibiotics: Reserve antibiotics for symptoms lasting 10-14 days or severe symptoms with fever, purulent discharge, and facial pain 1

2. Inadequate duration of therapy: Continue antibiotics for full 10-14 days for acute sinusitis 1, 2

3. Failing to switch antibiotics when appropriate: Change antibiotics if no improvement after 3-5 days 1, 2

4. Missing underlying conditions: Evaluate for allergic rhinitis, GERD, immunodeficiency when sinusitis is recurrent 1

5. Ignoring warning signs: Urgent evaluation needed for orbital swelling/pain, forehead swelling, or diplopia 1