What is the recommended treatment for sinusitis?

Treatment of Sinusitis

The recommended first-line treatment for acute sinusitis is symptomatic management with analgesics, intranasal corticosteroids, and saline nasal irrigation without antibiotics, as most cases are viral in origin. 1

Diagnosis and Classification

Sinusitis can be classified as:

• Acute viral rhinosinusitis: Most common, typically lasts <10 days
• Acute bacterial sinusitis: Symptoms persisting >10 days without improvement, severe symptoms with high fever and purulent discharge for 3-4 consecutive days, or worsening symptoms after initial improvement
• Chronic sinusitis: Symptoms lasting >12 weeks

Treatment Algorithm

First-Line Treatment (Viral/Early Sinusitis)

• Analgesics: Acetaminophen 650-1000mg every 6 hours as needed (not exceeding 4000mg/day) for pain relief 1
• Intranasal corticosteroids: Fluticasone, mometasone, or budesonide 1-2 sprays in each nostril once or twice daily 1
• Saline nasal irrigation: Isotonic or hypertonic (3-5%) saline solution 1-2 times daily 1

Adjunctive Therapies

• Topical decongestants (e.g., oxymetazoline): Can be used for temporary relief but limit to 3-5 days to prevent rebound congestion 1
• Oral decongestants (e.g., pseudoephedrine 60mg every 4-6 hours): Consider if no contraindications like hypertension, anxiety, glaucoma, or urinary retention 1

When to Consider Antibiotics

Antibiotics should be reserved for:

• Symptoms persisting >10-14 days without improvement
• Severe symptoms including fever with purulent nasal discharge, facial pain/tenderness, and periorbital swelling
• Worsening symptoms after initial improvement 2

Antibiotic Selection (When Indicated)

1. First-line: Amoxicillin-clavulanate (875mg/125mg twice daily for 10-14 days) 2, 1
2. For penicillin-allergic patients:
   • Non-anaphylactic reactions: Cefuroxime, cefpodoxime, or cefdinir 1
   • Anaphylactic reactions: Levofloxacin 500mg once daily for 10-14 days 3 or clindamycin 1

Special Considerations

Chronic or Recurrent Sinusitis

• Consider intranasal corticosteroids as adjunct to antibiotics 2
• Evaluate for underlying allergic factors 1
• Consider systemic corticosteroids for chronic non-infectious sinusitis (chronic hyperplastic sinusitis) 2
• Consider referral to specialist for surgical evaluation if medically resistant 2

When to Refer to a Specialist

Consultation should be sought when:

1. Clarification of allergic or immunologic basis is needed
2. Sinusitis is refractory to usual antibiotic treatment
3. Sinusitis is recurrent
4. Sinusitis is associated with unusual opportunistic infections
5. Sinusitis significantly affects quality of life 2

Warning Signs Requiring Urgent Attention

• High fever
• Severe headache
• Visual changes
• Facial swelling or erythema
• Worsening symptoms despite treatment 1

Monitoring and Follow-up

• Reassess in 3-5 days after starting treatment
• If no improvement after 3-5 days on antibiotics, consider alternative antibiotic 2
• If symptoms persist beyond 10 days or worsen after initial improvement, reevaluate for bacterial sinusitis 1

Common Pitfalls

1. Overdiagnosis and unnecessary antibiotic use: Most cases of sinusitis are viral and self-limiting
2. Inadequate duration of antibiotic therapy: When antibiotics are indicated, ensure adequate duration (10-14 days for acute disease)
3. Failure to address underlying factors: Allergies, anatomical abnormalities, or immunodeficiencies may contribute to recurrent sinusitis
4. Prolonged use of topical decongestants: Can lead to rebound congestion (rhinitis medicamentosa)

By following this evidence-based approach to sinusitis management, clinicians can improve patient outcomes while minimizing unnecessary antibiotic use and potential complications.