What is the recommended treatment for chronic sinusitis?

Treatment of Chronic Sinusitis

The recommended first-line treatment for chronic sinusitis includes daily high-volume saline irrigation combined with topical intranasal corticosteroids, with antibiotics reserved for acute bacterial exacerbations. 1

Medical Management Algorithm

First-Line Therapy

1. Intranasal Corticosteroids

   • Recommended as primary maintenance therapy 1
   • Improves overall symptom scores and polyp scores 2
   • Should be continued for at least 3 months 3

2. Saline Nasal Irrigation

   • High-volume irrigation daily 2
   • Significantly improves symptom scores compared to no treatment 2
   • Helps clear mucus and reduce inflammation 4

Second-Line Therapy (Based on Phenotype)

For Chronic Sinusitis WITH Nasal Polyps:

1. Short course of systemic corticosteroids

   • 1-3 weeks duration 2
   • Reduces polyp size for up to 3 months after treatment 2

2. Leukotriene antagonists

   • Improves nasal symptoms in patients with nasal polyps 2

3. Short course of doxycycline

   • 3 weeks duration
   • Reduces polyp size for up to 3 months after treatment 2

For Chronic Sinusitis WITHOUT Nasal Polyps:

1. Macrolide antibiotics
   • 3-month course may be considered
   • Associated with improved quality of life at 24 weeks after therapy 2

For Acute Exacerbations of Chronic Sinusitis

1. Antibiotics

   • Amoxicillin-clavulanate is a good choice for acute exacerbations 3
   • Typical adult dosage: 500-875 mg twice daily 3, 5
   • Duration: 10-14 days 3
   • Alternative for adults: Azithromycin 500 mg daily for 3 days 6

2. Decongestants

   • May be used short-term (5 days) to improve sinus drainage 3
   • Caution with prolonged use due to risk of rhinitis medicamentosa 3

Special Considerations

For Allergic Component

• Antihistamines
  • May be beneficial if allergic rhinitis is an underlying factor 3, 1
  • Not recommended for non-allergic chronic sinusitis 3

For Refractory Cases

• Endoscopic Sinus Surgery
  • Consider for patients who fail medical therapy 1
  • Has been shown to improve lower airway disease and peak expiratory flow 3
  • Requires CT evidence of sinus obstruction or infection 1

Common Pitfalls to Avoid

1. Overuse of antibiotics

   • Antibiotics should be reserved for acute bacterial exacerbations, not routine maintenance 1, 7
   • Recent evidence suggests antibiotics may not change clinical course compared to placebo in AECRS when combined with intranasal steroids 7

2. Inadequate duration of therapy

   • Complete the full course of antibiotics when prescribed 1
   • Continue intranasal corticosteroids for at least 3 months 3

3. Failure to identify underlying conditions

   • Allergic rhinitis, immunodeficiency, or anatomical abnormalities may contribute to recurrent or chronic sinusitis 1
   • Environmental irritants should be identified and avoided when possible 3

4. Missing complications

   • Watch for orbital or intracranial complications, especially with frontal or sphenoid sinusitis 1
   • Warning signs requiring urgent evaluation include orbital swelling, visual changes, and neurological symptoms 1

By following this evidence-based approach to chronic sinusitis management, clinicians can optimize patient quality of life, reduce symptom burden, and minimize the risk of acute exacerbations.