What are the treatment options for sinusitis?

Treatment Options for Sinusitis

The first-line treatment for acute sinusitis is amoxicillin for 10-14 days, with intranasal corticosteroids and saline irrigation as important adjunctive therapies. 1

Classification of Sinusitis

Sinusitis can be classified based on duration:

• Acute: symptoms < 4 weeks
• Subacute: symptoms 4-8 weeks
• Chronic: symptoms ≥ 8 weeks
• Recurrent: ≥ 3 episodes of acute sinusitis per year 1

Diagnosis

Diagnosis of sinusitis is primarily clinical, based on:

• Persistent symptoms (nasal symptoms or cough for >10 but <30 days without improvement)
• Severe symptoms (high fever and purulent nasal discharge for 3-4 consecutive days)
• Worsening symptoms (respiratory symptoms that worsen after initial improvement) 2

Physical examination may reveal:

• Mucosal erythema and purulent secretions
• Nasal polyps (more common in adults, rare in children)
• Middle ear effusions 3

Treatment Algorithm

1. Antibiotic Therapy

First-line antibiotic therapy:

• Amoxicillin for 10-14 days 1
• Continue for 7 days after the patient is well to ensure complete eradication 3

For patients who fail to respond after 3-5 days:

• Switch to high-dose amoxicillin-clavulanate or cefuroxime axetil 3

For penicillin-allergic patients:

• Clarithromycin is indicated for acute maxillary sinusitis caused by susceptible strains of H. influenzae, M. catarrhalis, or S. pneumoniae 4
• Alternative options include cefuroxime, cefpodoxime, or cefdinir 2

2. Adjunctive Therapies

Intranasal corticosteroids:

• Recommended for nasal congestion and overall symptom control 1
• Particularly helpful in patients with marked mucosal edema 3

Saline irrigation:

• Prevents crusting of secretions and facilitates mechanical removal of mucus 3
• Improves mucociliary transit times 3

Short-term decongestants:

• Can be used for symptomatic relief 1
• Both oral and topical forms may help with drainage 5

Oral corticosteroids:

• May be considered as short-term adjunctive therapy in patients who:
  • Fail to respond to initial treatment
  • Have nasal polyposis
  • Have marked mucosal edema 3
• Studies show improved short-term resolution of symptoms when combined with antibiotics 6

Special Considerations

Chronic or Recurrent Sinusitis

For patients with chronic or recurrent sinusitis:

• Evaluate for underlying allergic factors or immunodeficiency 1
• Consider endoscopic sinus surgery for patients who fail medical therapy 1
• IVIG may be appropriate for patients with immunoglobulin deficiency to prevent complications 3

Warning Signs Requiring Urgent Evaluation

• Orbital swelling or pain
• Visual changes or diplopia
• Forehead swelling
• Neurological symptoms 1

Common Pitfalls to Avoid

1. Failure to distinguish viral from bacterial sinusitis:

   • Viral sinusitis typically resolves within 7-10 days
   • Bacterial sinusitis shows persistent, severe, or worsening symptoms 1

2. Inadequate duration of antibiotic therapy:

   • Continue antibiotics for 7 days after symptoms resolve 3

3. Not addressing underlying factors:

   • Allergic rhinitis, immunodeficiency, and anatomical abnormalities can predispose to recurrent sinusitis 5

4. Overuse of antibiotics:

   • Antibiotics should be reserved for cases with clear evidence of bacterial infection to prevent resistance 1

By following this evidence-based approach to sinusitis treatment, focusing on appropriate antibiotic selection and important adjunctive therapies, clinicians can effectively manage this common condition while minimizing complications and recurrence.