What is the treatment for chronic pansinusitis?

Treatment of Chronic Pansinusitis

The first-line treatment for chronic pansinusitis should include saline nasal irrigation and intranasal corticosteroids, with antibiotics reserved only for cases with clear evidence of bacterial infection. 1, 2

Diagnosis and Classification

Before initiating treatment, it's important to confirm the diagnosis and determine if nasal polyps are present:

• Chronic rhinosinusitis (CRS) is defined as inflammation of the sinuses with symptoms lasting ≥3 months 1
• Diagnostic criteria include:
  • Nasal congestion/obstruction
  • Purulent rhinorrhea
  • Facial pain/pressure
  • Decreased sense of smell
• Endoscopic examination should be performed to confirm the presence or absence of nasal polyps 1

First-Line Treatment

Topical Intranasal Therapy

1. Saline Nasal Irrigation

   • Prevents crusting of secretions
   • Facilitates mechanical removal of mucus
   • Improves mucociliary transit times 2

2. Intranasal Corticosteroids

   • First-line pharmacologic treatment
   • Options include mometasone furoate, fluticasone propionate, beclometasone dipropionate 3
   • Reduces mucosal inflammation and swelling
   • Particularly effective for patients with marked mucosal edema 2

Antibiotic Therapy

• Not routinely recommended for chronic rhinosinusitis
• Recent high-quality evidence shows that amoxicillin-clavulanate for 14 days did not change the clinical course of acute exacerbations of chronic rhinosinusitis compared to placebo when both groups received intranasal steroids 4
• If bacterial infection is strongly suspected (based on purulent secretions and worsening symptoms), consider:
  • Amoxicillin-clavulanate as first-line 2
  • Alternatives for penicillin-allergic patients: cefpodoxime proxetil, cefuroxime axetil, cefdinir, or trimethoprim-sulfamethoxazole 2, 1
  • Duration: 10-14 days 1

Management of CRS with Nasal Polyps

For patients with nasal polyps, a more aggressive approach is needed:

1. Short course of oral corticosteroids

   • Consider prednisolone 25mg daily for 2 weeks
   • Followed by topical intranasal steroids
   • This approach has been shown to be more effective than topical steroids alone in decreasing polyp size and improving olfaction 5

2. Maintenance with high-dose intranasal steroids

   • After oral steroid course, continue with intranasal steroids
   • Higher doses may be needed for polyp control 1, 5

Additional Treatment Considerations

Adjunctive Therapies

• Avoid antifungal therapy - Not recommended for CRS as it lacks efficacy and has potential adverse effects 1
• Traditional Chinese acupuncture - Not recommended as there is no evidence it is more effective than placebo 1

When to Consider Surgery

• Failure of maximal medical therapy
• Presence of anatomic obstruction
• Recurrent acute exacerbations despite appropriate medical management
• Complications such as orbital or intracranial involvement 2, 6

Special Considerations

Allergic Component

• For patients with underlying allergy, consider adding antihistamines 3
• Allergy testing and management may benefit selected patients 1

Warning Signs Requiring Urgent Evaluation

• Orbital swelling or pain
• Visual changes
• Neurological symptoms
• These may indicate complications requiring immediate intervention 2, 6

Common Pitfalls to Avoid

1. Overuse of antibiotics for viral infections or non-infectious inflammation
2. Failure to identify nasal polyps, which require more aggressive treatment
3. Inadequate duration of intranasal steroid therapy
4. Missing complications that require urgent evaluation
5. Relying solely on imaging without clinical correlation 2

By following this treatment algorithm and avoiding common pitfalls, most patients with chronic pansinusitis can achieve significant symptom improvement and better quality of life.