What is the recommended treatment for chronic sinusitis?

Chronic Rhinosinusitis Treatment

The first-line treatment for chronic rhinosinusitis includes daily saline nasal irrigation and intranasal corticosteroids, with antibiotics reserved only for cases with clear evidence of bacterial infection. 1

Diagnosis and Definition

• Chronic rhinosinusitis (CRS) is defined as inflammation of the sinuses with symptoms lasting ≥3 months
• 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

Treatment Algorithm

First-Line Therapy (for all CRS patients)

1. Saline Nasal Irrigation

   • High-volume saline irrigation prevents crusting of secretions
   • Facilitates mechanical removal of mucus
   • Improves mucociliary transit times 1
   • Significantly improves symptom scores compared to no treatment 2

2. Intranasal Corticosteroids

   • Recommended for nasal congestion and overall symptom control
   • Particularly effective in patients with marked mucosal edema 1
   • Improves overall symptom scores and reduces polyp size when present 2
   • Reduces polyp recurrence after surgery 2

Additional Treatments Based on CRS Subtype

For CRS with Nasal Polyps

1. Short course of systemic corticosteroids (1-3 weeks)

   • Reduces polyp size for up to 3 months after treatment 1, 2
   • Should be followed by maintenance with high-dose intranasal steroids 1

2. Short course of doxycycline (3 weeks)

   • Alternative to systemic corticosteroids
   • Reduces polyp size for up to 3 months 2

3. Leukotriene antagonists

   • May be considered for improving nasal symptoms 2

For CRS without Nasal Polyps

1. Prolonged course of macrolide antibiotics (3 months)
   • May be considered for patients without polyps
   • Associated with improved quality of life at 24 weeks after therapy 2

For Bacterial Infection (Acute Exacerbation)

• First-line antibiotic: Amoxicillin-clavulanate for 10-14 days 1
• Alternatives for penicillin-allergic patients:
  • Cefpodoxime proxetil
  • Cefuroxime axetil
  • Cefdinir
  • Trimethoprim-sulfamethoxazole 1

Special Considerations

Allergy Management

• Consider allergy testing and management for selected patients with underlying allergy 1

Surgical Intervention

• Consider for patients who have failed medical therapy
• Includes options such as balloon sinuplasty
• Requires objective evidence of sinus disease 1

Common Pitfalls to Avoid

1. Overuse of antibiotics for viral infections

   • Distinction between viral rhinitis and bacterial sinusitis is necessary
   • Reserve antibiotics for clear evidence of bacterial infection 1

2. Missing complications requiring urgent evaluation

   • Warning signs: orbital swelling/pain, forehead swelling, diplopia, visual changes, neurological symptoms 1

3. Imaging overuse

   • Plain radiographs have significant false-positive and false-negative results
   • CT findings require clinical correlation to avoid overdiagnosis 1

4. Inadequate duration of treatment

   • Intranasal corticosteroids should be continued for at least 3 months 3
   • Antibiotics, when indicated, should be given for 10-14 days 1

When to Refer to a Specialist

• Chronic condition persisting for several months despite appropriate therapy
• Recurrent sinusitis
• Need for complex pharmacology for recalcitrant infections
• Presence of nasal polyps or comorbid conditions (asthma, atopic dermatitis, eosinophilic esophagitis) that may benefit from biologic therapy 4

The most recent evidence strongly supports the use of saline irrigation and intranasal corticosteroids as the cornerstone of CRS management, with additional therapies tailored to the specific subtype of CRS and presence or absence of nasal polyps 1, 2.