What is the recommended treatment for chronic sinusitis?

Treatment of Chronic Rhinosinusitis

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

Diagnostic Criteria

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 1

Physical examination should assess for:

• Mucosal erythema
• Purulent secretions
• Tenderness over sinuses
• Nasal polyps (via endoscopic examination) 1

Treatment Algorithm

First-Line Therapy (All Patients)

1. Saline Irrigation

   • Improves symptom scores compared to no treatment
   • Prevents crusting of secretions
   • Facilitates mechanical removal of mucus
   • Improves mucociliary transit times 1, 2

2. Intranasal Corticosteroids

   • Improves overall symptom scores
   • Particularly effective for nasal congestion
   • Essential for patients with marked mucosal edema 1, 2

Second-Line Therapy (Based on Subtype)

For Patients WITH Nasal Polyps:

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

   • More effective than topical steroids alone in decreasing polyp size
   • Improves olfaction 1, 2

2. Follow with maintenance high-dose intranasal steroids 1

3. Consider adjunctive therapies:

   • Short course of doxycycline (3 weeks)
   • Leukotriene antagonists 2

For Patients WITHOUT Nasal Polyps:

1. Consider macrolide antibiotics for 3 months
   • May improve quality of life
   • Benefits may persist for 24 weeks after therapy 2

For Cases with Bacterial Infection

Antibiotics should be used only when clear evidence of bacterial infection exists 1

1. First-line antibiotic:

   • Amoxicillin-clavulanate for 10-14 days 1

2. For penicillin-allergic patients:

   • Cefpodoxime proxetil
   • Cefuroxime axetil
   • Cefdinir
   • Trimethoprim-sulfamethoxazole 1

3. For acute exacerbations of chronic sinusitis:

   • Azithromycin 500mg daily for 3 days OR
   • Azithromycin 500mg on day 1, followed by 250mg daily on days 2-5 3

Special Considerations

Environmental Factors

• Identify and avoid environmental irritants
• Improve ventilation
• Consider air filters 4

Warning Signs Requiring Urgent Evaluation

• Orbital swelling or pain
• Forehead swelling
• Diplopia or visual changes
• Neurological symptoms 1

Referral Criteria

Refer to an otolaryngologist when:

• CRS persists despite appropriate medical therapy
• Recurrent sinusitis occurs
• Complex pharmacology is needed for recalcitrant infections
• Surgical intervention may be needed 1, 5

Common Pitfalls to Avoid

1. Overuse of antibiotics for viral infections

   • Distinguish between viral rhinitis and bacterial sinusitis 1

2. Failure to recognize complications

   • Be vigilant for orbital or intracranial complications 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 therapy

   • Intranasal corticosteroids should be continued for at least 3 months 4

5. Overlooking medication side effects

   • Monitor for sedation with antihistamines
   • Watch for insomnia, urinary difficulties, jitteriness, tachycardia, hypertension, and increased intraocular pressure with decongestants 4

The evidence strongly supports saline irrigation and intranasal corticosteroids as the cornerstone of CRS management, with additional therapies tailored based on the presence of nasal polyps and evidence of bacterial infection.