What is the recommended treatment for a patient with sinusitis?

Treatment of Sinusitis

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

Diagnosis and Assessment

Diagnostic Criteria

• Chronic rhinosinusitis (CRS) is defined as inflammation of the sinuses with symptoms lasting ≥3 months 1
• Key symptoms include:
  • Nasal congestion/obstruction
  • Purulent rhinorrhea
  • Facial pain/pressure
  • Decreased sense of smell 1

Physical Examination

• Look for:
  • Mucosal erythema and purulent secretions
  • Tenderness over sinuses
  • Dark circles beneath eyes
  • Periorbital edema
  • Pharyngeal erythema 1

Warning Signs Requiring Urgent Evaluation

• Orbital swelling or pain
• Swelling of the forehead
• Diplopia or visual changes
• Neurological symptoms 1

Treatment Algorithm

1. First-Line Treatment for All Patients

• Saline nasal irrigation
  • Prevents crusting of secretions
  • Facilitates mechanical removal of mucus
  • Improves mucociliary transit times 1
• Intranasal corticosteroids
  • Particularly effective for nasal congestion and overall symptom control
  • Especially beneficial in patients with marked mucosal edema 1
  • Should be continued for at least 3 months to ensure adequate duration of therapy 1

2. For Bacterial Sinusitis

• Antibiotics should be reserved only for cases with clear evidence of bacterial infection 1
• First-line antibiotic: Amoxicillin-clavulanate 1
  • Duration: 10-14 days 1
• For penicillin-allergic patients, alternatives include:
  • Cefpodoxime proxetil
  • Cefuroxime axetil
  • Cefdinir
  • Trimethoprim-sulfamethoxazole 1

3. For Patients with Nasal Polyps

• More aggressive approach:
  • Short course of oral corticosteroids followed by topical intranasal steroids
  • Maintenance with high-dose intranasal steroids after oral steroid course 1

Special Considerations

Environmental Management

• Identify and avoid environmental irritants
• Improve ventilation
• Consider air filters 1

Medication Side Effects to Monitor

• Antihistamines: Monitor for sedation
• Decongestants: Watch for insomnia, urinary difficulties, jitteriness, tachycardia, hypertension, and increased intraocular pressure 1

Common Pitfalls to Avoid

Overuse of Antibiotics

• Avoid prescribing antibiotics for viral infections
• Distinguish between viral rhinitis and bacterial sinusitis 1

Missing Complications

• Failure to recognize orbital or intracranial complications requiring urgent evaluation 1

Imaging Overuse

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

Referral Criteria

• Chronic condition persisting for several months
• Recurrent sinusitis
• Need for complex pharmacology for recalcitrant infections 1
• Consider surgical intervention (including balloon sinuplasty) for patients who have failed medical therapy and have objective evidence of sinus disease 1

While some research suggests that short-course (5-day) antibiotic therapy may be effective for acute bacterial sinusitis 2, 3, the most recent guidelines still recommend 10-14 days of antibiotic treatment for confirmed bacterial infections 1. High-dose amoxicillin formulations may lead to more rapid improvement but can also cause more severe diarrhea 4.