What is the treatment for sinusitis?

Treatment of Sinusitis

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

Diagnosis and Classification

Sinusitis can be classified as:

• Acute: Symptoms lasting less than 4 weeks
• Chronic: Symptoms lasting ≥3 months 1

Key diagnostic features include:

• Nasal congestion/obstruction
• Purulent rhinorrhea
• Facial pain/pressure
• Decreased sense of smell 1

Treatment Algorithm

Step 1: Initial Management for All Sinusitis Patients

• Saline nasal irrigation: Facilitates mechanical removal of mucus and improves mucociliary transit times 1
• Intranasal corticosteroids (e.g., fluticasone propionate): Particularly effective for nasal congestion and overall symptom control 1, 2
  • May start providing relief on the first day of use, but requires several days for full effectiveness 2
  • Can be used for up to 6 months in patients ≥12 years or up to 2 months in children 4-11 years 2

Step 2: For Suspected Bacterial Sinusitis

Bacterial infection should be suspected with:

• Persistent symptoms >10 days without improvement
• Severe symptoms (high fever, purulent discharge for 3-4 consecutive days)
• Worsening symptoms after initial improvement 3

If bacterial infection is confirmed:

• First-line antibiotic: Amoxicillin-clavulanate 1
• For penicillin-allergic patients: Cefpodoxime proxetil, cefuroxime axetil, cefdinir, or trimethoprim-sulfamethoxazole 1
• Duration: 10-14 days 1

Step 3: For Chronic Rhinosinusitis with Nasal Polyps

• Short course of oral corticosteroids followed by high-dose intranasal steroids 1
• Maintenance with high-dose intranasal steroids 1

Special Considerations

For Intranasal Corticosteroids

• Not associated with "rebound effect" seen with decongestants 2
• Does not cause drowsiness like some antihistamines 2
• Side effects are generally mild but may include:
  • Headaches or sneezing
  • Bad taste or smell
  • Minor nosebleeds
  • Dry or irritated nose or throat 2

Warning Signs Requiring Urgent Evaluation

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

Common Pitfalls to Avoid

1. Overuse of antibiotics for viral infections

   • Most cases of acute sinusitis are viral and resolve spontaneously 1, 4
   • Antibiotics should be reserved for clear bacterial cases 1

2. Missing complications requiring urgent care

   • Failure to recognize orbital or intracranial complications 1
   • If severe sinus pain, thick nasal discharge, or suspected infection occurs, discontinue intranasal steroids and seek medical attention 2

3. Imaging overuse

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

4. Inadequate duration of treatment

   • Intranasal corticosteroids should be continued for at least 3 months in chronic cases 1
   • Antibiotics should be continued until the patient is symptom-free and then for an additional 7 days 3

Referral Considerations

Consider referral to an allergist/immunologist or otolaryngologist for:

• Chronic condition persisting for several months
• Recurrent sinusitis
• Need for complex pharmacology for recalcitrant infections 1
• Surgical intervention may be considered for patients with chronic rhinosinusitis who have failed medical therapy 1