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

Diagnosis and Classification

Chronic rhinosinusitis (CRS) is defined as inflammation of the sinuses with symptoms lasting ≥3 months, characterized by:

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

CRS is categorized as:

• With or without nasal polyps
• Primary or secondary 2

First-Line Treatment

1. Saline Irrigation

• High-volume saline irrigation is recommended as a cornerstone therapy
• Prevents crusting of secretions
• Facilitates mechanical removal of mucus
• Improves mucociliary transit times 1
• Significantly improves symptom scores compared to no treatment 3

2. Intranasal Corticosteroids

• Recommended for all patients with CRS
• Particularly effective for patients with marked mucosal edema 1
• Improves overall symptom scores
• Reduces polyp size and recurrence after surgery 3
• Should be continued for at least 3 months to ensure adequate duration of therapy 1

Treatment Based on CRS Type

For CRS with Nasal Polyps:

1. Short course of oral corticosteroids (1-3 weeks) followed by maintenance with high-dose intranasal steroids 1, 3

   • More effective than topical steroids alone in decreasing polyp size and improving olfaction 1

2. Additional options:

   • Short course of doxycycline (3 weeks) - reduces polyp size for up to 3 months 3
   • Leukotriene antagonists - improve nasal symptoms 3

For CRS without Nasal Polyps:

1. Intranasal corticosteroids and saline irrigation remain first-line therapy 1, 3
2. Macrolide antibiotics (3-month course) may be considered
   • Associated with improved quality of life at 24 weeks after therapy 3

Management of Acute Exacerbations

For bacterial exacerbations of CRS:

• Amoxicillin-clavulanate is the first-line antibiotic treatment 1
• For penicillin-allergic patients, alternatives include:
  • Cefpodoxime proxetil
  • Cefuroxime axetil
  • Cefdinir
  • Trimethoprim-sulfamethoxazole 1
• Recommended duration: 10-14 days 1

When to Refer to a Specialist

Referral to an otolaryngologist is indicated for:

• CRS persisting for several months despite appropriate therapy
• Recurrent sinusitis
• Need for complex pharmacology for recalcitrant infections 1
• Patients with refractory CRS not responsive to first-line treatment 2
• Presence of alarm symptoms (orbital swelling/pain, forehead swelling, diplopia, visual changes, neurological symptoms) 1

Common Pitfalls to Avoid

1. Overuse of antibiotics for viral infections

   • Distinguish between viral rhinitis and bacterial sinusitis 1

2. Failure to recognize complications requiring urgent evaluation

   • Watch 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 require at least 3 months of continuous use 1

5. Overlooking environmental factors

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

Special Considerations

When using intranasal corticosteroids, special care should be taken in:

• Children
• Pregnant women
• Elderly patients
• Patients with comorbid conditions like asthma (where overall steroid intake may be high) 4

Surgical intervention, including balloon sinuplasty, may be considered for patients who have failed medical therapy and have objective evidence of sinus disease 1.