What is the treatment for sinusitis?

Treatment of Sinusitis

The first-line treatment for acute bacterial sinusitis is amoxicillin-clavulanate, with a recommended duration of 10-14 days for acute disease, while chronic sinusitis requires a comprehensive approach including antibiotics, intranasal corticosteroids, and saline irrigation for at least 6 weeks. 1

Diagnosis and Classification

Sinusitis can be classified based on duration of symptoms:

• Acute sinusitis: Symptoms lasting up to 4 weeks
• Subacute sinusitis: Symptoms lasting 1-3 months
• Chronic sinusitis: Symptoms lasting 3 months or more 2, 1

Common symptoms include:

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

Treatment of Acute Bacterial Sinusitis

First-line Antibiotic Therapy

• Mild disease (no antibiotics in previous 4-6 weeks):

  • Amoxicillin-clavulanate (1.75-4g/250mg per day)
  • Amoxicillin (1.5-4g/day)
  • Cefpodoxime proxetil, cefuroxime axetil, or cefdinir 2, 1

• Moderate disease or recent antibiotic use (within 4-6 weeks):

  • High-dose amoxicillin-clavulanate (4g/250mg per day)
  • Respiratory fluoroquinolones (gatifloxacin, levofloxacin, moxifloxacin) 2
  • Note: Fluoroquinolones should be reserved for more severe cases to prevent resistance 2

For Penicillin-Allergic Patients

• Trimethoprim-sulfamethoxazole (TMP/SMX)
• Doxycycline
• Macrolides (azithromycin, clarithromycin)
• Respiratory fluoroquinolones 2, 3
  • Note: Higher bacteriologic failure rates (20-25%) may occur with these alternatives 2

Duration of Therapy

• Standard duration: 10-14 days for acute sinusitis 2, 1
• Newer antibiotics may allow shorter courses 2
• Levofloxacin is FDA-approved for 5-day treatment at 750mg daily or 10-14 days at 500mg daily 4

Adjunctive Therapies

• Intranasal corticosteroids to reduce inflammation 2, 1
• Saline irrigation to facilitate mucus removal 1
• Decongestants (oral or topical) for symptomatic relief 2
• Analgesics for pain management 5

Treatment of Chronic Sinusitis

Comprehensive Approach

1. Antibiotics:

   • May require longer duration of therapy
   • Consider coverage for anaerobic pathogens in chronic infectious sinusitis 2

2. Anti-inflammatory therapy:

   • Intranasal corticosteroids for at least 6 weeks 1
   • Systemic corticosteroids may be considered for chronic non-infectious sinusitis or nasal polyps 2, 1

3. Saline irrigation:

   • Recommended for 6 weeks to prevent crusting and facilitate mucus removal 1

4. Address underlying conditions:

   • Allergic rhinitis: Antihistamines, mast cell stabilizers 5
   • Gastroesophageal reflux disease (GERD) if present 2
   • Immunodeficiency evaluation in recurrent cases 2, 1

Surgical Intervention

• Consider when maximal medical therapy fails after 6 weeks 1
• Goals: Improve ventilation and drainage of sinuses 5
• Options include:
  • Functional endoscopic sinus surgery
  • Balloon sinus dilation (in appropriate cases) 1

Special Considerations

Warning Signs Requiring Urgent Evaluation

• Orbital swelling/pain
• Forehead swelling
• Visual changes
• Neurological symptoms 1

Common Pitfalls to Avoid

1. Overuse of antibiotics for viral infections:

   • Most cases of acute sinusitis are viral in origin
   • Reserve antibiotics for symptoms lasting >10 days, severe symptoms, or worsening pattern 2, 3

2. Inadequate duration of therapy:

   • Premature discontinuation can lead to treatment failure
   • Complete the full course of antibiotics 3

3. Failure to address underlying conditions:

   • Allergic rhinitis, nasal polyps, and anatomical variants can predispose to chronic sinusitis 5, 6

4. Delayed referral:

   • Consider specialist referral for:
     • Recurrent sinusitis
     • Failed medical therapy
     • Complications
     • Suspected immunodeficiency 2, 1

By following this structured approach to sinusitis treatment, focusing on appropriate antibiotic selection, adequate duration of therapy, and addressing underlying factors, optimal outcomes can be achieved for both acute and chronic cases.