What are the treatment options for sinusitis?

Treatment Options for Sinusitis

For acute bacterial sinusitis, first-line treatment is amoxicillin for 10-14 days (continuing for 7 days after symptoms resolve), with alternative antibiotics such as amoxicillin-clavulanate or cefuroxime axetil if no improvement after 3-5 days. 1

Diagnosis of Sinusitis

Before initiating treatment, it's important to correctly diagnose sinusitis:

• Acute sinusitis: Symptoms lasting less than 4 weeks
• Subacute sinusitis: Symptoms lasting 4-8 weeks
• Chronic sinusitis: Symptoms lasting more than 8-12 weeks

Bacterial sinusitis is likely when:

• Symptoms persist ≥10 days beyond onset of upper respiratory symptoms
• Symptoms worsen within 10 days after initial improvement (double worsening)
• Severe symptoms with high fever and purulent nasal discharge for 3-4 consecutive days 1, 2

Treatment Algorithm for Acute Sinusitis

First-line treatments:

1. Antibiotics (for bacterial sinusitis):

   • Amoxicillin: First-line therapy for most adults
   • Duration: 10-14 days (continue for 7 days after patient is well) 1
   • Monitor response after 3-5 days of therapy 1

2. Nasal saline irrigation:

   • Prevents crust formation
   • Facilitates mechanical clearance of mucus
   • Improves mucociliary transport 1

3. Intranasal corticosteroids (e.g., fluticasone propionate):

   • Particularly helpful for patients with marked mucosal edema
   • May start providing relief on first day of use 1, 3
   • Can be used for up to 6 months in patients age 12+ or up to 2 months in children age 4-11 3

4. Decongestants:

   • Reduce inflammation and congestion
   • Limit use to short periods (5 days) due to potential side effects and rebound effect 1

Second-line/alternative treatments (if no improvement after 3-5 days):

• Amoxicillin-clavulanate (high-dose)
• Cefuroxime axetil
• For penicillin-allergic patients: cefpodoxime, cefdinir, clarithromycin, or azithromycin 1, 4

Treatment for Chronic Rhinosinusitis

1. First-line treatment:

   • Nasal saline irrigation
   • Intranasal corticosteroid sprays 5

2. Antibiotics (for active infections):

   • Amoxicillin-clavulanate
   • Clindamycin
   • Combination of metronidazole and a penicillin 6

3. Surgical intervention:

   • Consider when appropriate medical therapy fails
   • Endoscopic sinus surgery (ESS) provides:
     • Relief of nasal obstruction
     • Improved sinus ventilation and drainage
     • Enhanced delivery of topical medications 1

Special Considerations

• Asthma: May be initiated or worsened by sinusitis; consider chest auscultation and spirometry in patients with cough 1
• Nasal polyps: More common when sinusitis complicates allergic rhinitis 1, 7
• Children with nasal polyps: Consider evaluation for cystic fibrosis 1
• Immunocompromised patients: Consider Pseudomonas aeruginosa as potential pathogen 6

Monitoring and Follow-up

• Evaluate response to treatment after 3-5 days
• Consider changing antibiotics if no response
• Refer to specialist for:
  • Recurrent sinusitis
  • Lack of response to treatment
  • Presence of complications 1

Potential Pitfalls

1. Unnecessary imaging: Plain radiographs generally not necessary for diagnosis and have significant false-positive/negative results 1

2. Antibiotic overuse: Failure to distinguish viral rhinitis from bacterial sinusitis leads to unnecessary antibiotic use 1

3. Inadequate treatment duration: Can lead to relapse 1

4. Failure to recognize complications: Orbital or intracranial involvement can have serious consequences 1

5. Medication side effects:

   • Intranasal corticosteroids: Potential for minor nosebleeds, dry/irritated nose or throat
   • Decongestants: Rebound effect with prolonged use (>5 days) 1, 3