What is the treatment for recurring sinusitis?

Treatment of Recurring Sinusitis

For recurring sinusitis, a stepwise approach is recommended with initial medical management including antibiotics, intranasal corticosteroids, and saline irrigation, followed by surgical intervention if medical therapy fails. 1

Diagnosis and Evaluation

Before initiating treatment, proper diagnosis is essential:

• Chronic sinusitis is defined as inflammation of the paranasal sinuses with symptoms lasting ≥8 weeks 1
• CT scan is the gold standard for diagnosis, particularly for recurrent cases 1
• Consider testing for underlying conditions in recurrent cases:
  • Immunodeficiency
  • Cystic fibrosis (especially in children with nasal polyps)
  • Ciliary dysfunction 2, 1

Medical Management

First-Line Treatment

1. Antibiotics:

   • For acute bacterial exacerbations: Amoxicillin as first-line therapy 1, 3
   • For chronic/recurrent cases: Amoxicillin-clavulanate (high dose) is most effective 4
   • Duration: 10-14 days (continue for 7 days after symptoms resolve) 1
   • If no improvement in 3-5 days, switch antibiotics 2, 1

2. Intranasal Corticosteroids:

   • Reduce inflammation and facilitate drainage
   • Particularly beneficial as adjunct to antibiotics in recurrent cases 2, 1

3. Saline Irrigation:

   • Improves mucociliary clearance
   • Prevents crust formation
   • Particularly helpful after surgical intervention 1

Adjunctive Therapies

• Decongestants: Use for short periods only (≤5 days) to reduce congestion 1
• Mucolytics/Expectorants: May provide symptomatic benefit in selected cases 2
• Antihistamines: Consider if allergic component is present 2, 5

Surgical Management

Consider surgical intervention when:

1. Medical therapy fails despite adequate trials (multiple courses of appropriate antibiotics) 2, 1
2. Nasal polyps obstruct sinus drainage despite medical treatment 2
3. Anatomic defects exist that obstruct sinus outflow tract 2

Surgical options:

• Functional endoscopic sinus surgery (ESS) is the contemporary approach for most cases 1
• Open surgical procedures may be required depending on extent and location of disease 2

Management of Associated Conditions

1. Allergic Rhinitis:

   • Common trigger for recurrent sinusitis
   • Management includes allergen avoidance, antihistamines, and immunotherapy if appropriate 2, 5

2. Asthma:

   • Often worsened by sinusitis
   • Treating sinusitis can improve asthma symptoms 2, 6

3. Gastroesophageal Reflux Disease (GERD):

   • Consider GERD treatment in recurrent cases as it may contribute to sinusitis 2

Indications for Specialist Referral

Refer to a specialist when:

• Condition interferes with quality of life or causes significant loss of work/school
• Complications develop (e.g., orbital involvement)
• Sinusitis becomes chronic or recurs 2-3 times per year despite treatment
• Immunologic or allergic basis is suspected
• Complex pharmacology is needed for resistant pathogens 2, 1

Common Pitfalls to Avoid

• Overuse of antibiotics: Distinguish viral from bacterial causes before prescribing 1, 7
• Inadequate duration of therapy: Can lead to relapse 1
• Relying solely on symptoms: Imaging may be necessary to confirm diagnosis in recurrent cases 1
• Failure to identify complications: Such as orbital or intracranial involvement 1
• Overlooking contributing factors: Such as smoking, which can significantly worsen long-term outcomes 2