Treatment of Maxillary Sinus Disease
For acute bacterial maxillary sinusitis, amoxicillin-clavulanate is the first-line antibiotic treatment, with recommended dosage of 875/125 mg twice daily for 5-7 days. 1
Diagnosis and Classification
Acute bacterial maxillary sinusitis is characterized by:
- Persistent symptoms (>10 days without improvement)
- Severe symptoms (high fever and purulent nasal discharge for 3-4 consecutive days)
- Worsening symptoms after initial improvement
- Unilateral or bilateral infraorbital pain that increases when head is bent forward
- Purulent nasal discharge (anterior and/or posterior, often unilateral)
Treatment Algorithm
First-Line Antibiotic Therapy
- Amoxicillin-clavulanate (875/125 mg twice daily for 5-7 days) 1
- High-dose option (2000 mg amoxicillin component with 125 mg clavulanate twice daily) for areas with high prevalence of resistant S. pneumoniae 1
Alternative Antibiotics (for penicillin allergic patients)
- Second and third generation cephalosporins:
- Respiratory fluoroquinolones (for severe infections):
- Levofloxacin (500 mg once daily)
- Moxifloxacin (400 mg once daily) 1
Treatment Failure
If symptoms persist or worsen after 72 hours of initial therapy:
- Switch to broader-spectrum antibiotic based on initial treatment
- Consider respiratory fluoroquinolones 1
Adjunctive Therapies
These therapies help improve symptoms and promote drainage:
- Intranasal corticosteroids - reduce inflammation, particularly beneficial for patients with concurrent allergic rhinitis 1
- Saline nasal irrigation - helps clear mucus and reduce inflammation 1
- Nasal decongestants - can be used for up to 5 days to reduce congestion (caution: risk of rhinitis medicamentosa with prolonged use) 1
Special Considerations
Dental Origin
For unilateral maxillary sinusitis associated with an upper unilateral dental infection, antibiotic therapy is specifically indicated 2
Complicated Sinusitis
Signs of complicated sinusitis requiring hospitalization, bacteriological testing, and parenteral antibiotic therapy include:
- Meningeal syndrome
- Exophthalmos
- Palpebral edema
- Ocular mobility disorders
- Severe pain preventing sleep 2
Evidence Quality and Considerations
The recommendation for amoxicillin-clavulanate is supported by multiple guidelines and research. A randomized controlled trial showed that amoxicillin-clavulanate given every 12 hours (875/125 mg) is as effective and safe as administration every 8 hours (500/125 mg) for acute bacterial maxillary sinusitis, with clinical success rates of 93% and 88% respectively 3.
The Cochrane review on antibiotics for acute maxillary sinusitis confirmed that for radiographically confirmed acute maxillary sinusitis, penicillin or amoxicillin for 7-14 days is supported by evidence, though benefits must be weighed against potential adverse effects 4.
When comparing clarithromycin with amoxicillin-clavulanate, clinical success rates were similar (97% vs 93%), but amoxicillin-clavulanate caused more gastrointestinal side effects (38% vs 21%) 5.
Common Pitfalls to Avoid
Overuse of antibiotics: Not all sinus symptoms require antibiotics. Antibiotics are not indicated when nasal symptoms remain diffuse, bilateral, and of moderate intensity in an epidemic context 2
Inadequate duration: While shorter courses (5-7 days) are now recommended, premature discontinuation can lead to treatment failure
Ignoring dental causes: Always evaluate for dental infection in unilateral maxillary sinusitis 2
Prolonged decongestant use: Using nasal decongestants beyond 5 days can lead to rebound congestion (rhinitis medicamentosa) 1
Missing complications: Be vigilant for signs of complicated sinusitis requiring more aggressive management 2