What is the treatment for sinusitis?

Treatment of Sinusitis

The first-line treatment for sinusitis includes amoxicillin-clavulanate (1.75-4 g/250 mg per day) or high-dose amoxicillin (1.5-4 g/day), intranasal corticosteroids, and nasal saline irrigations, with treatment approaches differing based on whether the condition is acute or chronic. 1

Acute Sinusitis Treatment

Medical Management

1. Antibiotics (for bacterial sinusitis):

   • First-line: Amoxicillin-clavulanate or high-dose amoxicillin 1
   • Alternatives for penicillin-allergic patients: Cefpodoxime proxetil, cefuroxime axetil, or cefdinir 1
   • Duration: Continue until symptom-free plus an additional 7 days 2

2. Adjunctive treatments:

   • Intranasal corticosteroids (e.g., fluticasone propionate) 1, 3
     • May provide relief starting from first day of use
     • Requires regular daily use for full effectiveness 3
   • Nasal saline irrigations (hypertonic solution may be more effective) 1
   • Oral decongestants 4

When to Suspect Bacterial Sinusitis

• Symptoms persisting >10 days without improvement
• Severe symptoms (high fever and purulent nasal discharge for 3-4 consecutive days)
• Worsening symptoms after initial improvement 2

Chronic Sinusitis Treatment (symptoms >8-12 weeks)

First-line Medical Management

1. Nasal saline irrigation 5
2. Intranasal corticosteroid sprays 5
3. Antibiotics only if evidence of active, superimposed acute infection 5

Surgical Management

• Consider functional endoscopic sinus surgery (FESS) for patients who:

  • Have failed 8-12 weeks of appropriate medical management
  • Have persistent symptoms despite medical therapy
  • Show objective evidence of disease on CT scan 1

• Benefits of surgery include:

  • Improved sinus drainage and ventilation
  • Removal of diseased tissue
  • Better access for topical medications post-surgery
  • Reduction in symptoms and improved quality of life 1

Treatment Based on Sinusitis Type

Chronic Rhinosinusitis with Nasal Polyps

• More aggressive medical management with intranasal corticosteroids 5, 4
• Consider surgical intervention if medical management fails 1

Allergic Fungal Rhinosinusitis

• Requires specialized management and often surgical intervention 5

Important Considerations and Pitfalls

Comorbidities to Address

• Asthma: Sinusitis can initiate or worsen asthma; consider chest auscultation and spirometry in patients with cough 1
• Allergic rhinitis: Common contributor to sinusitis 6
• GERD: Consider treatment in recurrent cases 1
• Nasal polyps: More common when sinusitis complicates allergic rhinitis 6

When to Refer to a Specialist

• Recurrent sinusitis (2-3 episodes per year despite appropriate treatment)
• Significant impact on quality of life
• Suspected complications (orbital or intracranial involvement)
• Suspected immunologic or allergic basis
• Need for complex pharmacology for resistant pathogens
• Failure to respond to first-line medical therapy 1, 5

Common Pitfalls

• Failing to recognize contributing factors like smoking, which can worsen long-term outcomes 1
• Overlooking potential complications like orbital or intracranial involvement 1
• In children with nasal polyps, failing to consider evaluation for cystic fibrosis 1
• Overuse of antibiotics for viral sinusitis (most acute sinus infections are viral) 4

Monitoring and Follow-up

• Assess response to symptoms after 3-5 days of antibiotic therapy 4
• For chronic sinusitis, follow-up between 3-12 months to assess:
  • Symptom relief
  • Quality of life
  • Complications
  • Adherence to therapy
  • Need for rescue medications 1