What is the treatment for chronic sinusitis?

Treatment for Chronic Sinusitis

The first-line treatment for chronic sinusitis should include saline nasal irrigation and topical intranasal corticosteroids, which have demonstrated significant benefits for symptom relief with minimal adverse effects. 1

Classification and Diagnosis

Chronic sinusitis (or chronic rhinosinusitis - CRS) is defined as inflammation of the nasal and paranasal sinuses lasting longer than 3 months, characterized by:

• At least two cardinal symptoms: nasal blockage/obstruction, nasal drainage, facial pain/pressure, or reduced sense of smell
• Objective evidence of inflammation on nasal endoscopy or imaging

CRS can be classified as:

• With or without nasal polyps (important treatment modifier)
• Primary or secondary (based on underlying causes)

First-Line Treatment

Saline Irrigation

• Improves symptom scores compared to no treatment
• Enhances mucociliary clearance
• Prevents crust formation
• Hypertonic solutions may be more effective than isotonic solutions

Intranasal Corticosteroids

• Significantly improves overall symptom scores
• Particularly effective for reducing polyp size in CRS with polyps
• Reduces polyp recurrence after surgery
• Low risk of systemic side effects

Second-Line Treatments

For CRS with Nasal Polyps

1. Short course of systemic corticosteroids (1-3 weeks)

   • Reduces polyp size for up to 3 months after treatment
   • Monitor for side effects including insomnia, mood changes, and increased blood pressure

2. Short course of doxycycline (3 weeks)

   • Reduces polyp size for up to 3 months after treatment
   • Side effects include photosensitivity and gastrointestinal symptoms

3. Leukotriene antagonists

   • Improves nasal symptoms in patients with polyps
   • Consider especially in patients with comorbid asthma

For CRS without Nasal Polyps

• Macrolide antibiotics (3-month course)
  • May improve quality of life at 24 weeks after therapy
  • Consider for patients who fail first-line therapy

Antibiotic Therapy for Acute Exacerbations

For acute bacterial exacerbations of chronic sinusitis:

• First-line: Amoxicillin-clavulanate (1.75-4g/250mg per day) or high-dose amoxicillin (1.5-4g/day) 2
• Alternatives: Cefpodoxime proxetil, cefuroxime axetil, or cefdinir
• For resistant cases: Consider azithromycin (500mg daily for 3 days) 3

Treatment duration should be 10-14 days for most patients with acute exacerbations 1

Decongestants

• Topical and oral decongestants may theoretically increase ostial patency and reduce turbinate swelling
• However, prospective studies are lacking to assess their value in chronic sinusitis 1
• Caution with topical decongestants: limit use to 3-5 days to avoid rebound congestion (rhinitis medicamentosa)
• Oral decongestants may cause side effects including increased blood pressure, insomnia, and urinary retention

Antifungal Therapy

Clinicians should NOT prescribe topical or systemic antifungal therapy for patients with CRS due to lack of efficacy and potential adverse effects 1

Surgical Management

Consider referral for surgical evaluation when:

• Patient has failed appropriate medical management
• Symptoms persist despite 8-12 weeks of medical therapy
• Anticipated benefits exceed nonsurgical management alone 2

Functional endoscopic sinus surgery (FESS) aims to:

• Improve sinus drainage and ventilation
• Remove diseased tissue
• Provide better access for topical medications post-surgery

Common Pitfalls to Avoid

1. Overuse of antibiotics - Reserve for acute bacterial exacerbations with clear evidence of infection
2. Prolonged use of topical decongestants - Can lead to rebound congestion
3. Inadequate duration of treatment - Chronic sinusitis requires consistent long-term management
4. Failure to identify nasal polyps - Their presence significantly affects treatment approach
5. Neglecting comorbid conditions - Asthma, allergies, and immunodeficiencies can exacerbate CRS
6. Inappropriate use of antihistamines - Limited evidence for benefit in non-allergic CRS

Special Considerations

• Allergic rhinitis: Consider additional treatment with antihistamines if underlying allergy is present 4
• Asthma: CRS can worsen asthma symptoms; treating sinusitis may improve asthma control 2
• Nasal polyps: More aggressive treatment approach needed, including consideration of systemic corticosteroids and potential surgical intervention

By following this evidence-based approach to chronic sinusitis management, clinicians can effectively improve symptoms, reduce inflammation, and enhance patients' quality of life while minimizing unnecessary treatments and potential adverse effects.