What is the treatment for acute maxillary sinusitis?

Treatment of Acute Maxillary Sinusitis

Amoxicillin-clavulanate is the first-line treatment for acute maxillary sinusitis, with a recommended dosage of 875/125 mg twice daily for 5-7 days, supplemented by adjunctive therapies such as intranasal corticosteroids and saline irrigation. 1

Diagnosis Criteria

Before initiating treatment, confirm the diagnosis of acute bacterial rhinosinusitis (ABRS) when one of the following patterns is present:

• Persistent symptoms: Nasal discharge or cough for >10 days without improvement
• Severe symptoms: Fever ≥102.2°F (39°C) with purulent nasal discharge for ≥3 consecutive days
• Worsening symptoms: Initial improvement followed by worsening nasal discharge, cough, or fever 1

Antibiotic Therapy

First-line Treatment

• Amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days 1
• In areas with high resistance patterns, consider high-dose formulation (2000/125 mg twice daily) 1

Alternative Options for Penicillin-Allergic Patients

• Cephalosporins (if no history of anaphylaxis to penicillin):
  • Cefdinir: 300-600 mg twice daily for 5-7 days
  • Cefuroxime: 250-500 mg twice daily for 5-7 days
  • Cefpodoxime: 200-400 mg twice daily for 5-7 days 1
• Fluoroquinolones (reserve for patients who cannot take other antibiotics):
  • Levofloxacin: 750 mg once daily for 5 days 1, 2
  • Moxifloxacin: 400 mg once daily for 5-7 days 1

Adjunctive Therapies

These therapies help reduce inflammation and promote drainage:

1. Intranasal corticosteroids (e.g., mometasone furoate nasal spray)

   • Particularly beneficial for patients with concurrent allergic rhinitis
   • Reduces inflammation and promotes drainage 1

2. Saline nasal irrigation

   • Helps clear mucus and reduce inflammation
   • Safe for prolonged use 1

3. Nasal decongestants

   • Use for up to 5 days only to reduce congestion
   • Caution: risk of rhinitis medicamentosa with prolonged use 1

Monitoring and Follow-up

• Assess for clinical improvement within 72 hours of starting antibiotics
• If no improvement after 72 hours, consider switching to a broader-spectrum antibiotic 1
• For persistent symptoms beyond 3 weeks despite appropriate therapy, consider:
  • Referral to an otolaryngologist
  • Imaging studies (CT scan) to evaluate for anatomical variants or complications 1

Special Considerations

Dental Origin

• Evaluate for dental infection in unilateral maxillary sinusitis 1
• If dental origin is suspected, high-dose amoxicillin-clavulanate is particularly recommended 1

Warning Signs for Complications

Immediate referral is needed for:

• Orbital involvement (exophthalmos, palpebral edema, ocular mobility disorders)
• Severe pain preventing sleep
• Persistent fever despite appropriate therapy
• Meningeal syndrome 1

Treatment Efficacy Comparison

Clinical studies have shown comparable efficacy between different treatment regimens:

• Amoxicillin-clavulanate given every 12 hours is as effective as administration every 8 hours 3
• Cefuroxime axetil 250 mg twice daily shows similar efficacy to amoxicillin-clavulanate but with fewer gastrointestinal side effects 4
• Short-course (5-day) therapy with newer fluoroquinolones can be as effective as standard 10-day regimens 2, 5

Remember that antibiotic selection should consider local resistance patterns, and adjunctive therapies are essential components of effective treatment for acute maxillary sinusitis.