What is the treatment for sinusitis?

Treatment for Sinusitis

The primary treatment for acute bacterial sinusitis is antibiotics, with amoxicillin-clavulanate being the most effective first-line option, accompanied by intranasal corticosteroids and nasal saline irrigations. 1

Types of Sinusitis and Diagnosis

Sinusitis can be classified as:

• Acute sinusitis: Symptoms lasting less than 4 weeks
• Chronic sinusitis: Symptoms persisting for 12 weeks or longer

Diagnosis should be based on:

• At least 2 of 4 cardinal symptoms: facial pain/pressure, hyposmia/anosmia, nasal drainage, and nasal obstruction 2
• Appropriate criteria for antibiotic use include symptoms lasting 10-14 days or severe symptoms with fever, purulent nasal discharge, facial pain/tenderness, and periorbital swelling 3
• CT scan is the imaging technique of choice when symptoms are vague, physical findings are equivocal, or disease persists despite optimal therapy 3

Treatment Algorithm for Acute Bacterial Sinusitis

First-line Treatment:

1. Antibiotics:

   • Amoxicillin-clavulanate (high dose) is the most effective first-line antibiotic 1, 4
   • Duration: 10-14 days for acute disease, though shorter courses may be appropriate for newer antibiotics 3
   • If no improvement in 3-5 days, consider an alternative antibiotic 3

2. Adjunctive Therapies:

   • Intranasal corticosteroids (e.g., fluticasone) 1, 5
   • Saline nasal irrigation to improve mucociliary clearance 1, 6
   • Decongestants (oral or topical) may provide symptomatic relief 3

Alternative Antibiotics (for penicillin-allergic patients):

• Cephalosporins: cefuroxime, cefpodoxime, cefdinir 1, 7
• For serious drug allergies: clarithromycin or azithromycin 7

Treatment for Chronic Sinusitis

Medical Management:

1. Daily high-volume saline irrigation with topical corticosteroids as first-line therapy 6

2. Antibiotics:

   • Role is controversial in chronic sinusitis 3
   • For chronic infectious sinusitis, longer duration may be required with attention to anaerobic pathogens 3
   • Macrolide antibiotics for 3 months may improve quality of life in patients without polyps 6

3. Systemic Corticosteroids:

   • Consider for chronic non-infectious sinusitis (chronic hyperplastic sinusitis) 3
   • Short course (1-3 weeks) beneficial for patients with nasal polyps 6

4. Other Therapies:

   • Leukotriene antagonists may improve nasal symptoms in patients with polyps 6
   • Short course of doxycycline (3 weeks) may reduce polyp size 6

Surgical Management:

• Consider when medical therapy fails 1
• Functional endoscopic sinus surgery (FESS) is indicated for patients who:
  • Have failed appropriate medical management
  • Have persistent symptoms despite 8-12 weeks of medical therapy
  • Have objective evidence of disease on CT scan 1

Special Considerations

Associated Conditions:

• Allergic rhinitis: Common complication that can lead to sinusitis 8
• Asthma: May be triggered or worsened by sinusitis; treatment of sinusitis can improve asthma symptoms 1, 8
• GERD: Consider treatment in recurrent cases as it may contribute to sinusitis 1
• Nasal polyps: More common when sinusitis complicates allergic rhinitis 8

When to Refer to a Specialist:

• When condition interferes with quality of life or causes significant loss of work/school
• When complications develop (e.g., orbital involvement)
• For patients with suspected immunologic or allergic basis
• For recurrent sinusitis (2-3 episodes per year despite appropriate treatment) 1

Common Pitfalls and Caveats

1. Overdiagnosis and unnecessary antibiotic use: Ensure appropriate criteria for antibiotic use are met 3

2. Inadequate duration of therapy: Complete the full course of antibiotics even if symptoms improve 7

3. Failure to address contributing factors: Consider allergies, immunodeficiency, cystic fibrosis, or GERD 1

4. Overlooking complications: Be vigilant for orbital or intracranial involvement 1

5. Inadequate follow-up: Postoperative follow-up should occur between 3-12 months to assess symptom relief, quality of life, and complications 1