Treatment of Chronic Sinusitis
The recommended first-line treatment for chronic sinusitis includes daily high-volume saline irrigation and intranasal corticosteroids, with antibiotics reserved for acute bacterial exacerbations. 1, 2
Definition and Classification
Chronic sinusitis is defined as inflammation of the paranasal sinuses lasting for at least 3 consecutive months, characterized by at least two cardinal symptoms:
- Nasal blockage/obstruction/congestion
- Anterior or posterior nasal drainage
- Facial pain or pressure
- Reduced sense of smell (hyposmia)
It can be categorized as:
- With or without nasal polyps
- Primary or secondary (due to underlying conditions)
First-Line Treatment
1. Saline Nasal Irrigation
- Helps clear mucus and reduce inflammation
- Safe for prolonged use
- Significantly improves symptom scores compared to no treatment 2
- Should be performed with high-volume saline solution daily
2. Intranasal Corticosteroids
- Essential for reducing inflammation
- Improves overall symptom scores and polyp scores 2
- Reduces polyp recurrence after surgery
- Should be continued for at least 3 months after symptoms resolve 3
Treatment for Acute Bacterial Exacerbations
When chronic sinusitis has an acute bacterial exacerbation (worsening symptoms with evidence of infection), antibiotics may be indicated:
Antibiotic Options:
First-line choice: Amoxicillin-clavulanate
For penicillin allergies:
- 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
For severe penicillin allergies:
- Levofloxacin: 500 mg once daily for 5-7 days
- Doxycycline: standard adult dosing for 5-7 days 1
Alternative option: Azithromycin
- Dosage: 500 mg daily for 3 days 5
- Note: Increasing resistance patterns may limit effectiveness
Additional Treatments Based on Polyp Status
For Chronic Sinusitis WITH Nasal Polyps:
Short course of systemic corticosteroids (1-3 weeks) 2
- Reduces polyp size for up to 3 months after treatment
Short course of doxycycline (3 weeks) 2
- Also shown to reduce polyp size for up to 3 months
Leukotriene antagonists 2
- Improves nasal symptoms in patients with polyps
For Chronic Sinusitis WITHOUT Nasal Polyps:
- Prolonged course of macrolide antibiotics (3 months) 2
- Associated with improved quality of life at 24 weeks after therapy
- Should be considered for refractory cases not responding to first-line therapy
Management of Chronic Sinusitis Exacerbations
For acute exacerbations of chronic sinusitis:
- Intensify saline irrigation and intranasal corticosteroids
- Consider short course of appropriate antibiotics (as listed above)
- Add oral decongestants for short-term use (5 days maximum) 3
- Caution with side effects: insomnia, urinary difficulties, jitteriness, tachycardia, hypertension
When to Refer to a Specialist
Refer to an otolaryngologist when:
- Symptoms persist despite appropriate medical therapy
- Anatomical obstruction is suspected
- Patient has nasal polyps that may benefit from surgical intervention 3, 6
- Alarm symptoms are present
- Considering biologic therapy for patients with comorbid conditions (asthma, atopic dermatitis, eosinophilic esophagitis) 6
Common Pitfalls to Avoid
- Overuse of antibiotics: Reserve for true bacterial exacerbations, not routine management of chronic sinusitis
- Prolonged use of decongestants: Can lead to rhinitis medicamentosa; limit to 5 days 3
- Inadequate duration of intranasal corticosteroids: Should be continued for 3 months after symptoms resolve 3
- Failure to identify and address environmental triggers: Avoidance of irritants is an important part of management 3
- Missing underlying conditions: Allergic rhinitis, immunodeficiency, and anatomical abnormalities should be identified and treated 1
By following this treatment approach, most patients with chronic sinusitis can achieve significant symptom improvement and better quality of life.