What is the treatment for chronic sinusitis?

Treatment of Chronic Sinusitis

The first-line treatment for chronic sinusitis should be saline nasal irrigation and topical intranasal corticosteroids. 1

Definition and Classification

Chronic sinusitis (also called chronic rhinosinusitis or CRS) is defined as inflammation of the nasal and paranasal sinuses lasting more than 12 weeks, characterized by:

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

CRS is classified as:

• With or without nasal polyps
• Primary or secondary (due to underlying conditions)

First-Line Medical Management

Topical Therapy

• Saline nasal irrigation: Recommended for all patients with CRS to improve mucociliary clearance and reduce crusting 1

  • Use high-volume isotonic saline solutions
  • Helps remove inflammatory mediators and improves sinus drainage

• Intranasal corticosteroids: Essential for reducing mucosal inflammation 1

  • Options include mometasone furoate, fluticasone propionate, beclomethasone dipropionate
  • Demonstrated to improve overall symptom scores and reduce polyp size
  • Should be continued long-term as maintenance therapy

Management Based on Polyp Status

For CRS with Nasal Polyps:

1. Short-course systemic corticosteroids (1-3 weeks) 2

   • Effectively reduces polyp size for up to 3 months after treatment
   • Use with caution due to systemic side effects

2. Short-course doxycycline (3 weeks) 2

   • Can reduce polyp size for up to 3 months
   • Alternative to systemic steroids

3. Leukotriene antagonists 2

   • May improve nasal symptoms in patients with polyps
   • Consider as adjunctive therapy

For CRS without Nasal Polyps:

1. Macrolide antibiotics (3-month course) 2
   • May improve quality of life
   • Consider for patients without polyps who fail first-line therapy

Antibiotic Therapy for Acute Exacerbations

For acute bacterial exacerbations of CRS, consider:

• Amoxicillin-clavulanate (first-line) 3, 4

  • Dosage: 1.75-4g/250mg per day
  • Duration: 10-14 days or until symptom-free plus 7 days 1

• Alternative antibiotics if no improvement after 3 days: 3

  • Cefpodoxime proxetil
  • Cefuroxime axetil
  • Cefdinir
  • Ciprofloxacin (shown to be as effective as amoxicillin/clavulanate with fewer GI side effects) 5

Role of Decongestants and Antihistamines

• Decongestants: May temporarily improve sinus and nasal ventilation 1

  • Use should be limited (≤5 days for topical) to avoid rebound congestion
  • Caution with hypertension, glaucoma, urinary retention, and insomnia

• Antihistamines: Not recommended for routine treatment of CRS 1

  • May have a role only if the underlying risk factor is allergic rhinitis 1
  • First-generation antihistamines may cause sedation 1

Antifungal Therapy

• Antifungal therapy is not recommended for patients with CRS 1
  • Systematic reviews show lack of efficacy
  • Potential for adverse effects and unnecessary cost

When to Consider Surgical Management

Functional endoscopic sinus surgery (FESS) should be considered when: 3

• CRS is refractory to appropriate medical treatment
• Symptoms persist >12 weeks despite maximal medical therapy
• Complications of acute sinusitis occur (orbital or intracranial involvement)
• Anatomic abnormalities contribute to sinus obstruction

Common Pitfalls in CRS Management

1. Overuse of antibiotics without clear evidence of bacterial infection
2. Prolonged use of topical decongestants leading to rhinitis medicamentosa
3. Inadequate duration of intranasal corticosteroid therapy
4. Failure to identify and treat underlying conditions (allergies, immunodeficiencies)
5. Inappropriate use of antihistamines in non-allergic CRS
6. Inadequate technique with nasal irrigation reducing effectiveness

Follow-up and Monitoring

• Assess symptom relief, quality of life, and adherence to therapy
• Monitor for complications and need for rescue medications
• Consider referral to specialist if symptoms persist despite appropriate therapy

Remember that chronic sinusitis often requires long-term management strategies, and patient education about proper medication administration techniques is crucial for treatment success.