What is the treatment for sinusitis?

Treatment for Sinusitis

The first-line treatment for acute bacterial sinusitis in adults includes amoxicillin-clavulanate (1.75-4 g/250 mg per day) or high-dose amoxicillin (1.5-4 g/day), along with intranasal corticosteroids and nasal saline irrigations. 1

Medical Management of Sinusitis

Acute Sinusitis Treatment

1. Antimicrobial Therapy:

   • First-line: Amoxicillin-clavulanate (high dose) 1, 2
   • Alternative options for penicillin-allergic patients:
     • Cefpodoxime proxetil, cefuroxime axetil, or cefdinir 1, 3
     • For serious drug allergies: clarithromycin or azithromycin 3

2. Adjunctive Treatments:

   • Intranasal corticosteroids (e.g., fluticasone propionate) 1, 4
     • May provide relief starting from the first day of use 4
     • Requires regular daily use for full effectiveness 4
   • Nasal saline irrigations to improve mucociliary clearance 1
   • Symptomatic relief with analgesics and decongestants 5

Chronic Sinusitis Treatment

Defined as symptoms persisting >12 weeks:

1. Medical Management:

   • Intranasal corticosteroids as primary therapy 1, 6
   • Saline nasal irrigations 1, 6
   • For bacterial exacerbations: amoxicillin-clavulanate, clindamycin, or metronidazole plus penicillin 2
   • Long-term management may include antihistamines or mast cell stabilizers for allergic components 5

2. Surgical Management:

   • Indicated when medical treatment fails 1, 6
   • Functional Endoscopic Sinus Surgery (FESS) for:
     • CRS refractory to medical treatment (symptoms >12 weeks) 1
     • Complications of acute sinusitis (orbital or intracranial involvement) 1
     • Anatomic abnormalities contributing to sinus obstruction 1
     • CRS with nasal polyps refractory to medical treatment 1

Important Clinical Considerations

Diagnosis

• Acute bacterial sinusitis presents with:

  • Persistent symptoms (nasal symptoms/cough >10 but <30 days without improvement) 3
  • Severe symptoms (high fever and purulent nasal discharge for 3-4 consecutive days) 3
  • Worsening symptoms (respiratory symptoms that worsen after initial improvement) 3

• Chronic rhinosinusitis requires at least two of four cardinal symptoms for ≥12 weeks:

  • Facial pain/pressure
  • Hyposmia/anosmia
  • Nasal drainage
  • Nasal obstruction 6

Pathogens

• Acute sinusitis: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 2, 3
• Chronic sinusitis: Anaerobic bacteria and Staphylococcus aureus 2
• Immunocompromised patients: Consider Pseudomonas aeruginosa 2

Treatment Duration

• Continue antibiotics until the patient is symptom-free plus an additional 7 days 3
• Intranasal corticosteroids can be used for up to 6 months in patients ≥12 years or up to 2 months in children 4-11 years before physician reassessment 4

When to Refer

• Recurrent sinusitis (2-3 episodes per year despite appropriate treatment) 1
• Significant impact on quality of life 1
• Suspected immunologic or allergic basis 1
• Need for complex pharmacology for resistant pathogens 1
• Failed medical management requiring surgical evaluation 6
• Severe complications (intraorbital or intracranial sepsis) 5

Potential Side Effects and Complications

Medication Side Effects

• Fluticasone propionate nasal spray:
  • Rare serious side effects include allergic reactions (swelling, rash, wheezing) 4
  • More common side effects: headaches, sneezing, minor nosebleeds, dry/irritated nose or throat 4
  • Growth effects possible in children with prolonged use 4

Complications of Sinusitis

• Orbital complications
• Intracranial sepsis
• These potentially lethal complications require urgent evaluation with CT scanning, IV broad-spectrum antibiotics, and surgical drainage 5

Treatment Pitfalls

• Failure to recognize resistant pathogens (β-lactamase producing H. influenzae, M. catarrhalis, penicillin-resistant S. pneumoniae) 2
• Inadequate duration of antibiotic therapy 3
• Overlooking contributing factors like smoking, GERD, and asthma 1
• Neglecting to address underlying allergic or vasomotor components 5, 7