What is the treatment for sinusitis?

Treatment of Sinusitis

The first-line treatment for acute bacterial sinusitis in adults is amoxicillin-clavulanate or high-dose amoxicillin, along with intranasal corticosteroids and nasal saline irrigations. 1

Acute Sinusitis Management

Medical Treatment

1. Antimicrobial Therapy (for acute bacterial sinusitis):

   • First-line options:
     • Amoxicillin-clavulanate (1.75-4 g/250 mg per day) or
     • High-dose amoxicillin (1.5-4 g/day) for 10-14 days 2, 1
   • Alternative options (especially for penicillin-allergic patients):
     • Cefpodoxime proxetil, cefuroxime axetil, or cefdinir 1
     • Trimethoprim-sulfamethoxazole or macrolide/sulfonamide combinations 2

2. Adjunctive Therapy:

   • Intranasal corticosteroids (e.g., fluticasone propionate) 1, 3
     • Adult dosing: 200 mcg once daily (two 50-mcg sprays in each nostril) or 100 mcg twice daily 3
   • Nasal saline irrigations to improve mucociliary clearance 1
   • Decongestants (oral or topical) to facilitate drainage 2, 4

When to Suspect Acute Bacterial Sinusitis

• Persistent symptoms (nasal symptoms or cough for >10 but <30 days without improvement)
• Severe symptoms (high fever and purulent nasal discharge for 3-4 consecutive days)
• Worsening symptoms (respiratory symptoms that worsen after initial improvement) 5

Chronic Sinusitis Management

Medical Treatment

1. First-line therapy:

   • Nasal saline irrigation
   • Intranasal corticosteroid sprays 6

2. Antimicrobial options (if indicated):

   • Amoxicillin-clavulanate
   • Clindamycin
   • Combination of metronidazole and a penicillin 7

3. Long-term management for underlying conditions:

   • For allergic rhinitis: topical corticosteroids, antihistamines, or mast cell stabilizers 4
   • Address contributing factors: smoking cessation, GERD management, asthma control 1

Surgical Management

• Indicated when medical management fails after 12 weeks of symptoms 6
• Functional endoscopic sinus surgery (FESS) is the preferred approach 1
• Conservative approach tailored to the extent of disease 1
• Postoperative continuation of medical therapy is essential 1

Special Considerations

Pediatric Patients

• Children (4 years and older): Start with fluticasone 100 mcg (1 spray in each nostril once daily)
• Increase to 200 mcg only if inadequate response
• Maximum daily dose: 200 mcg 3

Microbiology

• Acute sinusitis: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis 7, 5
• Chronic sinusitis: Anaerobic bacteria and Staphylococcus aureus predominate 7
• Pseudomonas aeruginosa in immunocompromised patients 7

Common Pitfalls

1. Inadequate duration of antibiotic therapy:

   • Continue treatment until the patient is symptom-free plus an additional 7 days 5

2. Failure to recognize bacterial resistance:

   • Be aware of increasing prevalence of beta-lactamase-producing organisms and penicillin-resistant S. pneumoniae 7, 5

3. Missing complications:

   • Watch for orbital or intracranial involvement requiring urgent evaluation and specialist referral 1, 4

4. Overlooking contributing factors:

   • Allergic rhinitis, anatomical variants, and immunodeficiency can predispose to chronic sinusitis 4, 6

5. Inappropriate use of antibiotics:

   • Not all sinusitis cases require antibiotics, particularly those of viral etiology 6

When to Refer

• Recurrent sinusitis (2-3 episodes per year despite appropriate treatment)
• Significant impact on quality of life
• Suspected immunologic or allergic basis
• Need for complex pharmacology for resistant pathogens 1