What are the treatment options for chronic sinusitis?

Management of Chronic Sinusitis

The first-line treatment for chronic sinusitis should be saline nasal irrigation and topical intranasal corticosteroids, which provide symptomatic relief and improved quality of life with minimal side effects. 1

Diagnosis and Classification

• Chronic sinusitis is defined as inflammation of the sinuses lasting >12 weeks with at least two cardinal symptoms:

  • Nasal blockage/obstruction/congestion
  • Anterior or posterior nasal drainage
  • Facial pain or pressure
  • Reduced or lost sense of smell (hyposmia)

• Classification:

  • With or without nasal polyps (important for treatment decisions)
  • Primary or secondary (based on underlying cause)

First-Line Treatment

1. Saline Nasal Irrigation

• Improves mucociliary clearance
• Reduces crusting and inflammation
• Use high-volume saline irrigation daily
• Benefits supported by systematic reviews of RCTs 1, 2

2. Intranasal Corticosteroids

• Reduces inflammation and improves symptoms
• Options include fluticasone propionate, mometasone furoate
• Proper technique is essential:
  • Shake bottle well
  • Look down by bending neck
  • Aim toward outer wall (not septum)
  • Avoid sniffing hard 1
• May begin to provide relief on first day but takes several days for full effectiveness 3
• Can be used long-term without "rebound effect" seen with decongestants 3

Additional Treatment Options

For Chronic Sinusitis with Nasal Polyps:

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

   • Reduces polyp size for up to 3 months after treatment 2
   • Monitor for side effects, especially in patients with comorbidities 4

2. Short course of doxycycline (3 weeks)

   • Can reduce polyp size for up to 3 months 2

3. Leukotriene antagonists

   • May improve nasal symptoms in patients with polyps 2

For Chronic Sinusitis without Polyps:

• Macrolide antibiotics (3-month course)
  • May improve quality of life at 24 weeks after therapy 2
  • Consider for patients not responding to first-line therapy

Management of Acute Exacerbations

• Acute exacerbations are defined as transient worsening of symptoms 5
• Treatment options:
  • Intensify saline irrigation and intranasal corticosteroids
  • Consider short course of antibiotics if bacterial infection is suspected
  • Short course of oral corticosteroids may be considered, though evidence is limited 5

Surgical Considerations

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

  • Medical treatment fails despite appropriate therapy
  • Symptoms persist >12 weeks despite medical management
  • Complications of acute sinusitis occur (orbital or intracranial involvement)
  • Anatomic abnormalities contribute to sinus obstruction 6

• Post-surgical care:

  • Continue intranasal corticosteroids and saline irrigation
  • Regular follow-up to assess symptom relief and quality of life 6

Special Considerations

Nasal Polyps

• Confirm presence or absence of polyps as they affect treatment approach 1
• Patients with polyps may benefit more from corticosteroid therapy 1
• Consider referral for specialty evaluation if polyps are present 1

Antifungal Therapy

• Do not prescribe topical or systemic antifungal therapy for chronic sinusitis
• Evidence shows lack of efficacy with potential for adverse effects 1

Pitfalls and Caveats

1. Medication technique matters

   • Improper use of nasal sprays can reduce effectiveness
   • Patient education on proper administration technique is essential 1

2. Avoid prolonged use of decongestants

   • Can cause rebound congestion (unlike corticosteroid sprays) 1
   • Limit use to 3-5 days

3. Monitor for corticosteroid side effects

   • Nasal irritation, epistaxis (nosebleeds)
   • Systemic effects rare with topical use but possible with prolonged high-dose use 3
   • Special caution in children, pregnant women, elderly, and patients with comorbid conditions like asthma 4

4. Consider contributing factors

   • Allergies, smoking, GERD, and asthma can worsen outcomes 6
   • Address these factors as part of comprehensive management

By following this evidence-based approach to chronic sinusitis management, focusing on saline irrigation and intranasal corticosteroids as first-line therapy, most patients can achieve significant symptom relief and improved quality of life.