What is the management approach for maxillary sinusitis?

Management of Maxillary Sinusitis

Antimicrobial therapy is the mainstay of treatment for acute maxillary sinusitis, with amoxicillin-clavulanate being the first-line antibiotic choice due to increasing bacterial resistance patterns. 1

Diagnosis

Clinical Criteria

• Acute maxillary sinusitis is diagnosed when at least two of these major criteria are present:
  • Unilateral or bilateral infraorbital pain (worse when bending forward)
  • Purulent rhinorrhea (often unilateral)
  • Pain upon pressure over the infected sinus cavity 2

Imaging

• CT scan is the gold standard for diagnosis, especially for chronic or complicated cases
• Plain radiographs have moderate sensitivity (76%) and specificity (79%) compared to sinus puncture 2
• Imaging should be performed >4 weeks after acute infection and after medical management 1

Treatment Algorithm

1. Acute Bacterial Maxillary Sinusitis

First-line Antibiotic Therapy:

• Amoxicillin-clavulanate (875/125 mg twice daily for 7-14 days) 2, 1
• Alternative options:
  • Second-generation cephalosporins: cefuroxime-axetil
  • Third-generation cephalosporins: cefpodoxime-proxetil, cefotiam-hexetil
  • For penicillin-allergic patients: pristinamycin 2

Duration:

• Standard treatment: 7-10 days
• Short-course regimens with cefuroxime-axetil or cefpodoxime-proxetil: 5 days 1

Treatment Monitoring:

• If no clinical improvement within 3 days, consider alternative antibiotic 1
• Fluoroquinolones active against pneumococci (levofloxacin, moxifloxacin) should be reserved for complicated cases or treatment failures 2, 3

2. Adjunctive Therapies

• Intranasal corticosteroids: Recommended to reduce inflammation and improve sinus drainage 1
• Nasal saline irrigations: Improve mucociliary clearance and prevent crust formation 1
• Analgesics and antipyretics: For symptom relief 2
• Decongestants: May provide temporary relief but evidence is limited 2

3. Dental-Origin Maxillary Sinusitis

• Requires specific treatment addressing the dental infection 2
• For periapical disease-induced sinusitis, irrigation through the root canal may be effective 4

Indications for Specialist Referral

Refer to an ENT specialist when:

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

Surgical Management Indications

Consider surgical intervention when:

• Nasal polyps obstruct sinus drainage despite medical treatment
• Recurrent or persistent sinusitis despite adequate medical management
• Anatomic defects exist that obstruct sinus outflow
• Complications are threatened (brain abscess, meningitis, etc.) 2

Common Pitfalls and Caveats

1. Antibiotic overuse: Not all sinusitis requires antibiotics. Viral sinusitis with mild symptoms of short duration should not be treated with antibiotics to avoid promoting resistance 2

2. Inadequate duration: Premature discontinuation of antibiotics may lead to treatment failure and recurrence

3. Incorrect diagnosis: Symptoms of sinusitis can overlap with viral rhinitis; purulent nasal secretion is more helpful in differentiating between the two 5

4. Ignoring underlying factors: Allergies, anatomical abnormalities, or immunodeficiencies may contribute to recurrent sinusitis and should be addressed 2

5. Delayed referral: Patients with recurrent or chronic sinusitis should be referred to specialists earlier rather than later 2, 1

By following this structured approach to the management of maxillary sinusitis, clinicians can optimize outcomes while minimizing complications and recurrence.