What are the management options for sinusitis?

Management of Sinusitis

The primary therapy for acute bacterial sinusitis is antibiotics, with amoxicillin being the first-line treatment for most adults, while chronic sinusitis requires a comprehensive approach including intranasal corticosteroids, saline irrigation, and addressing underlying factors. 1

Acute Sinusitis Management

Diagnosis

• Acute sinusitis typically presents as a persistent upper respiratory tract infection (10-14 days without improvement) or with severe symptoms (high fever and purulent nasal discharge) 1
• Symptoms include nasal congestion, purulent rhinorrhea, postnasal drainage, facial/dental pain, headache, and cough 1

Antibiotic Therapy

• Amoxicillin is the first-line antibiotic for uncomplicated acute bacterial sinusitis 1, 2
• Standard course is 10-14 days for acute disease 1
• For patients allergic to or intolerant of amoxicillin, alternatives include:
  • Cephalosporins (cefuroxime, cefpodoxime, cefprozil, cefdinir) 1, 3
  • Macrolides (clarithromycin, azithromycin) 1, 3
  • Quinolones 1
• For acute bacterial sinusitis, azithromycin dosage is 500 mg once daily for 3 days 4
• If no improvement after 3-5 days, switch to a different antibiotic 1

Poor Response to Initial Treatment

• For poor response to amoxicillin, consider high-dose amoxicillin-clavulanate 1
• For sinusitis that fails to improve after 21-28 days, consider broader-spectrum agents with possible anaerobic coverage (clindamycin or metronidazole) 1

Adjunctive Therapies

• Intranasal corticosteroids may be helpful as an adjunct to antibiotics 1
• Short-term oral corticosteroids may be considered for patients who fail to respond to initial treatment or have marked mucosal edema 1
• Saline irrigation helps prevent crusting of secretions and facilitates mucus removal 1, 5
• Comfort measures include:
  • Adequate hydration and rest
  • Analgesics for pain management
  • Warm facial packs and steamy showers
  • Sleeping with head elevated 1

Chronic Sinusitis Management

Definition and Approach

• Chronic sinusitis is defined as symptoms lasting longer than 8 weeks 1
• Recurrent sinusitis consists of 3 or more episodes of acute sinusitis per year 1

Medical Management

• Intranasal corticosteroids are a first-line therapy for chronic sinusitis 1, 5
• Daily high-volume saline irrigation is recommended 5
• For chronic infectious sinusitis, longer duration of antibiotic therapy may be required 1
• For chronic non-infectious sinusitis (chronic hyperplastic sinusitis), consider systemic corticosteroids 1
• For patients with nasal polyps, consider:
  • Short course of systemic corticosteroids (1-3 weeks)
  • Short course of doxycycline (3 weeks)
  • Leukotriene antagonists 5
• For patients without polyps, a prolonged course (3 months) of macrolide antibiotics may be considered 5

Addressing Underlying Factors

• Evaluate and treat allergic rhinitis with:
  • Environmental control measures
  • Pharmacotherapy (antihistamines, intranasal corticosteroids)
  • Allergen immunotherapy in selected patients 1
• Consider evaluation for:
  • Immunodeficiency (quantitative immunoglobulin measurement, functional antibody tests)
  • Gastroesophageal reflux disease (GERD)
  • Cystic fibrosis in children with nasal polyps 1

Surgical Management

• Consider surgical intervention for medically resistant sinusitis 1
• Functional endoscopic sinus surgery may result in significant improvement for localized persistent disease within the ostiomeatal complex 1

When to Consult a Specialist

Consultation with an allergist-immunologist or otolaryngologist is recommended when:

• Clarification of allergic or immunologic basis for sinusitis is needed
• Sinusitis is refractory to usual antibiotic treatment
• Sinusitis is recurrent
• Sinusitis is associated with unusual opportunistic infections
• Sinusitis significantly affects quality of life
• Concomitant conditions are present (asthma, nasal polyps, immunodeficiencies) 1

Common Pitfalls and Caveats

• Overdiagnosis of sinusitis and unnecessary antibiotic use is common 1
• Appropriate criteria for antibiotic use: symptoms for 10-14 days OR severe symptoms including fever with purulent nasal discharge and facial pain 1
• Imaging studies (CT scans) are generally not necessary for diagnosis of acute sinusitis but may be needed for chronic or recurrent cases 1, 2
• Patients should be instructed to complete the full course of antibiotics to prevent relapse 1
• Failure to address underlying factors (allergies, anatomical abnormalities) may lead to recurrent or chronic sinusitis 1