Treatment of Chronic Sinusitis
The treatment of chronic sinusitis should include intranasal corticosteroids and saline nasal irrigation as first-line therapy, with consideration for antibiotics in cases of infectious etiology, and surgical intervention for medically refractory cases. 1, 2
First-Line Therapies
Intranasal Corticosteroids
- Intranasal corticosteroids are a cornerstone of chronic sinusitis treatment, reducing inflammation and improving mucociliary clearance 3
- Should be used daily for optimal effectiveness, with relief potentially beginning on the first day but requiring several days to reach full effectiveness 4
- Can be used for up to 6 months in patients 12 years or older, and up to 2 months in children 4-11 years old before reassessment 4
- Do not cause rebound congestion like decongestant sprays, making them suitable for long-term use 4
- May cause mild side effects such as nasal stinging or epistaxis (nosebleeds) 4, 5
Saline Nasal Irrigation
- High-volume saline irrigation significantly improves symptom scores compared to no treatment 2
- Helps clear mucus, reduce inflammation, and improve medication delivery to the sinonasal mucosa 1
- Can be used in conjunction with intranasal corticosteroids for enhanced effectiveness 1
Additional Medical Therapies
Antibiotics
- The role of antibiotics in chronic sinusitis is controversial, with limited evidence supporting their routine use 1
- For chronic infectious sinusitis, a minimum 3-week course of antibiotics effective against common pathogens (H. influenzae, anaerobes, S. pneumoniae) may be beneficial 1
- Macrolide antibiotics for 3 months may improve quality of life in patients without nasal polyps 2
- If no improvement is seen within 3-5 days of antibiotic therapy, consider alternative antibiotics 1
Oral Corticosteroids
- Short courses (1-3 weeks) of systemic corticosteroids may be considered for patients with nasal polyps 2
- Systemic corticosteroids can reduce polyp size for up to 3 months after treatment 2
- For chronic non-infectious sinusitis (chronic hyperplastic sinusitis), systemic corticosteroids may be particularly beneficial 1
Other Adjunctive Therapies
- Antihistamines may be beneficial when chronic sinusitis is associated with allergic rhinitis 1
- Leukotriene antagonists may improve nasal symptoms in patients with nasal polyps 2
- Oral decongestants may theoretically help by decreasing nasal resistance and increasing ostial patency, though prospective studies are lacking 1
- Topical nasal decongestants should be limited to 5 days to avoid rhinitis medicamentosa (rebound congestion) 1
Advanced Treatment Options
Corticosteroid Irrigations
- Off-label nasal steroid irrigations may provide better distribution to the paranasal sinuses than standard nasal sprays 6
- Studies show benefit of budesonide and mometasone irrigations over nasal corticosteroid sprays alone 6
Surgical Intervention
- Consider endoscopic sinus surgery for patients with:
Special Considerations
Chronic Sinusitis with Nasal Polyps
- Confirm the presence or absence of nasal polyps, as this affects treatment approach 1
- Patients with polyps may benefit from:
Underlying Conditions
- Evaluate for and treat underlying conditions that may contribute to chronic sinusitis:
- Allergic rhinitis - consider allergen testing and appropriate management 1
- Immunodeficiency - consider immunoglobulin measurements and functional antibody tests 1
- Gastroesophageal reflux disease (GERD) - medical treatment may improve sinusitis symptoms 1
- Aspirin sensitivity - aspirin desensitization may be beneficial 1