What is the treatment for chronic pansinusitis?

Treatment for Chronic Pansinusitis

First-line treatment for chronic pansinusitis includes nasal saline irrigation and intranasal corticosteroid sprays, with antibiotics reserved for cases with evidence of active infection. 1

Diagnosis and Evaluation

• Chronic pansinusitis is defined by the presence of at least two out of four cardinal symptoms (facial pain/pressure, hyposmia/anosmia, nasal drainage, nasal obstruction) for at least 12 consecutive weeks, plus objective evidence on examination or imaging 1
• Objective evidence should be obtained through anterior rhinoscopy, endoscopy, or sinus computed tomography 1
• Evaluation should rule out underlying conditions such as allergies, aspirin hypersensitivity, immotile-cilia syndrome, or other exogenous factors 2

Treatment Algorithm

First-Line Therapy

1. Nasal saline irrigation - Enhances mucociliary clearance and improves sinus drainage 1
2. Intranasal corticosteroid sprays - Reduces local inflammation and improves symptoms 1

Second-Line Therapy (for inadequate response to first-line)

1. Antibiotics - Consider when there is evidence of an active, superimposed acute sinus infection 1
   • Selection should be based on likely pathogens and local resistance patterns
   • Typical duration is 2-4 weeks for adequate treatment 1

Refractory Cases

1. Endoscopic sinus surgery - Indicated when medical management fails 1

   • Aims to improve sinus ventilation and drainage
   • Allows for removal of polyps and diseased tissue 3
   • Facilitates better access for topical medications post-surgery 1

2. Post-surgical management

   • Continued nasal irrigation 4
   • Topical corticosteroids 4
   • Regular endoscopic follow-up with debridement when necessary 4

Special Considerations

• Allergic fungal sinusitis requires a comprehensive approach:

  • Meticulous surgical exenteration 4
  • Immunotherapy with relevant fungal and non-fungal antigens 4
  • Topical and systemic corticosteroids as needed 4
  • Patient self-irrigation and cleaning 4

• Primary ciliary dyskinesia cases may require:

  • More aggressive surgical intervention (endoscopic endonasal pansinusotomy) 3
  • Targeted antibacterial therapy based on culture and sensitivity 3
  • Adjunctive hormonal therapy 3

Referral Guidelines

• Patients not responding to first-line medical therapy should be referred to an otolaryngologist 1
• Consider referral to an allergist or pulmonologist for patients with suspected comorbidities (vasculitides, granulomatous diseases, cystic fibrosis, immunodeficiency) 1

Common Pitfalls and Caveats

• Failure to identify underlying conditions can lead to treatment failure 2
• Approximately 40% of cases may show chronic progression despite appropriate treatment 2
• Long-term medical therapy is typically required even after surgical intervention 2
• Regular follow-up is essential as recurrence rates are high, particularly in cases with polyps 3