What is the treatment for acute sinusitis?

Treatment of Acute Sinusitis

For acute sinusitis, first-line treatment should include symptomatic management with analgesics, nasal saline irrigation, and decongestants, with antibiotics reserved for cases with severe symptoms, symptoms lasting more than 10 days, or worsening symptoms after initial improvement. 1

Diagnosis and Classification

• Acute sinusitis is defined as symptoms and signs lasting less than 4 weeks 1
• Bacterial sinusitis should be suspected when symptoms persist beyond 10 days without improvement, symptoms are severe (high fever with purulent nasal discharge for 3-4 consecutive days), or symptoms worsen after initial improvement 2
• Differential diagnoses include allergic rhinitis, viral upper respiratory infections, nasal polyps, and sinonasal tumors 1

First-Line Treatment

Symptomatic Management

• Analgesics (such as acetaminophen or NSAIDs) should be offered for pain relief 1
• Saline nasal irrigation can promote mucus clearance and temporarily reduce tissue edema 1
• Topical nasal decongestants may be used short-term to relieve nasal congestion 1
• Intranasal corticosteroids provide modest but clinically important benefits (number needed to treat of 14) 1

Antibiotic Therapy

• Antibiotics should be reserved for patients with:
  • Symptoms lasting more than 10-14 days without improvement 1
  • Severe symptoms including fever with purulent nasal discharge 1
  • Worsening symptoms after initial improvement 1
• First-line antibiotic choice:
  • Amoxicillin is generally effective, inexpensive, and well-tolerated 1
  • For patients at risk of resistant organisms (recent antibiotic use, contact with children in daycare), high-dose amoxicillin-clavulanate is recommended 1, 2
• Alternative antibiotics for penicillin-allergic patients:
  • Doxycycline or trimethoprim-sulfamethoxazole for adults 1
  • Cephalosporins (cefuroxime, cefpodoxime, cefdinir) if no history of anaphylaxis 1, 2
  • Macrolides or respiratory fluoroquinolones for severe allergies 2

Duration of Antibiotic Therapy

• Standard duration is 10-14 days for traditional antibiotics 1, 3
• Shorter courses (5-7 days) may be appropriate with newer antibiotics like respiratory fluoroquinolones 4, 3
• Continue antibiotics until the patient is symptom-free for 7 days to prevent relapse 2

Treatment Monitoring and Adjustment

• If no improvement after 3-5 days of initial antibiotic therapy, consider changing to a different antibiotic 1
• For treatment failures, consider broader-spectrum antibiotics or possible resistant pathogens 1

Adjunctive Therapies

• Intranasal corticosteroids may be beneficial, especially when there is marked mucosal edema 1
• Short-term oral corticosteroids may be considered for patients who fail to respond to initial treatment 1, 5
• Guaifenesin (expectorant) has theoretical benefits but insufficient evidence in sinusitis 1
• Antihistamines should be avoided unless the patient has concurrent allergic rhinitis 1, 6

Special Considerations

• Consider underlying factors such as allergic rhinitis, immunodeficiency, or anatomical abnormalities in recurrent or chronic cases 1, 5
• Consultation with a specialist should be considered for:
  • Sinusitis refractory to standard antibiotic treatment 1
  • Recurrent sinusitis (more than 3-4 episodes per year) 1
  • Complications such as orbital or intracranial involvement 1

Common Pitfalls to Avoid

• Overdiagnosis of bacterial sinusitis leading to unnecessary antibiotic use 1
• Using antihistamines in non-allergic patients, which may thicken secretions 1, 6
• Prolonged use of topical decongestants, which can lead to rebound congestion 1
• Failure to recognize complications requiring urgent intervention, such as orbital cellulitis or intracranial extension 1