What is the best treatment for sinusitis?

Treatment of Sinusitis

The best treatment for sinusitis is antibiotics, specifically amoxicillin as first-line therapy for acute bacterial sinusitis, with intranasal corticosteroids as adjunctive therapy to reduce inflammation and improve symptoms. 1, 2

Diagnosis and Clinical Presentation

• Acute bacterial sinusitis typically presents with nasal congestion, purulent rhinorrhea (often unilateral), facial or dental pain, postnasal drainage, headache, and cough 1, 2
• Diagnosis is primarily clinical, with symptoms persisting for 10-14 days without improvement, or severe symptoms including fever with purulent nasal discharge and facial pain 1
• CT imaging is the technique of choice when confirmation is needed for vague symptoms, equivocal physical findings, or persistent disease despite optimal therapy 1

Antibiotic Therapy for Acute Bacterial Sinusitis

• Amoxicillin is the recommended first-line antibiotic at a dose of 1.5-4 g/day for 10-14 days 1, 2
• If no improvement occurs after 3-5 days, switch to amoxicillin-clavulanate which provides better coverage against beta-lactamase producing organisms 1, 2
• For penicillin-allergic patients, alternatives include:
  • Second-generation cephalosporins: cefuroxime-axetil 1, 2
  • Third-generation cephalosporins: cefpodoxime-proxetil, cefotiam-hexetil 1, 3
  • Pristinamycin (in case of beta-lactam allergy) 1

Treatment Duration

• A 10-14 day course of antibiotics is generally adequate for acute bacterial sinusitis 1
• Newer antibiotics may be effective with shorter courses (5 days), particularly for uncomplicated acute maxillary sinusitis in adults 4
• Treatment should continue until the patient is symptom-free plus an additional 7 days 1

Adjunctive Therapy

• Intranasal corticosteroids (e.g., fluticasone) are beneficial as adjuncts to antibiotic therapy for reducing inflammation in both acute and chronic sinusitis 1, 2, 5
• Saline irrigation helps clear secretions and provides symptomatic relief 2, 6
• Decongestants (topical and oral) may decrease nasal resistance and theoretically increase ostial patency, though evidence is limited 1
• Antihistamines are not recommended for acute bacterial sinusitis but may be helpful in chronic sinusitis if the underlying risk factor is allergic rhinitis 1, 2

Special Considerations for Chronic Sinusitis

• The role of antibiotics in chronic sinusitis is more controversial 1
• For chronic infectious sinusitis, longer duration of therapy may be required with attention to anaerobic pathogens 1, 3
• For chronic non-infectious (hyperplastic) sinusitis, systemic corticosteroids should be considered 1
• Medically resistant sinusitis may require surgical intervention, particularly when there is localized persistent disease within the ostiomeatal complex 1, 6

When to Refer to a Specialist

• Sinusitis refractory to standard antibiotic treatment 1, 2
• Recurrent sinusitis 1, 2
• Presence of complications (orbital, intracranial) 1, 6
• Sinusitis associated with unusual opportunistic infections 1
• When sinusitis significantly affects quality of life 1
• Presence of nasal polyps, immunodeficiencies, or anatomical abnormalities 2, 6

Pitfalls and Caveats

• Overdiagnosis of sinusitis and unnecessary antibiotic use is common; appropriate criteria for antibiotic use are symptoms persisting for 10-14 days or severe symptoms of acute infection 1
• When using intranasal corticosteroids, patients should be monitored for local infections with Candida albicans, which may require treatment and discontinuation of the intranasal steroid 5
• Fluoroquinolones (levofloxacin, moxifloxacin) should be reserved for situations where major complications are likely or when first-line therapy fails 1
• Patients with underlying conditions such as allergic rhinitis, immunodeficiencies, or GERD may require specific management of these conditions to improve sinusitis outcomes 1, 2