What is the treatment for sinusitis?

Treatment of Sinusitis

The primary therapy for acute bacterial sinusitis is antibiotics, with amoxicillin (1.5-4g/day) or amoxicillin-clavulanate recommended as first-line treatment for 10-14 days, alongside adjunctive therapies such as intranasal corticosteroids and saline irrigation. 1, 2

Diagnosis and Classification

• Acute sinusitis typically presents with persistent symptoms (nasal symptoms or cough for >10 but <30 days without improvement), severe symptoms (high fever and purulent nasal discharge for 3-4 consecutive days), or worsening symptoms (respiratory symptoms that worsen after initial improvement) 3
• Appropriate criteria for antibiotic use include symptoms of sinusitis for 10-14 days or severe symptoms including fever with purulent nasal discharge, facial pain/tenderness, and periorbital swelling 1
• Chronic sinusitis is defined as signs and symptoms persisting for 8 weeks or longer 1

Antibiotic Therapy

For Acute Bacterial Sinusitis:

• First-line therapy (mild disease, no antibiotics in previous 4-6 weeks): 1, 2

  • Amoxicillin (1.5-4g/day) for 10-14 days
  • Amoxicillin-clavulanate (1.75-4g/250mg per day)
  • Alternatives: cefpodoxime proxetil, cefuroxime axetil, or cefdinir

• For moderate disease or recent antibiotic use (within 4-6 weeks): 1

  • High-dose amoxicillin-clavulanate (4g/250mg per day)
  • Respiratory fluoroquinolones (gatifloxacin, levofloxacin, moxifloxacin)
  • Note: Widespread use of fluoroquinolones for milder disease may promote resistance

• For penicillin allergies: 1, 2

  • Cefuroxime, cefpodoxime, or cefdinir
  • For serious drug allergies: clarithromycin or azithromycin (note: higher bacteriologic failure rates of 20-25% possible)

For Chronic Sinusitis:

• The role of antibiotics in chronic sinusitis is controversial 1
• For chronic infectious sinusitis, longer duration of therapy might be required, with attention to anaerobic pathogens 1
• For chronic non-infectious/hyperplastic sinusitis, systemic corticosteroids should be considered 1

Monitoring and Follow-up

• If no improvement after 3-5 days of initial therapy, consider alternative antibiotics 1, 2
• For partial response, continue antibiotics for another 10-14 days or consider antibiotics with broader coverage 1
• For poor response, consider high-dose amoxicillin-clavulanate, cefuroxime, cefpodoxime, or respiratory fluoroquinolones 1

Adjunctive Therapies

• Intranasal corticosteroids: Helpful as an adjunct to antibiotic therapy for acute and chronic sinusitis; reduces inflammation and promotes drainage 1, 4, 5

  • Adult dosing: 200 mcg once daily (two 50-mcg sprays in each nostril) or 100 mcg twice daily 4
  • Pediatric dosing (≥4 years): Start with 100 mcg (1 spray in each nostril once daily) 4

• Saline irrigation: Improves mucociliary clearance, prevents crusting of secretions, and facilitates mechanical removal of mucus 1, 5

• Other symptomatic treatments: 1, 2

  • Decongestants (oral and topical)
  • Analgesics for pain relief
  • Hydration
  • Warm facial compresses
  • Steam inhalation

• Mucolytics/Expectorants: May provide symptomatic benefit in selected cases, though evidence for efficacy in sinusitis is limited 1

Special Considerations

Chronic/Recurrent Sinusitis:

• Evaluate for underlying factors: 1, 2

  • Allergic rhinitis (present in many patients with sinusitis)
  • Nonallergic rhinitis
  • Immunodeficiency
  • Anatomical abnormalities
  • Gastroesophageal reflux disease (GERD)

• For allergic rhinitis component: 2, 6

  • Environmental control measures
  • Antihistamines
  • Intranasal corticosteroids
  • Allergen immunotherapy in selected patients

When to Refer to a Specialist:

• Sinusitis refractory to usual antibiotic treatment 1
• Recurrent sinusitis (typically 3 or more episodes per year) 1
• Sinusitis associated with unusual opportunistic infections 1
• Presence of complications or significant impact on quality of life 1
• Presence of nasal polyps, anatomical abnormalities, or suspected immunodeficiency 1, 2

Surgical Considerations

• Medically resistant sinusitis may respond to appropriate nasal-sinus surgery 1
• Functional endoscopic sinus surgery may result in significant improvement for localized persistent disease within the ostiomeatal complex 1
• Consider surgical consultation for patients with obstructing nasal polyps, significant nasal septal deviation, or persistent symptoms despite aggressive medical management 1, 7

Pitfalls and Caveats

• Overdiagnosis of sinusitis and unnecessary antibiotic use is common 1
• Viral upper respiratory infections are the most common cause of sinusitis-like symptoms and typically resolve without antibiotics 1, 3
• Antibiotics should be reserved for patients with symptoms lasting >10-14 days or severe symptoms 1
• Chronic sinusitis often has non-infectious components requiring anti-inflammatory rather than antimicrobial treatment 5
• Treatment of underlying conditions (allergies, GERD) is essential for managing recurrent or chronic sinusitis 1, 2