What is the treatment for chronic sinusitis?

Treatment of Chronic Sinusitis

Intranasal corticosteroids and saline nasal irrigation are the first-line therapies for chronic sinusitis, with antibiotics considered for cases with infectious etiology and surgical intervention for medically refractory cases. 1

First-Line Treatments

• Intranasal corticosteroids (such as fluticasone propionate) reduce inflammation, decrease nasal polyp size, and improve nasal symptoms including blockage, rhinorrhea, and loss of smell 1, 2
• Patients may start to feel relief the first day of using intranasal corticosteroids, but it takes several days to reach full effectiveness 3
• Saline nasal irrigation helps clear mucus, reduces inflammation, and improves medication delivery to the sinonasal mucosa 1
• Combined use of intranasal corticosteroids with saline irrigation provides enhanced effectiveness compared to either treatment alone 1, 4

Antibiotic Therapy

• The use of antibiotics in chronic sinusitis is controversial with limited evidence supporting routine use 1, 4
• For chronic infectious sinusitis, a minimum 3-week course of antibiotics effective against common pathogens (H. influenzae, anaerobes, S. pneumoniae) may be beneficial 1
• If no improvement is seen within 3-5 days of antibiotic therapy, consider alternative antibiotics 1
• Macrolide antibiotics for 3 months may improve quality of life in patients without nasal polyps 4

Additional Medical Therapies

• Short courses of systemic (oral) corticosteroids (1-3 weeks) are recommended for severe chronic sinusitis with nasal polyps or when rapid symptomatic improvement is needed 1, 2, 4
• A 3-week course of doxycycline may reduce polyp size for up to 3 months after treatment in patients with nasal polyps 4
• Leukotriene antagonists may improve nasal symptoms in patients with nasal polyps 4
• Topical corticosteroid delivery via nasal irrigation may improve penetration and absorption into the sinonasal mucosa compared to standard nasal sprays 5

Surgical Intervention

• Endoscopic sinus surgery should be considered for patients with:
  • Documented chronic sinus infection refractory to medical therapy
  • Anatomic obstruction amenable to surgical correction
  • Localized persistent disease within the ostiomeatal complex
  • Nasal polyps that don't respond to medical therapy 1
• Intranasal corticosteroids should be continued postoperatively to maintain symptom control 1, 2

Special Considerations

• Evaluate and treat underlying conditions that may contribute to chronic sinusitis, such as:
  • Allergic rhinitis (consider allergen testing and appropriate management)
  • Immunodeficiency
  • Gastroesophageal reflux disease (GERD)
  • Aspirin sensitivity 1
• When using intranasal corticosteroids, take special care in children, pregnant women, and elderly patients, especially those with comorbid conditions like asthma where overall steroid intake may be high 2
• Unlike decongestant nasal sprays, intranasal corticosteroids do not cause rebound effects and can be used for extended periods (up to 6 months in patients 12 or older, up to 2 months in children 4-11 years old) 3

Common Pitfalls and Caveats

• Topical decongestants can cause rebound hyperemia (rhinitis medicamentosa) when used for extended periods 6
• Oral decongestants may cause systemic side effects including increased blood pressure, central nervous system stimulation, insomnia, and urinary retention 6
• The most common side effect of intranasal corticosteroids is epistaxis (nosebleeds), with a significantly increased risk compared to placebo 7
• If severe sinus pain or thick nasal discharge develops, or if symptoms aren't improving after one week of treatment, discontinue intranasal corticosteroids and consult a physician as an infection may be present 3
• Consider specialist consultation when sinusitis is refractory to usual antibiotic treatment, recurrent, or significantly affects quality of life 1