What is the best approach for managing chronic recurrent sinusitis?

Management of Chronic Recurrent Sinusitis

The best approach for managing chronic recurrent sinusitis is a combination of daily saline nasal irrigation and intranasal corticosteroids as first-line therapy, with consideration of additional treatments based on specific patient factors and response to initial management. 1, 2, 3

Diagnosis and Evaluation

• Chronic rhinosinusitis (CRS) is defined as 12 weeks or longer of two or more symptoms (mucopurulent drainage, nasal obstruction, facial pain/pressure, decreased sense of smell) AND documented inflammation by endoscopy or imaging 1
• Recurrent acute rhinosinusitis is defined as 4 or more episodes per year of acute bacterial rhinosinusitis without symptoms between episodes 1
• Confirm diagnosis with objective documentation of sinonasal inflammation using anterior rhinoscopy, nasal endoscopy, or CT scan 1
• Assess for modifying factors such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia 1

First-Line Treatment

• Daily high-volume saline nasal irrigation (150ml) improves mucociliary function, decreases mucosal edema, and mechanically rinses infectious debris and allergens 1, 4, 5
• Daily intranasal corticosteroids (INCS) reduce inflammation, improve sinus drainage, and prevent exacerbations 1, 2, 6
• The combination of saline irrigation and INCS is more effective than either treatment alone 2, 3
• Consider corticosteroid nasal irrigation (rather than simple spray) for more effective delivery, especially post-surgery 7, 8

Additional Therapeutic Options

• For patients with nasal polyps, consider:
  • Short course (5-7 days) of systemic corticosteroids 2, 3
  • Doxycycline for 3 weeks 3
  • Leukotriene antagonists 3
• For patients without polyps with persistent symptoms, consider:
  • Macrolide antibiotics for 3 months 3
• For acute bacterial exacerbations:
  • High-dose amoxicillin-clavulanate (1.5-4g/day) for 10-14 days 9
  • For penicillin-allergic patients: cefuroxime, cefpodoxime, or cefdinir 9

Evaluation for Underlying Factors

• Consider testing for allergies and immune function 1, 4
• Obtain CT of paranasal sinuses to evaluate for structural abnormalities 1
• Confirm presence or absence of nasal polyps, as this guides treatment options 1

Surgical Consideration

• Consider referral to an otolaryngologist if there are:
  • Anatomical abnormalities
  • Nasal polyps
  • Persistent symptoms despite aggressive medical management 4
• Continue intranasal corticosteroids postoperatively if surgery is performed 2

Lifestyle Modifications and Prevention

• Practice good hand hygiene to minimize exposure to viral pathogens 1, 4
• Counsel patients that smoking increases sinusitis risk and recommend cessation 1
• Maintain adequate hydration and sleep with head elevated to improve sinus drainage 9, 4

Common Pitfalls and Caveats

• Avoid using topical decongestants for more than 3 days due to risk of rhinitis medicamentosa 2
• Ensure proper technique for intranasal medication administration to maximize efficacy and minimize side effects 2
• Do not prescribe topical or systemic antifungal therapy for CRS as it is not recommended 1
• Monitor for local side effects of INCS such as nasal irritation and bleeding by periodically examining the nasal septum 2

Follow-up and Monitoring

• Schedule follow-up within 3-5 days of initiating treatment for acute episodes 9
• Regular follow-up every 3-6 months to assess effectiveness of preventive measures 4
• If symptoms do not improve after 3-4 weeks of appropriate therapy, consider referral to a specialist 2