What is the treatment for sinusitis?

Treatment of Sinusitis

The primary treatment for acute bacterial sinusitis is antibiotics, with amoxicillin (1.5-4 g/day) recommended as first-line therapy for a 10-14 day course in mild cases, while intranasal corticosteroids are beneficial as adjunctive therapy. 1, 2

Diagnosis and Classification

• Acute sinusitis typically presents with persistent symptoms (>10-14 days) or severe symptoms including fever with purulent nasal discharge, facial pain/tenderness, and periorbital swelling 1
• Chronic sinusitis is defined by symptoms persisting for 8 weeks or longer 1, 3
• Recurrent sinusitis refers to repeated episodes of acute sinusitis, typically 3 or more times per year 1

Antibiotic Treatment Algorithm

For Acute Bacterial Sinusitis:

Mild Disease (No antibiotics in previous 4-6 weeks):

• First-line: Amoxicillin (1.5-4 g/day) for 10-14 days 1, 2
• If no improvement after 3-5 days, switch to alternative antibiotic 1, 2
• For penicillin allergies: Consider cefpodoxime, cefuroxime axetil, or cefdinir 1, 2
• For severe penicillin allergies: TMP/SMX, doxycycline, azithromycin, or clarithromycin (note: 20-25% bacteriologic failure rates possible) 1

Moderate Disease or Recent Antibiotic Use (within 4-6 weeks):

• High-dose amoxicillin/clavulanate (4 g/250 mg per day) 1, 2
• Respiratory fluoroquinolones (gatifloxacin, levofloxacin, moxifloxacin) - use cautiously to avoid promoting resistance 1
• Ceftriaxone (1 g/day IM or IV for 5 days) for severe cases 1

For Chronic Sinusitis:

• Longer duration of antibiotic therapy may be required 1
• Consider coverage for anaerobic pathogens 1
• For non-infectious chronic sinusitis (chronic hyperplastic sinusitis), systemic corticosteroids should be considered 1

Adjunctive Treatments

Pharmacologic Adjuncts:

• Intranasal corticosteroids (e.g., fluticasone) reduce inflammation and are beneficial as adjuncts to antibiotics 1, 2, 4
• Decongestants (oral or topical) may provide symptomatic relief by improving sinus drainage 1, 5
• Antihistamines are indicated only when allergic rhinitis is present concurrently 5, 6
• Mucolytics and expectorants (e.g., guaifenesin) may provide symptomatic benefit in selected cases, though evidence for efficacy in sinusitis is limited 1

Non-Pharmacologic Adjuncts:

• Saline nasal irrigation helps prevent crusting of secretions and facilitates mucus removal 1, 2, 3
• Steam inhalation, hot compresses, adequate hydration, and sleeping with head elevated can provide symptomatic relief 2, 5, 7

Follow-up and Management of Poor Response

• Evaluate response to treatment after 3-5 days 1, 2
• For partial response: Continue antibiotic for another 10-14 days or consider switching to broader-spectrum options 1, 2
• For poor response: Switch to high-dose amoxicillin-clavulanate, cefuroxime, cefpodoxime, or respiratory fluoroquinolones 1
• Consider CT scan if symptoms persist despite appropriate therapy 1

When to Refer to a Specialist

• Sinusitis refractory to standard antibiotic treatment 1
• Recurrent sinusitis (≥3 episodes per year) 1
• Sinusitis associated with unusual opportunistic infections 1
• Sinusitis significantly affecting quality of life 1
• Presence of complications or anatomical abnormalities 1, 2
• Suspected immunodeficiency or other underlying conditions 1

Special Considerations

• Evaluate for underlying factors such as allergic rhinitis, nonallergic rhinitis, or gastroesophageal reflux disease 1, 2
• Consider immunodeficiency in cases of recurrent sinusitis, especially when associated with otitis media, bronchitis, or pneumonia 1
• Intravenous immunoglobulin (IVIG) is indicated only in patients with proven functional impairment of humoral immunity 1
• Surgical intervention (functional endoscopic sinus surgery) may be necessary for medically resistant sinusitis or anatomical abnormalities 1

Common Pitfalls to Avoid

• Overdiagnosis of sinusitis and unnecessary antibiotic treatment - reserve antibiotics for symptoms lasting 10-14 days or severe symptoms 1
• Inadequate duration of antibiotic therapy - ensure full course completion 8, 7
• Failure to address underlying conditions (allergies, anatomical abnormalities) 1, 6
• Inappropriate use of antihistamines in non-allergic sinusitis 5, 6
• Neglecting the relationship between sinusitis and asthma - treating sinusitis may improve asthma control 5, 6