What are the drugs of choice for treating chronic sinusitis?

Drugs of Choice for Chronic Sinusitis

Intranasal corticosteroids combined with saline irrigation are the first-line therapy for chronic sinusitis, with antibiotics reserved for cases with evidence of bacterial infection. 1

First-Line Therapy

• Intranasal corticosteroids: These are the cornerstone of treatment for chronic sinusitis due to their anti-inflammatory effects and documented efficacy in relieving nasal congestion 2, 1

  • Options include fluticasone propionate, mometasone furoate, budesonide, and beclomethasone dipropionate
  • No significant differences in efficacy have been demonstrated between different intranasal corticosteroid molecules 3

• Saline irrigation: Daily high-volume saline irrigation should be used alongside intranasal corticosteroids 1

  • Improves symptom scores compared with no treatment
  • Prevents crusting of secretions and facilitates mechanical removal of mucus 2
  • Hypertonic saline may improve mucociliary clearance more effectively than normal saline 2

Antibiotic Therapy

• For chronic infectious sinusitis: Longer duration of therapy may be required, with attention to anaerobic pathogens 2

  • Macrolide antibiotics (for 3 months) may improve quality of life in patients without polyps 1
  • Ciprofloxacin (500 mg twice daily) has shown 85% effectiveness in treating acute exacerbations of chronic sinusitis 4

• For non-infectious chronic sinusitis (chronic hyperplastic sinusitis): Antibiotics play a controversial role and should not be the primary treatment 2

Additional Therapies Based on Phenotype

For Chronic Sinusitis with Nasal Polyps:

• Short course of systemic corticosteroids (1-3 weeks): Reduces polyp size for up to 3 months after treatment 1
• Doxycycline (3-week course): Reduces polyp size compared to placebo for 3 months after treatment 1
• Leukotriene antagonists: Improve nasal symptoms in patients with nasal polyps 1

Adjunctive Therapies:

• Decongestants: May provide symptomatic relief by widening ostia and reducing turbinate swelling 2

  • Topical agents (nasal sprays) act rapidly but can cause rebound hyperemia with extended use
  • Oral decongestants (pseudoephedrine, phenylephrine) should be used cautiously due to potential systemic effects 2

• Other adjunctive therapies that may provide symptomatic benefit in selected cases include:

  • Antihistamines (particularly for patients with allergic rhinitis component) 2
  • Mucolytics and expectorants 2

Treatment Algorithm

1. Initial therapy: Intranasal corticosteroids + saline irrigation for all patients 1, 5

2. If inadequate response after 4-6 weeks:

   • For patients with polyps: Add short course of systemic corticosteroids, doxycycline, or leukotriene antagonist 1
   • For patients without polyps: Consider macrolide antibiotic for 3 months 1

3. For persistent symptoms despite medical therapy:

   • Refer to otolaryngologist for consideration of endoscopic sinus surgery 2, 5
   • Continue intranasal corticosteroids postoperatively 6

Special Considerations

• Underlying conditions: Evaluate and treat conditions that may contribute to chronic sinusitis:

  • Allergic rhinitis: Consider allergen testing and specific therapy 2
  • Gastroesophageal reflux disease (GERD): Medical treatment may improve sinusitis symptoms 2
  • Immunodeficiency: Consider testing in cases of recurrent sinusitis 2

• Specialist referral is indicated when:

  • Sinusitis is refractory to usual treatment
  • Sinusitis is recurrent
  • There are unusual opportunistic infections
  • Sinusitis significantly affects quality of life 2

Common Pitfalls

• Overuse of antibiotics: Avoid unless there is clear evidence of bacterial infection 2
• Inadequate duration of intranasal corticosteroid therapy: These medications require consistent, long-term use 6
• Neglecting saline irrigation: This simple intervention significantly improves outcomes 1
• Failure to address underlying conditions: Allergic rhinitis, GERD, and immunodeficiency can perpetuate chronic sinusitis 2