What is the treatment for sinusitis?

Treatment of Sinusitis

The first-line treatment for acute bacterial sinusitis is amoxicillin, while chronic sinusitis should be primarily managed with intranasal corticosteroids and saline irrigation. 1, 2

Acute Sinusitis Management

• Amoxicillin is recommended as the first-line antibiotic for uncomplicated acute bacterial sinusitis, with a standard course of 10-14 days 1
• Diagnosis of acute bacterial sinusitis is based on:
  • Persistent symptoms (>10 days without improvement)
  • Severe symptoms (high fever and purulent nasal discharge)
  • Worsening symptoms after initial improvement 3
• For patients allergic to or intolerant of amoxicillin, alternatives include cephalosporins (cefuroxime, cefpodoxime, cefprozil, cefdinir), macrolides, and quinolones 4, 1
• If no improvement after 3-5 days of initial antibiotic therapy, consider switching to a different antibiotic 1
• For poor response to initial treatment, consider high-dose amoxicillin-potassium clavulanate, which provides coverage against resistant bacteria 4

Chronic Sinusitis Management

• Chronic sinusitis is defined as symptoms persisting for 8 weeks or longer 1
• Intranasal corticosteroids are the cornerstone of treatment due to their anti-inflammatory effects 2
  • Fluticasone propionate has been shown to decrease nasal mucosal eosinophils and basophils, though the direct relationship to long-term symptom relief is not established 5
• Daily saline irrigation is essential for chronic sinusitis to prevent crusting and facilitate mechanical removal of mucus 2
  • Hypertonic saline may improve mucociliary clearance more effectively than normal saline 2
• For chronic infectious sinusitis, longer duration of antibiotic therapy may be required with attention to anaerobic pathogens 2
• Consider a short course of systemic corticosteroids for patients with nasal polyps 1

Adjunctive Therapies

• Decongestants may provide symptomatic relief by reducing turbinate swelling and widening sinus ostia 2, 6
• Antihistamines are indicated only when allergic rhinitis is present as a comorbidity 6, 7
• Mucolytics and expectorants may provide symptomatic benefit in selected cases 2, 8
• Non-pharmacologic measures include steam inhalation and hot, dry air to promote ciliary function 6

Treatment Algorithm for Sinusitis

1. Acute Sinusitis:

   • Start with amoxicillin 10-14 days 1
   • If no improvement after 3-5 days, switch to amoxicillin-clavulanate or another appropriate antibiotic 4, 1
   • Add decongestants for symptomatic relief 6

2. Chronic Sinusitis:

   • Daily intranasal corticosteroids (e.g., fluticasone propionate) 2, 5
   • Regular saline irrigation 2
   • Consider antibiotics only if clear evidence of bacterial infection 2
   • For patients with nasal polyps, consider short course of systemic corticosteroids 1

Special Considerations

• Evaluate and treat underlying conditions such as allergic rhinitis, gastroesophageal reflux disease, and immunodeficiency 2, 9
• Recurrent sinusitis (3 or more episodes per year) requires evaluation for underlying inflammation, allergy, immunodeficiency, and anatomical abnormalities 4
• Consider referral to an otolaryngologist for:
  • Failed medical management
  • Chronic or recurrent sinusitis significantly affecting quality of life
  • Suspected structural abnormalities 9
• Consider referral to an allergist-immunologist for:
  • Evaluation of underlying allergic factors
  • Assessment for immunodeficiency, especially in patients with recurrent sinusitis associated with otitis media, bronchitis, or pneumonia 4

Common Pitfalls

• Overdiagnosis of sinusitis and unnecessary antibiotic use is common 1
• Failure to complete the full course of antibiotics may lead to relapse 1
• Overuse of topical decongestants can lead to rhinitis medicamentosa 4
• Failure to address underlying factors (allergies, anatomical abnormalities) may lead to recurrent or chronic sinusitis 1