What is the treatment for sinusitis with cough in adults?

Treatment of Sinusitis with Cough in Adults

For adults with sinusitis accompanied by cough, the recommended treatment includes saline nasal irrigation and intranasal corticosteroids as first-line therapy, with antibiotics reserved for cases of confirmed acute bacterial sinusitis that meet specific diagnostic criteria. 1

Distinguishing Types of Sinusitis

• Viral rhinosinusitis (VRS) is self-limited, typically lasting 7-10 days, and accounts for most cases of acute sinusitis 1
• Acute bacterial rhinosinusitis (ABRS) should be diagnosed when symptoms persist >10 days without improvement, severe symptoms occur with high fever and purulent discharge for 3-4 consecutive days, or symptoms worsen after initial improvement 2
• Chronic rhinosinusitis (CRS) is defined as symptomatic inflammation lasting ≥12 weeks with objective documentation of sinonasal inflammation 1

Treatment for Viral Rhinosinusitis with Cough

• Symptomatic relief with analgesics (acetaminophen, ibuprofen) for pain or fever 1
• Saline nasal irrigation to cleanse nasal passages and improve mucociliary clearance 1
• Topical intranasal corticosteroids to reduce inflammation 1
• Decongestants may provide symptomatic relief but evidence for efficacy is limited 1
• Antibiotics are NOT recommended for VRS as they are ineffective for viral illness 1

Treatment for Acute Bacterial Rhinosinusitis with Cough

First-line therapy:

• Saline nasal irrigation and intranasal corticosteroids for symptomatic relief 1
• Watchful waiting (without antibiotics) is an appropriate initial strategy for uncomplicated ABRS 1

When antibiotics are indicated:

• Amoxicillin with or without clavulanate for 5-10 days is the first-line antibiotic choice 1, 2
• For penicillin-allergic patients: doxycycline or a respiratory fluoroquinolone (like levofloxacin) 1, 3
• Levofloxacin is FDA-approved for acute bacterial sinusitis at 750 mg once daily for 5 days or 500 mg once daily for 10-14 days 3

For cough specifically:

• First-generation antihistamine/decongestant combinations may help with cough related to post-nasal drip 1
• Guaifenesin may be used as an expectorant, though evidence for efficacy in sinusitis is limited 1

Treatment for Chronic Rhinosinusitis with Cough

• Daily saline nasal irrigation and topical intranasal corticosteroids are the mainstay of treatment 1, 4
• For CRS with nasal polyps: consider a short course (1-3 weeks) of systemic corticosteroids 4
• For persistent cough due to upper airway cough syndrome (UACS): first-generation antihistamine/decongestant combinations may be effective 1
• For CRS without polyps: a 3-month course of macrolide antibiotics (like azithromycin) may improve quality of life 4

Special Considerations

• Assess for comorbid conditions that modify management, such as asthma, which frequently coexists with sinusitis and may contribute to cough 1
• For patients with recurrent or chronic sinusitis with cough, consider referral for nasal endoscopy to confirm diagnosis and exclude other causes 1
• If cough persists despite appropriate sinusitis treatment, consider other causes such as asthma, gastroesophageal reflux disease, or non-asthmatic eosinophilic bronchitis 1

Treatment Pitfalls to Avoid

• Overuse of antibiotics for presumed bacterial sinusitis when symptoms are actually due to viral infection 1
• Prolonged use of topical decongestants (>3-5 days) can lead to rhinitis medicamentosa 1
• Failure to distinguish between different types of sinusitis (viral, bacterial, chronic) leading to inappropriate treatment 1
• Inadequate duration or technique with nasal saline irrigation and intranasal corticosteroids, which are the cornerstone of therapy 4
• Not addressing the cough component specifically, which may require targeted therapy beyond standard sinusitis treatment 1