What is the recommended treatment for sinusitis with frequent cough?

Treatment of Sinusitis with Frequent Cough

The recommended first-line treatment for sinusitis with frequent cough includes intranasal corticosteroids and saline irrigation, with antibiotics reserved for cases with clear evidence of bacterial infection or when symptoms persist beyond 7-10 days. 1, 2

Diagnosis and Classification

• Sinusitis with cough is often part of Upper Airway Cough Syndrome (UACS), previously known as postnasal drip syndrome 1
• Acute sinusitis is generally defined as symptoms lasting less than 3 weeks, while chronic sinusitis persists beyond 12 weeks 1
• Common symptoms include nasal congestion, purulent rhinorrhea, postnasal drip, facial pain/pressure, and cough 3

First-Line Treatment Approach

Non-Pharmacological Measures

• Saline irrigation to prevent crusting of secretions and facilitate mechanical removal of mucus 2
• Adequate hydration, warm facial compresses, and sleeping with head elevated 3

Pharmacological Treatment

• Intranasal corticosteroids are the cornerstone of treatment due to their anti-inflammatory effects 2, 1
• Intranasal corticosteroids have been shown to significantly improve symptoms compared to placebo 1
• For acute sinusitis with cough, a short course (3-5 days) of decongestants may help relieve symptoms, but prolonged use should be avoided 1

Antibiotic Therapy

When to Use Antibiotics

• Antibiotics should be reserved for:
  • Symptoms lasting more than 7-10 days 1
  • Severe symptoms with high fever and purulent nasal discharge 1
  • Worsening symptoms after initial improvement 4

Antibiotic Selection

• First-line options:
  • Amoxicillin-clavulanate 1, 4
  • Second/third-generation cephalosporins (cefuroxime-axetil, cefpodoxime-proxetil) 1
• For penicillin-allergic patients:
  • Pristinamycin 1
  • Azithromycin 500mg daily for 3 days 5

Treatment Based on Sinusitis Type

Acute Viral or Post-Viral Sinusitis

• Symptomatic treatment with intranasal corticosteroids and saline irrigation 1, 2
• Decongestants for short-term relief (3-5 days maximum) 1
• Antibiotics generally not recommended 6

Acute Bacterial Sinusitis

• Antibiotics for 7-10 days (amoxicillin-clavulanate preferred) 1, 4
• Intranasal corticosteroids as adjunctive therapy 1, 3
• Consider fluoroquinolones (levofloxacin, moxifloxacin) only for complicated cases or treatment failures 1

Chronic Sinusitis

• Long-term intranasal corticosteroids 2, 7
• High-volume saline irrigation daily 7
• For patients with nasal polyps, consider:
  • Short course of systemic corticosteroids (1-3 weeks) 7
  • Leukotriene antagonists 7
• For patients without polyps with persistent symptoms, consider macrolide antibiotics for 3 months 7

Special Considerations for Cough

• Cough associated with sinusitis is typically due to postnasal drip 1
• First-generation antihistamine/decongestant combinations may be helpful for cough specifically, but sedation is a common side effect 1
• Consider initiating therapy once daily at bedtime before increasing to twice daily to minimize sedation 1

When to Refer to a Specialist

• Sinusitis refractory to standard treatment 2
• Recurrent episodes (more than 3-4 per year) 3
• Presence of complications or suspected anatomical abnormalities 3
• Immunocompromised patients 8

Common Pitfalls to Avoid

• Overuse of antibiotics in viral or post-viral sinusitis 2, 6
• Prolonged use of decongestants (>5 days) leading to rebound congestion 1
• Failure to address underlying conditions like allergic rhinitis or GERD 2
• Inadequate duration of antibiotic therapy when truly indicated 4