Treatment of Sinusitis
The primary treatment for acute bacterial sinusitis is a 10-14 day course of antibiotics, with amoxicillin as the first-line choice for most patients. 1
Diagnosis and Classification
- Acute sinusitis is defined as symptoms and signs lasting less than 4 weeks 1
- Diagnosis is primarily based on clinical history, physical examination, and possibly ancillary evaluations 1
- Acute bacterial sinusitis typically presents as:
- Persistent symptoms (nasal symptoms or cough for >10 but <30 days without improvement)
- Severe symptoms (high fever and purulent nasal discharge for 3-4 consecutive days)
- Worsening symptoms (respiratory symptoms that worsen after initial improvement) 2
Antibiotic Treatment for Acute Bacterial Sinusitis
First-line Treatment:
- Amoxicillin is the drug of choice for uncomplicated cases due to effectiveness, low cost, and good tolerability 1, 3
- Standard dosing: 500 mg twice daily for adults 1
- For more severe infections: higher doses (875 mg twice daily) are recommended 1, 4
- Duration: 10-14 days is generally adequate for acute disease 1
Alternative First-line Options:
- For patients allergic to or intolerant of amoxicillin:
Second-line Treatment:
- For patients with poor response to initial therapy (no improvement within 3-5 days):
Treatment Based on Sinusitis Type
- Maxillary sinusitis (most common): First-line antibiotics as above 1
- Frontal, ethmoidal, or sphenoidal sinusitis: Requires definite antibiotic therapy, consider fluoroquinolones active against pneumococci (levofloxacin, moxifloxacin) 1
- Chronic sinusitis: May require longer duration of therapy with possible attention to anaerobic pathogens; systemic corticosteroids may be beneficial 1
Adjunctive Therapies
- Intranasal corticosteroids: Helpful as an adjunct to antibiotic therapy in acute and chronic sinusitis 1
- Oral corticosteroids: May be reasonable for short-term use when patients fail to respond to initial treatment or have marked mucosal edema 1
- Comfort measures:
- Adequate rest and hydration
- Analgesics as needed
- Warm facial packs
- Steamy showers
- Sleeping with head elevated 1
- Saline irrigation: Beneficial in chronic sinusitis with no serious adverse effects 5
- Decongestants: May provide symptomatic benefit, but topical decongestants should not be used for more than 3 days to avoid rebound congestion 5
Follow-up and Treatment Failure
- If no improvement after 3-5 days of treatment, switch to a different antibiotic 1
- For partial response (symptomatically improved but not back to normal):
- Continue antibiotic treatment for another 10-14 days or
- Consider second-line antibiotic options 1
- For poor response (little or no improvement):
Special Considerations
- Recurrent sinusitis (≥3 episodes per year): Evaluate for underlying inflammation, allergy, immunodeficiency, and anatomic abnormalities 1
- Patients with allergic rhinitis: Consider antihistamines as there might be a role for them in chronic sinusitis if the underlying risk factor is allergic rhinitis 1
- Medically resistant sinusitis: May respond to appropriate nasal-sinus surgery, particularly functional endoscopic sinus surgery for localized persistent disease 1
When to Refer to a Specialist
- Need to clarify allergic or immunologic basis for sinusitis
- Sinusitis refractory to usual antibiotic treatment
- Recurrent sinusitis
- Sinusitis associated with unusual opportunistic infections
- Sinusitis significantly affecting quality of life 1