What are the symptoms and treatment options for sinusitis (infection of the paranasal sinuses)?

From the Guidelines

Sinusitis can be effectively managed with a combination of over-the-counter medications, home remedies, and, in severe cases, antibiotics, with the most recent and highest quality study 1 guiding the treatment approach. The symptoms of sinusitis include cloudy or colored drainage from the nose, stuffy or congested nose, and pain or pressure in the face, head, or around the eyes, as outlined in the clinical practice guideline 1. To determine if sinusitis is caused by viruses or bacteria, it is essential to consider the duration of symptoms, with acute viral sinusitis likely if symptoms have lasted less than 10 days and are not worsening, and acute bacterial sinusitis likely if symptoms do not improve within 10 days or worsen after initial improvement 1. Treatment options for sinusitis include:

• Nasal saline rinses twice daily
• Over-the-counter decongestants like pseudoephedrine (Sudafed) for 3-5 days
• Pain relievers like acetaminophen (Tylenol) or ibuprofen (Advil)
• Warm compresses to the face for 5-10 minutes several times daily
• Staying hydrated and using a humidifier to keep nasal passages moist If symptoms persist beyond 7-10 days, develop a high fever, or include severe facial pain or headache, it is recommended to see a doctor, as antibiotics like amoxicillin (typically 500mg three times daily for 5-7 days) may be necessary for bacterial infections 1. It is crucial to note that antibiotics are only effective for bacterial infections, not viral ones, which is why they are not recommended immediately, and most sinus infections are viral and will resolve on their own within 7-10 days with supportive care, while bacterial infections typically cause more severe symptoms that worsen after 5-7 days rather than improving 1. Radiographic imaging of the paranasal sinuses is unnecessary for diagnosis in patients who already meet clinical diagnostic criteria, but may be obtained when a complication of ABRS or an alternative diagnosis is suspected 1. The American College of Radiology (ACR) has stated that plain films of the sinuses are inaccurate in a high percentage of patients and should be supplanted by CT imaging, and a meta-analysis of 6 studies showed that sinus radiography has moderate sensitivity (76%) and specificity (79%) compared with sinus puncture in diagnosing ABRS 1. In terms of treatment, the use of intranasal corticosteroids has been shown to be helpful, but there are no prospective, randomized, double-blind studies that have proven that either nasal or oral decongestants are efficacious in either acute or chronic sinusitis 1. The treatment of chronic sinusitis is even less clear-cut, but a minimum of 3 weeks of treatment with an antibiotic effective against H influenzae, mouth anaerobes, and S pneumoniae, along with a minimum of 3 weeks of oral treatment with an older-generation A/D twice per day, and 5 days of treatment with a nasal decongestant twice per day, has been efficacious in some studies 1. It is essential to educate patients about the rationale for management and worsening signs and symptoms that should prompt them to contact a physician, and to offer symptomatic treatment or reassurance as the preferred initial approach for patients with mild or moderate symptoms 1. Narrow-spectrum agents with activity against the most likely pathogens, such as Streptococcus pneumoniae, should be used for patients with severe or persistent moderate symptoms and specific findings of bacterial rhinosinusitis 1.

From the FDA Drug Label

1.4 Acute Bacterial Sinusitis: 5 Day and 10 to 14 Day Treatment Regimens Levofloxacin is approved for the treatment of acute bacterial sinusitis (ABS) using either 750 mg by mouth x 5 days or 500 mg by mouth once daily x 10 to 14 days To evaluate the safety and efficacy of a high dose short course of levofloxacin, 780 outpatient adults with clinically and radiologically determined acute bacterial sinusitis were evaluated in a double-blind, randomized, prospective, multicenter study comparing levofloxacin 750 mg by mouth once daily for five days to levofloxacin 500 mg by mouth once daily for 10 days Clinical success rates (defined as complete or partial resolution of the pre-treatment signs and symptoms of ABS to such an extent that no further antibiotic treatment was deemed necessary) in the microbiologically evaluable population were 91.4% (139/152) in the levofloxacin 750 mg group and 88.6% (132/149) in the levofloxacin 500 mg group at the test-of-cure (TOC) visit (95% CI [-4. 2,10] for levofloxacin 750 mg minus levofloxacin 500 mg).

The symptoms of sinusitis are not explicitly stated in the provided drug labels, but the treatment options for acute bacterial sinusitis include:

• Levofloxacin 750 mg by mouth once daily for 5 days
• Levofloxacin 500 mg by mouth once daily for 10 to 14 days 2

From the Research

Symptoms of Sinusitis

• The symptoms of sinusitis can vary, but common presentations include:
  • Onset with persistent symptoms (nasal symptoms or cough or both for more than 10 but less than 30 days without evidence of improvement) 3
  • Onset with severe symptoms (high fever and purulent nasal discharge for 3-4 consecutive days) 3
  • Onset with worsening symptoms (respiratory symptoms, with or without fever, which worsen after several days of improvement) 3
• Sinus disease is often associated with viral upper respiratory tract infections and occurs in 90% of individuals with the common cold, with acute bacterial sinusitis occurring in 0.5 to 2% of these individuals 4

Treatment Options for Sinusitis

• The initial management of acute sinusitis should be directed toward the relief of symptoms with a 7-day course of decongestants and mucoevacuents 4
• For patients who fail to improve with symptomatic treatment, a 10-day course of amoxicillin is recommended 4
• Therapy may be initiated with high-dose amoxicillin or amoxicillin-clavulanate, with alternatives including cefuroxime, cefpodoxime, or cefdinir 3
• In cases of serious drug allergy, clarithromycin or azithromycin may be prescribed 3
• Short-course antibiotic treatment (up to 7 days) has similar effectiveness to longer-course treatment (6-10 days) for patients with acute uncomplicated bacterial sinusitis 5
• Adults with clinically diagnosed acute bacterial sinusitis were more likely to improve rapidly when treated with high-dose amoxicillin/clavulanate than with standard-dose 6
• Antibiotics were more effective when given within the first 10 days of treatment, and patients with poor oro-dental condition or recent antibiotic use may derive the most benefit from an antibiotic prescription 7