What is the treatment for sinusitis?

Treatment of Sinusitis

The treatment of sinusitis should be tailored based on the type (acute vs. chronic) and severity, with amoxicillin-clavulanate being the preferred first-line antibiotic for acute bacterial sinusitis due to its effectiveness against common pathogens including resistant bacteria. 1

Acute Bacterial Sinusitis Treatment

First-Line Antibiotic Therapy

• Amoxicillin-clavulanate is the preferred first-line treatment for acute bacterial sinusitis due to increasing bacterial resistance patterns 1
• For less severe cases, high-dose amoxicillin (90 mg/kg/day in 2 divided doses, maximum 1g every 12 hours) may be considered 1
• Duration of antibiotic therapy is typically 7-10 days, though some experts recommend continuing until the patient is symptom-free plus an additional 7 days 1

Alternative Antibiotics (for penicillin-allergic patients)

• Second-generation cephalosporins: cefuroxime axetil 1
• Third-generation cephalosporins: cefpodoxime proxetil, cefdinir 1
• Pristinamycin (particularly in case of beta-lactam allergy) 1
• Clindamycin (for suspected anaerobic pathogens) 1

Severe Cases or Treatment Failures

• Fluoroquinolones active against pneumococci (levofloxacin, moxifloxacin) should be reserved for:
  • Frontal, fronto-ethmoidal, or sphenoidal sinusitis 1
  • Failure of first-line antibiotic therapy in maxillary sinusitis 1
  • Cases requiring broader coverage after bacteriological/radiological investigations 1, 2

Chronic Sinusitis Treatment

Medical Management

• Intranasal corticosteroids are recommended as first-line therapy to reduce inflammation 3
• High-volume saline irrigation helps improve mucociliary clearance 3
• For chronic sinusitis with nasal polyps:
  • Short course of systemic corticosteroids (1-3 weeks) 3
  • Short course of doxycycline (3 weeks) 3
  • Leukotriene antagonists may be beneficial 3
• For chronic sinusitis without polyps:
  • Prolonged course (3 months) of macrolide antibiotics may be considered 3

Evaluation of Underlying Factors

• Patients with chronic or recurrent sinusitis should be evaluated for:
  • Underlying inflammation and allergies 1
  • Immunodeficiency 1
  • Anatomic abnormalities 1

Adjunctive Therapies

Decongestants

• Topical and oral decongestants may help decrease nasal resistance and improve sinus ventilation 1
• Caution: Topical decongestants should not be used for more than 3 days to avoid rebound congestion (rhinitis medicamentosa) 1, 4

Antihistamines

• Not recommended for acute bacterial sinusitis 1
• May be beneficial in chronic sinusitis if the underlying risk factor is allergic rhinitis 1

Corticosteroids

• Short-term systemic corticosteroids may be considered for acute hyperalgic sinusitis 1
• Intranasal corticosteroids are particularly useful in chronic hyperplastic eosinophilic rhinosinusitis 1, 3

Special Considerations

Recurrent Sinusitis

• Defined as 3 or more episodes of acute sinusitis per year 1
• Requires evaluation of underlying risk factors 1
• Consider consultation with allergist-immunologist or otolaryngologist 1

Complicated Sinusitis

• Signs of complicated sinusitis include: meningeal syndrome, exophthalmos, palpebral edema, ocular mobility disorders, severe pain 1
• Requires hospitalization, bacteriological testing, and parenteral antibiotic therapy 1

Common Pitfalls to Avoid

• Treating viral rhinosinusitis with antibiotics (most cases of sinusitis are viral in origin) 5
• Using fluoroquinolones as first-line therapy (should be reserved for specific situations) 1, 2
• Prolonged use of topical decongestants leading to rhinitis medicamentosa 1, 4
• Failing to evaluate for underlying causes in chronic or recurrent sinusitis 1