What is the treatment for sinusitis?

Treatment of Sinusitis

The first-line treatment for acute bacterial sinusitis is amoxicillin (1.5-4 g/day) for 10-14 days, with amoxicillin-clavulanate as an alternative for patients who have received antibiotics in the previous 4-6 weeks or have moderate disease. 1, 2

Diagnosis and Classification

• Sinusitis presents with symptoms including nasal congestion, purulent rhinorrhea, facial pain/pressure, and postnasal drip 2
• Acute sinusitis lasts less than 4 weeks, while chronic sinusitis persists for 8 weeks or longer 1
• Recurrent sinusitis is defined as 3 or more episodes of acute sinusitis per year 1

Antibiotic Treatment for Acute Bacterial Sinusitis

First-line Options:

• Amoxicillin 1.5-4 g/day for 10-14 days for mild disease in patients who haven't received antibiotics in the previous 4-6 weeks 1, 2
• Amoxicillin-clavulanate (1.75-4 g/250 mg per day) for patients with recent antibiotic use or moderate disease 1
• Alternative options for penicillin-allergic patients include cefpodoxime, cefuroxime axetil, or cefdinir 1, 2

For Poor Response to Initial Treatment:

• If no improvement after 72 hours, switch to high-dose amoxicillin-clavulanate (4 g/250 mg per day), cefuroxime, cefpodoxime, cefprozil, or cefdinir 1
• For severe cases or treatment failures, respiratory fluoroquinolones (gatifloxacin, levofloxacin, moxifloxacin) may be considered 1, 3
• Levofloxacin 750 mg daily for 5 days has shown 91.4% clinical success rates for acute bacterial sinusitis 3

Adjunctive Treatments

• Intranasal corticosteroids reduce inflammation and are particularly useful for patients with allergic components 4, 2
• Saline irrigation prevents crusting of secretions and facilitates mechanical removal of mucus 1, 4
• Decongestants may provide symptomatic relief by reducing mucosal edema and improving sinus drainage 4, 5
• Analgesics for pain management and comfort measures such as adequate hydration, warm facial compresses, and sleeping with head elevated 2
• Mucolytics like guaifenesin may help loosen secretions, though evidence specifically for sinusitis is limited 1

Management of Chronic Sinusitis

• Intranasal corticosteroids are the cornerstone of treatment for chronic sinusitis 4
• Longer duration of antibiotic therapy may be required, with attention to anaerobic pathogens 4
• Evaluation and treatment of underlying conditions such as allergic rhinitis, immunodeficiency, or anatomical abnormalities 1, 4
• For patients with allergic components, antihistamines may provide symptomatic benefit 4, 6

Follow-up and Referral

• Assess response to treatment after 72 hours; continue antibiotics for another 10-14 days for partial response 1, 2
• Consider specialist referral for:
  • Sinusitis refractory to standard treatment 1, 4
  • Recurrent episodes (3 or more per year) 1
  • Presence of complications or suspected underlying conditions 1, 2
  • Presence of nasal polyps or anatomical abnormalities 1

Common Pitfalls and Caveats

• Overuse of antibiotics for viral sinusitis should be avoided; bacterial sinusitis is more likely when symptoms persist beyond 10 days or worsen after initial improvement 4, 7
• Antihistamines should be used cautiously in acute sinusitis without allergic components as they may thicken secretions 5
• Macrolides like azithromycin have lower efficacy against common sinusitis pathogens and should be reserved for patients with true penicillin allergy 1, 8
• Underlying conditions such as allergic rhinitis, immunodeficiency, or anatomical abnormalities should be addressed to prevent recurrence 1, 6