What is the treatment for sinusitis?

Treatment for Sinusitis

The primary treatment for acute bacterial sinusitis is amoxicillin as first-line antibiotic therapy for a 10-14 day course, while chronic sinusitis management requires intranasal corticosteroids as first-line therapy along with saline irrigation and potentially longer antibiotic courses for infectious cases. 1

Acute Sinusitis Management

• Amoxicillin is the first-line antibiotic for uncomplicated acute bacterial sinusitis, with a standard course of 10-14 days 1, 2

• Appropriate criteria for antibiotic use include symptoms persisting for 10-14 days without improvement or severe symptoms including fever with purulent nasal discharge and facial pain 2, 1

• If no clinical improvement is seen within 3-5 days of initiating antibiotic therapy, an alternative antibiotic should be considered 2, 1

• For patients allergic to or intolerant of amoxicillin, alternatives include:

  • Cephalosporins (e.g., cefaclor) 2
  • Trimethoprim-sulfamethoxazole 2
  • Macrolides (though increasing resistance is a concern) 2
  • Fluoroquinolones (for adults with moderate disease and beta-lactam allergy) 2, 3

• Amoxicillin-clavulanate is recommended for:

  • Patients with moderate disease 3
  • Recent antibiotic use (past six weeks) 3
  • No response to initial therapy 2
  • Cases where anaerobic pathogens are suspected 2

Adjunctive Therapies for Acute Sinusitis

• Decongestants (topical and oral) may help decrease nasal resistance and improve sinus ventilation, though topical decongestants should not be used for more than 3 days to avoid rebound congestion 2, 3
• Saline nasal irrigation helps clear secretions and has no serious adverse effects 3, 4
• Antihistamines are generally NOT recommended for acute bacterial sinusitis unless the patient has concomitant allergies that are currently symptomatic 5, 2
• Analgesics provide symptomatic relief for pain and headache 5, 4
• Steam inhalation may help promote drainage and provide symptomatic relief 5, 4

Chronic Sinusitis Management

• Chronic sinusitis is defined as symptoms lasting longer than 8 weeks 1
• Intranasal corticosteroids are the first-line therapy for chronic sinusitis 1, 4
  • Fluticasone propionate nasal spray at 100 mcg twice daily (one 50-mcg spray in each nostril twice daily) has been shown to be effective 6
• Daily high-volume saline irrigation is recommended for symptom relief and to promote drainage 1, 7
• For chronic infectious sinusitis, longer duration of antibiotic therapy may be required, with attention to anaerobic pathogens 2, 1
• Amoxicillin-clavulanate is a good choice for acute exacerbations of chronic sinusitis 2
• Antihistamines may be beneficial in chronic sinusitis if the underlying risk factor is allergic rhinitis 2

Special Considerations

• For patients with nasal polyps, consider a short course of systemic corticosteroids 1, 8
• Patients with chronic sinusitis should be evaluated for underlying factors such as:
  • Allergic rhinitis 2, 8
  • Non-allergic rhinitis 2
  • Anatomical abnormalities 4
  • Immunodeficiency (in cases of recurrent sinusitis) 2
  • Gastroesophageal reflux disease (GERD) 2

Surgical Management

• Consider surgical intervention for medically resistant sinusitis 2, 1
• Functional endoscopic sinus surgery may result in significant improvement for localized persistent disease within the ostiomeatal complex 2, 1
• Surgery aims to improve ventilation and facilitate drainage of the sinuses, allowing restoration of normal function 4

Common Pitfalls and Caveats

• Overdiagnosis of sinusitis and unnecessary antibiotic use is common 2, 1
• Failure to address underlying factors (allergies, anatomical abnormalities) may lead to recurrent or chronic sinusitis 1
• Patients should complete the full course of antibiotics to prevent relapse 1
• Sinusitis may be associated with asthma, and some patients with asthma may not respond optimally to therapy until their sinusitis is diagnosed and treated 2, 5