What is the treatment for acute sinusitis?

Treatment of Acute Sinusitis

The treatment of acute sinusitis should begin with symptomatic management including analgesics, nasal saline irrigation, and short-term decongestants, with antibiotics reserved only for cases with severe symptoms, symptoms lasting more than 10-14 days without improvement, or worsening symptoms after initial improvement. 1, 2

Diagnosis and Classification

• Acute sinusitis is defined as symptoms and signs lasting less than 4 weeks 1
• Patients with symptoms for fewer than 7 days are unlikely to have bacterial infection and should be managed symptomatically 2
• Radiographic imaging is generally not necessary for uncomplicated sinusitis due to high rates of false positives and negatives 2

First-Line Treatment: Symptomatic Management

• Pain medications (acetaminophen or NSAIDs) should be offered for pain relief and fever reduction 1, 2
• Saline nasal irrigation promotes mucus clearance and temporarily reduces tissue edema 1
• Topical nasal decongestants may be used short-term (no more than 3 days) to relieve nasal congestion to avoid rebound congestion 1, 3
• Adequate hydration, rest, warm facial packs, steamy showers, and sleeping with head elevated are beneficial supportive measures 2
• Intranasal corticosteroids provide modest but clinically important benefits, with a number needed to treat of 14 1

Antibiotic Therapy: When to Use

• Antibiotics should be reserved for specific scenarios:
  • Symptoms lasting more than 10-14 days without improvement
  • Severe symptoms (high fever and purulent nasal discharge for 3-4 consecutive days)
  • Worsening symptoms after initial improvement 1, 2

Antibiotic Selection

• Amoxicillin is the first-line antibiotic choice - effective, inexpensive, and well-tolerated 1, 2
• Standard course is 10-14 days or until the patient is well for 7 days 2
• For patients at risk of resistant organisms, high-dose amoxicillin-clavulanate is recommended 1
• Alternative antibiotics for penicillin-allergic patients:
  • Mild disease: trimethoprim-sulfamethoxazole or doxycycline 1, 3
  • Moderate disease: fluoroquinolones (such as levofloxacin) 2, 4

Treatment Monitoring and Adjustment

• Assess response after 3-5 days of treatment 1, 2
• If not improving, switch to broader-spectrum antibiotics such as:
  • High-dose amoxicillin-clavulanate
  • Cefuroxime
  • Cefpodoxime
  • Other second-generation cephalosporins 2, 5
• If symptoms worsen (especially with headache or high fever), patients should contact their physician 2

Adjunctive Therapies

• Intranasal corticosteroids are particularly beneficial when there is marked mucosal edema or underlying allergic rhinitis 1, 2
• Short-term oral corticosteroids may be considered for patients who fail to respond to initial treatment 1, 2
• Guaifenesin has theoretical benefits but insufficient evidence in sinusitis 1
• Antihistamines should be avoided unless the patient has concurrent allergic rhinitis, as they may thicken secretions 1, 6

Special Considerations

• Evaluate for underlying risk factors in recurrent or chronic cases (allergic rhinitis, structural abnormalities) 1, 2
• Consider referral to a specialist if symptoms persist despite appropriate therapy 2
• Dental-related sinusitis (5-10% of cases) is typically unilateral and requires dental care along with sinus drainage and broad-spectrum antibiotics 7

Common Pitfalls to Avoid

• Overdiagnosis of bacterial sinusitis leading to unnecessary antibiotic use 1, 2
• Using antihistamines in non-allergic patients 1
• Prolonged use of topical decongestants beyond 3 days, which can lead to rebound congestion 1, 3
• Using broad-spectrum antibiotics as initial therapy when narrow-spectrum would suffice 2
• Inadequate duration of antibiotic therapy 2
• Failure to recognize complications requiring urgent intervention, such as orbital cellulitis or intracranial extension 1