What is the recommended treatment for chronic sinusitis?

Treatment of Chronic Sinusitis

For chronic rhinosinusitis, initiate daily high-volume saline irrigation combined with topical intranasal corticosteroids as first-line therapy, with antibiotics reserved only for documented acute bacterial exacerbations, not for routine chronic management. 1, 2

First-Line Medical Management

Topical Intranasal Corticosteroids

• Topical intranasal corticosteroids are the cornerstone of chronic sinusitis treatment, demonstrating significant improvement in overall symptom scores (standardized mean difference -0.46) and reducing polyp recurrence after surgery by 41% 1, 2
• Continue intranasal corticosteroids for at least 3 months, and maintain postoperatively if surgery becomes necessary 1
• These agents reduce inflammation, decrease polyp size, and improve nasal blockage, rhinorrhea, and loss of smell 3

Saline Irrigation

• High-volume saline nasal irrigation significantly improves symptom scores (standardized mean difference 1.42) compared to no treatment 2
• Recommend daily use as part of routine maintenance therapy 1
• Both hypertonic and normal saline preparations are effective with no serious adverse effects 4

The Antibiotic Controversy in Chronic Sinusitis

The role of antibiotics in chronic sinusitis is fundamentally controversial and differs dramatically from acute sinusitis management. 1

When Antibiotics May Be Considered

• For chronic infectious sinusitis with documented bacterial infection, longer duration therapy (minimum 3 weeks) targeting H. influenzae, mouth anaerobes, and S. pneumoniae may be required 1
• For acute bacterial exacerbations superimposed on chronic disease, amoxicillin-clavulanate is a reasonable selection 1
• For chronic sinusitis without polyps, a 3-month course of macrolide antibiotics improved quality of life at 24 weeks (standardized mean difference -0.43), though this represents a single time point benefit 2

Critical Distinction: Infectious vs. Non-Infectious

• In chronic non-infectious sinusitis (chronic hyperplastic sinusitis), systemic corticosteroids should be considered instead of antibiotics 1
• The bacterial etiology in chronic sinusitis is poorly defined, unlike acute sinusitis where S. pneumoniae and H. influenzae predominate 1

Second-Line Therapies

For Patients with Nasal Polyps

• Short-course systemic corticosteroids (1-3 weeks) reduce polyp size for up to 3 months post-treatment and improve polyp scores (standardized mean difference -0.73) 1, 2
• Doxycycline for 3 weeks reduces polyp size compared to placebo 2
• Leukotriene antagonists improve nasal symptoms in polyp patients 2
• Confirm polyp presence or absence, as this is a critical modifying factor for treatment selection 1

Adjunctive Therapies

• Oral decongestants and first-generation antihistamine/decongestant combinations for minimum 3 weeks, combined with 5 days of nasal decongestant, showed efficacy in descriptive studies 1
• However, no prospective randomized trials prove decongestant efficacy in chronic sinusitis 1
• Antihistamines have a role only if underlying allergic rhinitis is present 1

What NOT to Use

Do not prescribe topical or systemic antifungal therapy for chronic sinusitis—systematic reviews of RCTs show lack of efficacy despite significant cost and adverse effects 1

When Medical Therapy Fails

Surgical Consideration

• Functional endoscopic sinus surgery should be considered when documented chronic sinus infection is refractory to maximal medical therapy and anatomic obstruction amenable to surgery is present 1
• Surgery is only recommended after medical treatment failure, not as initial therapy 3
• Continue intranasal corticosteroids postoperatively 1

Specialist Referral Indications

Refer to otolaryngology when: 1

• Sinusitis is refractory to usual treatment
• Recurrent sinusitis occurs
• Need to clarify allergic or immunologic basis
• Significant impact on quality of life and performance
• Associated complications: nasal polyps, asthma, immunodeficiencies, aspirin sensitivity, allergic fungal disease

Underlying Conditions to Address

Evaluate and treat contributing factors: 1

• Allergic rhinitis (most common associated factor)—found in significant proportion of chronic sinusitis patients
• Non-allergic rhinitis—present in 26% of chronic sinusitis patients
• Gastroesophageal reflux disease—medical treatment of GERD results in significant improvement in sinusitis symptoms
• Asthma—medical or surgical management of sinusitis improves asthma outcomes
• Consider immunodeficiency testing if recurrent infections occur

Common Pitfalls

• Overuse of antibiotics: Chronic sinusitis is not primarily a bacterial infection requiring prolonged antibiotics in most cases 1
• Stopping topical corticosteroids too early: These require months of therapy, not days or weeks 1
• Using topical decongestants beyond 5 days: Risk of rhinitis medicamentosa 1
• Failing to distinguish between acute exacerbations and chronic baseline symptoms: Only the former may warrant antibiotics 5