What is the treatment for sinusitis?

Treatment of Sinusitis

For acute bacterial sinusitis, start with amoxicillin as first-line therapy for 10-14 days, and for chronic sinusitis, use intranasal corticosteroids combined with daily high-volume saline irrigation as the foundation of treatment. 1, 2

Acute Bacterial Sinusitis

When to Start Antibiotics

Antibiotics are indicated when patients present with one of three clinical patterns 3:

• Persistent symptoms: Nasal congestion, purulent rhinorrhea, or cough lasting 10-14 days without improvement 1
• Severe onset: High fever (≥39°C) with purulent nasal discharge for 3-4 consecutive days 3
• Worsening symptoms: Initial improvement followed by clinical deterioration 3

First-Line Antibiotic Selection

Amoxicillin remains the first-line choice for uncomplicated acute bacterial sinusitis 1:

• Standard dosing for 10-14 days 1
• For penicillin-allergic patients, use cephalosporins (cefuroxime, cefpodoxime, cefdinir), macrolides, or quinolones 1

Managing Treatment Failure

If no improvement occurs after 3-5 days of initial therapy, switch antibiotics 1:

• For partial response: Continue treatment for another 10-14 days or escalate therapy 4
• For poor response or high-resistance regions: Use high-dose amoxicillin-clavulanate, cefuroxime, cefpodoxime, cefprozil, or cefdinir 4
• For persistent failure after 21-28 days: Consider broader-spectrum agents with or without anaerobic coverage (clindamycin or metronidazole) 4

Critical pitfall: Patients must complete the full antibiotic course to prevent relapse, even if symptoms improve earlier 1

Adjunctive Therapies for Acute Sinusitis

Beyond antibiotics, symptom management includes 5, 6:

• Decongestants (oral or topical) to reduce turbinate swelling and widen ostia 5
• Analgesics for pain control 5
• Steam inhalation and saline irrigation to promote drainage 5
• Avoid antihistamines unless concurrent allergic rhinitis is active, as they can thicken secretions 5

Chronic Sinusitis (≥8 Weeks Duration)

First-Line Medical Management

Intranasal corticosteroids are the cornerstone of chronic sinusitis treatment 2:

• Fluticasone propionate nasal spray: Start adults at 200 mcg daily (two 50-mcg sprays per nostril once daily or 100 mcg twice daily) 7
• Pediatric patients (≥4 years): Begin with 100 mcg daily (one spray per nostril once daily) 7
• Maximum benefit may take several days; some patients respond within 12 hours 7
• These agents reduce mucosal inflammation, improve nasal congestion, and decrease eosinophil infiltration 4, 7

Daily high-volume saline irrigation is equally essential 2, 8:

• Hypertonic saline may be more effective than normal saline for improving mucociliary clearance 4, 2
• Prevents crusting and mechanically removes mucus 2
• Saline irrigation improved symptom scores significantly compared to no treatment (SMD 1.42) 8

Role of Antibiotics in Chronic Sinusitis

Antibiotics have a controversial and limited role in chronic sinusitis 2:

• For chronic infectious sinusitis, longer antibiotic courses (3 months) may be required with attention to anaerobic pathogens 2
• Macrolide antibiotics for 3 months improved quality of life in patients without nasal polyps 8
• Avoid routine antibiotic use in non-infectious chronic sinusitis 2

Additional Therapies for Chronic Sinusitis

For patients with nasal polyps 1, 8:

• Short course (1-3 weeks) of systemic corticosteroids reduces polyp size for up to 3 months 8
• Doxycycline for 3 weeks also reduces polyp size 8
• Leukotriene antagonists improve nasal symptoms in polyp patients 8

Adjunctive measures 2:

• Decongestants for symptomatic relief, but use cautiously due to systemic effects 2
• Mucolytics and expectorants may benefit selected cases 2

Recurrent Sinusitis (≥3 Episodes/Year)

Patients with recurrent or chronic sinusitis require evaluation for underlying factors 4, 1:

• Allergic rhinitis: Test for IgE sensitization to inhalant allergens; treat with environmental control, pharmacotherapy, and consider immunotherapy 4
• Anatomical abnormalities: Septal deviation, middle turbinate deformity, or ostiomeatal obstruction 4
• Immunodeficiency: Measure quantitative IgG, IgA, IgM levels and specific antibody responses, especially if associated with recurrent otitis, bronchitis, or pneumonia 4
• Nasal polyps: May require systemic corticosteroids or surgical intervention 4

Failure to address these underlying conditions leads to treatment failure and recurrence 1

Surgical Intervention

Consider referral to otolaryngology for 4, 2:

• Medically resistant sinusitis despite aggressive therapy 4
• Obstructing nasal polyps after appropriate medical trial 4
• Significant anatomical obstruction (septal deviation compressing middle turbinate, ostiomeatal complex obstruction) 4
• Recurrent sinusitis significantly affecting quality of life 2

Functional endoscopic sinus surgery improves ventilation and drainage for localized persistent disease 1

Common Pitfalls to Avoid

Overdiagnosis and antibiotic overuse 1, 2:

• Only prescribe antibiotics when symptoms persist ≥10-14 days OR severe symptoms (fever + purulent discharge + facial pain) are present 1
• Avoid antibiotics for viral upper respiratory infections that haven't met duration criteria 1

Premature discontinuation of therapy 1:

• Patients must complete the full antibiotic course even with symptom improvement 1

Neglecting underlying conditions 1:

• Always evaluate and treat allergic rhinitis, GERD, and anatomical abnormalities 2
• Chronic sinusitis often requires long-term maintenance with intranasal corticosteroids even after acute treatment 4

Inappropriate use of antihistamines in acute sinusitis 5:

• These agents thicken secretions and impair drainage unless active allergic rhinitis is present 5