What is the treatment for episodes of sinusitis and allergic rhinitis?

Treatment of Sinusitis and Allergic Rhinitis

For allergic rhinitis, intranasal corticosteroids are the first-line treatment for patients whose symptoms affect quality of life, while acute bacterial sinusitis requires antibiotics only when symptoms persist beyond 7-10 days or are severe. 1

Allergic Rhinitis Management

First-Line Pharmacotherapy

• Intranasal corticosteroids (fluticasone, mometasone, triamcinolone, budesonide) are the most effective medication class for controlling all major symptoms including nasal congestion, rhinorrhea, sneezing, and itching. 1, 2, 3

• These agents work by blocking multiple inflammatory mediators (histamine, prostaglandins, cytokines, leukotrienes), not just histamine alone like oral antihistamines. 4

• Maximum effect may take several days, so regular daily use is essential rather than as-needed dosing. 4

Second-Line Options

• Second-generation oral antihistamines (cetirizine, loratadine, fexofenadine, desloratadine) are recommended for patients with primary complaints of sneezing and itching. 1, 3

• Intranasal antihistamines (azelastine, olopatadine) may be offered for seasonal, perennial, or episodic allergic rhinitis. 1, 3

• Oral leukotriene receptor antagonists (montelukast) should NOT be offered as primary therapy for allergic rhinitis. 1, 5

Combination Therapy

• Combination pharmacologic therapy may be offered when monotherapy provides inadequate response. 1

• The combination of intranasal corticosteroid plus intranasal antihistamine is more effective than either alone for moderate to severe persistent allergic rhinitis. 3

Severe or Intractable Cases

• A short course (5-7 days) of oral corticosteroids may be appropriate for very severe or intractable symptoms, but single or recurrent parenteral corticosteroid administration is contraindicated due to greater potential for long-term side effects. 1, 5

Allergen Avoidance and Environmental Controls

• Advise avoidance of known allergens or environmental controls (removal of pets, air filtration systems, bed covers, acaricides) when specific allergens correlate with clinical symptoms. 1

• For severe seasonal allergic rhinitis, patients should stay inside air-conditioned buildings with windows and doors closed whenever possible. 1

Immunotherapy

• Offer or refer for immunotherapy (sublingual or subcutaneous) for patients with inadequate response to pharmacologic therapy with or without environmental controls. 1

• Allergen immunotherapy may prevent development of new allergen sensitizations and reduce future risk of asthma in patients with allergic rhinitis. 1

Sinusitis Management

Acute Bacterial Rhinosinusitis (ABRS)

• Antibiotics are indicated only when symptoms persist beyond 7-10 days or when symptoms are severe at onset. 1, 6, 7

• Most acute upper respiratory infections lasting less than 7 days are viral and do not require antibiotic treatment. 1, 7

Antibiotic Selection

• First-line: Amoxicillin or trimethoprim-sulfamethoxazole for uncomplicated cases. 1

• For poor response or regions with high antibiotic resistance: High-dose amoxicillin-clavulanate, cefuroxime, cefpodoxime, cefprozil, or cefdinir. 1

• Quinolones, macrolides, and ketolides may also be considered. 1

• For sinusitis failing to improve after 21-28 days, consider broader-spectrum agents with or without anaerobic coverage (clindamycin or metronidazole). 1

Adjunctive Therapies

• Nasal saline irrigations are beneficial for promoting drainage and reducing symptoms. 1

• Oral and topical decongestants may be used to promote drainage, but topical decongestants should be limited to less than 3 days to avoid rhinitis medicamentosa. 1, 2

• Intranasal corticosteroids may be beneficial, particularly when underlying allergic rhinitis is present. 1, 8

Recurrent Sinusitis and Underlying Risk Factors

Evaluation for Underlying Causes

• Patients with chronic or recurrent sinusitis (≥3 episodes per year) should be evaluated for underlying inflammation, allergy, immunodeficiency, and anatomic abnormalities. 1

• Perform or refer for specific IgE allergy testing (skin or blood) when allergic rhinitis is suspected as a contributing factor. 1

Treatment of Underlying Allergic Rhinitis

• Treating coexisting allergic rhinitis is essential, as sinusitis is a common complication of allergic rhinitis due to inflammation and obstruction of sinus ostia. 1, 8, 6

• Emphasis of therapy includes environmental control, pharmacotherapy with intranasal corticosteroids, and in selected patients, allergen immunotherapy. 1

When to Refer

• Consider consultation with an allergist-immunologist for treatment of underlying allergic factors, evaluation of unusual pathogens, immunodeficiency, or when symptoms are inadequately controlled. 1

• Consider consultation with an otolaryngologist for structural abnormalities, severe nasal septal deviation, obstructing nasal polyps, or refractory sinusitis despite aggressive medical management. 1

Important Caveats

• Radiographic imaging (CT scan) is not required for diagnosis of acute uncomplicated sinusitis but is indicated for chronic sinusitis or treatment failures. 1, 7

• Assess for comorbid conditions including asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, and otitis media, as these frequently coexist with allergic rhinitis. 1

• First-generation antihistamines should be avoided due to sedative and anticholinergic effects. 2

• Treatment of allergic rhinitis may improve asthma control in patients with coexisting conditions. 1