What are the treatment options for sinusitis?

Treatment of Sinusitis

For acute bacterial sinusitis, start with amoxicillin 1.5-4 g/day for 10-14 days as first-line therapy, and for chronic sinusitis, use intranasal corticosteroids as the primary treatment. 1

Acute Sinusitis Management

When to Treat with Antibiotics

• Initiate antibiotics when symptoms persist for 10-14 days without improvement OR when severe symptoms are present (high fever with purulent nasal discharge and facial pain) 1
• Amoxicillin is the first-line antibiotic choice at doses of 1.5-4 g/day for 10-14 days 1, 2

Treatment Algorithm for Acute Disease

Initial therapy:

• Start amoxicillin as outlined above 1
• Add supportive measures: adequate hydration, analgesics, warm facial compresses, steam showers, and sleeping with head elevated 2
• Consider intranasal corticosteroids as adjunctive therapy to reduce inflammation 2

If no improvement after 3-5 days:

• Switch to high-dose amoxicillin-clavulanate (875 mg/125 mg every 12 hours for respiratory infections per FDA dosing) 2, 3
• Alternative options include cefuroxime, cefpodoxime, or cefdinir 4, 2

For partial response after initial course:

• Continue antibiotics for an additional 10-14 days 4
• Alternatively, switch to broader-spectrum agents listed above 4

For poor response after 21-28 days:

• Use high-dose amoxicillin-clavulanate, cefuroxime, or cefpodoxime with or without anaerobic coverage (clindamycin or metronidazole) 4
• Consider CT scan if not already performed 4
• Evaluate for underlying risk factors including allergic rhinitis, anatomic abnormalities, or immunodeficiency 4

Alternative Antibiotics for Penicillin Allergy

• Cephalosporins (cefuroxime, cefpodoxime, cefdinir) 2
• Quinolones or macrolides in regions with high antibiotic resistance 4, 1

Critical Pitfall

Complete the full antibiotic course to prevent relapse, even if symptoms improve earlier 1. Overdiagnosis and unnecessary antibiotic use is common—only prescribe when criteria above are met 1.

Chronic Sinusitis Management (≥8 weeks duration)

First-Line Therapy

Intranasal corticosteroids are the cornerstone of treatment due to their anti-inflammatory effects and documented efficacy in relieving nasal congestion 5

Daily high-volume saline irrigation (150 ml hypertonic 2% saline) is strongly recommended 1:

• Prevents crusting and facilitates mechanical mucus removal 5
• Hypertonic saline may improve mucociliary clearance more effectively than normal saline 5
• Evidence shows improvement in disease-specific quality of life scores at 3 and 6 months compared to usual care 6

Antibiotic Role in Chronic Disease

• For chronic infectious sinusitis, longer antibiotic duration may be required with attention to anaerobic pathogens 5
• Antibiotics play a controversial role in non-infectious chronic sinusitis and should not be primary treatment 5
• Consider chronic hyperplastic eosinophilic rhinosinusitis, which does not respond to antibiotics and may require systemic corticosteroids 4

Adjunctive Therapies

• Decongestants may provide symptomatic relief by widening ostia, but use cautiously due to systemic effects 5
• Antihistamines for patients with concurrent allergic rhinitis component 5
• For nasal polyps, consider short course of systemic corticosteroids or doxycycline 1

Address Underlying Conditions

Evaluate and treat:

• Allergic rhinitis (test for IgE sensitization to inhalant allergens; use environmental control, pharmacotherapy, and consider immunotherapy) 4
• Other rhinitic conditions (vasomotor rhinitis, NARES, rhinitis medicamentosa) 4
• Gastroesophageal reflux disease 2, 5
• Immunodeficiency (measure quantitative IgG, IgA, IgM and specific antibody responses) 4

Recurrent Sinusitis (≥3 episodes/year)

• Evaluate for underlying inflammation, allergy, immunodeficiency, and anatomic abnormalities 4
• Refer to allergist-immunologist for comprehensive evaluation, particularly if associated with otitis media, bronchitis, bronchiectasis, or pneumonia 4
• Consider otolaryngology consultation for structural abnormalities (significant septal deviation, middle turbinate deformity, obstructing polyps) 4

Surgical Management

Consider functional endoscopic sinus surgery for:

• Medically resistant sinusitis 1
• Localized persistent disease within the ostiomeatal complex 1
• Obstructing nasal polyps after appropriate medical trial including oral corticosteroids 4
• Radiographic evidence of ostiomeatal obstruction despite aggressive medical management 4

Key Clinical Caveats

• Low-volume nebulized saline (5 ml) is inferior to intranasal corticosteroids and should not be used as primary therapy 6
• Do not substitute two 250 mg/125 mg amoxicillin-clavulanate tablets for one 500 mg/125 mg tablet—they contain different clavulanic acid ratios 3
• Failure to address underlying allergies or anatomical abnormalities leads to recurrent or chronic disease 1
• In patients with renal impairment (GFR <30 mL/min), avoid the 875 mg/125 mg amoxicillin-clavulanate dose 3