What are the management options for sinusitis symptoms in adults?

Management of Sinusitis Symptoms in Adults

For symptomatic relief of sinusitis in adults, clinicians should recommend analgesics (acetaminophen or ibuprofen), nasal saline irrigation, and topical intranasal corticosteroids, while avoiding routine use of antihistamines and oral steroids. 1

Distinguishing Viral from Bacterial Sinusitis

Before initiating symptom management, it is critical to differentiate between viral rhinosinusitis (VRS) and acute bacterial rhinosinusitis (ABRS), as this determines whether antibiotics are appropriate. 1

• Diagnose ABRS when: 1

  • Symptoms persist ≥10 days without improvement (persistent pattern), OR
  • Symptoms worsen within 10 days after initial improvement (double-worsening pattern)

• VRS is most likely when: 1

  • Symptoms last <7 days
  • Gradual improvement is occurring
  • No severe unilateral facial pain or high fever

First-Line Symptomatic Relief (For Both VRS and ABRS)

Analgesics

• Acetaminophen or ibuprofen should be used to relieve facial pain, headache, and fever. 1
• Pain assessment and management is a strong recommendation for ABRS. 1

Nasal Saline Irrigation

• Saline irrigations (physiologic or hypertonic) effectively relieve nasal congestion, facilitate mucus clearance, and improve mucociliary function. 1
• This intervention has demonstrated consistent benefit in reducing nasal symptom scores. 1

Topical Intranasal Corticosteroids

• Intranasal steroid sprays provide modest symptom relief after 15 days of use. 1
• The number needed to treat is 14 (meaning 14 patients must use them for 1 additional patient to improve). 1
• Side effects include headache, nasal itching, and epistaxis, but these are generally mild. 1
• Despite the modest benefit, the low risk profile makes this a reasonable option based on patient preference. 1

Additional Symptomatic Options

Decongestants

• Oral decongestants (pseudoephedrine) may provide symptomatic relief but should be avoided in patients with hypertension or anxiety. 1
• Topical nasal decongestants can be used for rapid relief but must be limited to 3-5 days maximum to prevent rebound congestion (rhinitis medicamentosa). 1

What to Avoid

Antihistamines

• Antihistamines should NOT be used routinely in non-allergic patients with sinusitis, as they have side effects without proven benefit for symptom relief. 1
• They may be considered only if concurrent allergic rhinitis is present. 1

Oral Corticosteroids

• Oral steroids should not be used routinely for acute sinusitis. 1
• Short-term use may be reasonable only when patients fail initial treatment, demonstrate nasal polyposis, or have marked mucosal edema. 1

Guaifenesin and Dextromethorphan

• Evidence of clinical efficacy is lacking for these agents, and their use should be based on patient preference rather than expected benefit. 1

Antibiotic Considerations (When ABRS is Diagnosed)

If ABRS is confirmed and antibiotics are indicated:

• Watchful waiting (without antibiotics) is an appropriate option for uncomplicated ABRS with mild symptoms. 1

• Most patients improve naturally within 7 days, and antibiotics only modestly increase symptom relief (number needed to treat: 10-15). 1

• If antibiotics are prescribed: 1

  • Amoxicillin with or without clavulanate is first-line therapy for 5-10 days
  • High-dose amoxicillin-clavulanate (875 mg/125 mg every 12 hours) is preferred for more severe infections or treatment failures 1, 2, 3
  • Continue treatment for 7 days after symptom resolution (typically 10-14 days total) 1

Chronic Rhinosinusitis (CRS) Management

For symptoms lasting ≥12 weeks: 1, 4

• Confirm diagnosis with objective evidence of sinonasal inflammation using nasal endoscopy or CT imaging (strong recommendation). 1, 4
• Saline nasal irrigation and/or topical intranasal corticosteroids are recommended for symptom relief. 4
• Short courses of systemic corticosteroids may benefit patients with nasal polyps. 4
• Antifungal therapy is NOT recommended for CRS. 4

Common Pitfalls to Avoid

• Do not rely on mucus color to determine need for antibiotics—purulent discharge reflects neutrophils, not necessarily bacteria. 4
• Do not obtain imaging studies (plain films or CT) for routine acute sinusitis unless complications or alternative diagnoses are suspected. 1
• Do not prescribe azithromycin as first-line therapy—it has weak activity against common sinusitis pathogens and higher failure rates. 2
• Do not use topical decongestants beyond 3-5 days—this causes rebound congestion. 1

Patient Education Points

• Most sinusitis cases (90%) improve naturally within 7-15 days. 1
• Symptomatic relief measures are safe and effective regardless of whether infection is viral or bacterial. 1
• Antibiotics provide only modest benefit and carry risks of adverse effects and bacterial resistance. 1
• Patients should return for reassessment if symptoms worsen at any time or fail to improve after 7 days of treatment. 1