What is the recommended treatment for chronic sinusitis?

Treatment of Chronic Sinusitis

Intranasal corticosteroids combined with daily high-volume saline irrigation should be initiated as first-line therapy for all patients with chronic sinusitis, regardless of polyp status. 1, 2

First-Line Medical Management

Core Therapies (Start These First)

• Intranasal corticosteroids reduce inflammation, decrease nasal polyp size, and improve nasal blockage, rhinorrhea, and loss of smell, and should be used daily as maintenance therapy 2, 3
• High-volume saline nasal irrigation (not just spray) clears mucus, reduces inflammation, improves medication delivery to sinonasal mucosa, and significantly improves symptom scores (standardized mean difference 1.42) 1, 2, 3
• Combined use provides superior effectiveness compared to either treatment alone and should be continued long-term 2

When to Add Antibiotics

The role of antibiotics in chronic sinusitis is controversial and limited, but consider a minimum 3-week course in these specific situations: 4, 1

• Evidence of active bacterial superinfection (purulent discharge, fever, acute worsening)
• Target coverage: H. influenzae, anaerobes, and S. pneumoniae 4
• If no improvement within 3-5 days, switch to alternative antibiotics such as high-dose amoxicillin-clavulanate, cefuroxime, or respiratory fluoroquinolones 4, 1
• Amoxicillin is generally first-line when antibiotics are indicated (10-14 days for acute exacerbations) 4
• For chronic infectious sinusitis specifically, consider longer courses (minimum 3 weeks) 4, 1

Critical pitfall: Avoid routine antibiotic use in chronic sinusitis without evidence of acute bacterial infection, as efficacy is not well-established for chronic inflammation alone. 3

Second-Line Therapies for Inadequate Response

For Patients WITH Nasal Polyps

• Short course of oral corticosteroids (1-3 weeks) reduces polyp size for up to 3 months and provides rapid symptomatic improvement 1, 3
• Doxycycline 3-week course reduces polyp size compared to placebo for 3 months 3
• Leukotriene antagonists improve nasal symptoms in polyp patients 3

For Patients WITHOUT Nasal Polyps

• Macrolide antibiotic for 3 months (not short courses) may improve quality of life, with benefits seen at 24 weeks after therapy 3
• This is distinct from short antibiotic courses and represents anti-inflammatory rather than antimicrobial therapy

Adjunctive Measures

• Oral decongestants may provide symptomatic relief but can cause systemic side effects (hypertension, CNS stimulation, insomnia, urinary retention) 2
• Topical decongestants (oxymetazoline) should be limited to maximum 5 days to prevent rhinitis medicamentosa (rebound congestion) 4, 2
• Adequate hydration, warm facial packs, sleeping with head elevated 4

Surgical Intervention

Consider endoscopic sinus surgery when: 1, 2

• Documented chronic sinus infection refractory to medical therapy (failed 3+ months of appropriate treatment)
• Anatomic obstruction amenable to surgical correction
• Localized persistent disease within the ostiomeatal complex
• Nasal polyps unresponsive to medical therapy including oral corticosteroids

Post-surgical management: Continue intranasal corticosteroids indefinitely to maintain symptom control and reduce polyp recurrence (relative risk 0.59) 2, 3

Evaluation for Underlying Conditions

Assess and treat contributing factors that perpetuate chronic sinusitis: 1, 2

• Allergic rhinitis: Consider allergen testing and appropriate management
• Immunodeficiency: Check immunoglobulin levels and functional antibody tests in refractory cases
• GERD: Treat if present
• Aspirin sensitivity: Screen in patients with polyps and asthma
• Structural abnormalities: Deviated septum, concha bullosa

When to Refer to Specialist

Refer to otolaryngology when: 2, 5

• Failure to respond to first-line medical therapy after 3 months
• Recurrent acute exacerbations despite maintenance therapy
• Significant quality of life impairment despite treatment
• Consideration for endoscopic sinus surgery

Consider allergy/immunology referral for suspected allergic rhinitis, immunodeficiency, aspirin sensitivity, or refractory disease 1

Common Pitfalls to Avoid

• Do not use short courses of antibiotics (10-14 days) for chronic sinusitis unless treating acute bacterial superinfection 4, 3
• Do not use topical decongestants beyond 3-5 days due to rebound congestion risk 4, 2
• Do not rely on antihistamines unless allergic rhinitis is documented; they have anticholinergic effects that may thicken secretions 4
• Do not discontinue intranasal corticosteroids after surgery; they prevent polyp recurrence 2, 3
• Do not use macrolides as short courses; if using for anti-inflammatory effect, commit to 3-month duration 3