What is the treatment for sinusitis?

Treatment of Sinusitis

Acute Bacterial Sinusitis

Amoxicillin is the first-line antibiotic for uncomplicated acute bacterial sinusitis, prescribed for 10-14 days. 1

When to Start Antibiotics

Antibiotics are appropriate only when specific criteria are met to avoid overdiagnosis and unnecessary treatment 1:

• Persistent symptoms for 10-14 days without improvement 2, 1
• Severe presentation with high fever (≥39°C) plus purulent nasal discharge for 3-4 consecutive days 3
• Worsening symptoms after initial improvement from a viral upper respiratory infection 3

Initial Antibiotic Selection

First-line therapy: 2, 1

• Amoxicillin (standard dose for adults; 90 mg/kg for children, not exceeding 2g every 12 hours)
• Alternative for penicillin allergy: Trimethoprim-sulfamethoxazole (adults only), cephalosporins, macrolides, or quinolones 2

Treatment Failure Protocol

If no improvement after 3-5 days, switch antibiotics 2, 1:

• High-dose amoxicillin-clavulanate (875/125 mg twice daily for adults; 90 mg/kg amoxicillin with 6.4 mg/kg clavulanate for children) 2, 4
• Alternative second-line agents: Cefuroxime, cefpodoxime, cefprozil, or cefdinir 2
• For persistent failure after 21-28 days: Consider broader-spectrum agents with or without anaerobic coverage (clindamycin or metronidazole) 2

Adjunctive Therapies for Acute Sinusitis

Intranasal corticosteroids may be added to antibiotic therapy, particularly when initial treatment fails, nasal polyposis is present, or marked mucosal edema exists 2:

• Fluticasone propionate 200 mcg daily (two 50-mcg sprays per nostril once daily) 5
• Mometasone furoate is also recommended 4

Supportive measures 2:

• Adequate hydration and rest
• Analgesics for pain control
• Warm facial compresses
• Steam inhalation
• Sleeping with head elevated
• Saline nasal irrigation 6

Decongestants (oral or topical) may provide symptomatic relief but should be used cautiously 6, 7

Common Pitfall

Antihistamines should be avoided in acute sinusitis unless the patient has concurrent symptomatic allergic rhinitis, as they can thicken secretions and impair drainage 6

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Chronic Sinusitis (≥8 weeks duration)

Intranasal corticosteroids are the first-line therapy for chronic sinusitis, NOT antibiotics. 1, 4

Primary Treatment Approach

Intranasal corticosteroids 1, 4, 8:

• Fluticasone propionate 100-200 mcg daily 5
• Continue long-term to control inflammation 7

High-volume saline irrigation daily 1, 8

Role of Antibiotics in Chronic Sinusitis

Antibiotics have LIMITED evidence in chronic sinusitis and should be reserved for specific situations 4:

• Acute bacterial superinfection with systemic symptoms (high fever, severe facial pain, periorbital complications) 4
• Chronic infectious sinusitis may require longer antibiotic courses (duration not well-established), with attention to anaerobic pathogens 2, 1
• European guidelines show amoxicillin-clavulanate has no statistically significant benefit over placebo in chronic rhinosinusitis without nasal polyps 4

When antibiotics ARE used: Amoxicillin-clavulanate 875/125 mg twice daily for 10-14 days or until symptom-free for 7 days 4

Chronic Hyperplastic (Non-infectious) Sinusitis

Systemic corticosteroids should be considered when chronic sinusitis does not respond to antibiotics, suggesting a non-infectious etiology with eosinophilic predominance 2:

• Short course of oral corticosteroids for marked mucosal edema or nasal polyps 1, 4
• Doxycycline may be considered for patients with nasal polyps 1

Evaluation for Underlying Factors

All patients with chronic or recurrent sinusitis (≥3 episodes/year) require evaluation for 2, 1:

• Allergic rhinitis: Test for IgE sensitization to inhalant allergens; treat with environmental control, pharmacotherapy, and immunotherapy 2
• Non-allergic rhinitis: Including vasomotor rhinitis, NARES, rhinitis medicamentosa 2
• Anatomic abnormalities: Septal deviation, middle turbinate abnormalities, ostiomeatal complex obstruction 2
• Nasal polyps 2
• Immunodeficiency: Measure quantitative IgG, IgA, IgM levels and specific antibody responses, especially if associated with recurrent otitis media, bronchitis, or pneumonia 2
• Gastroesophageal reflux disease (GERD): Medical treatment may improve sinusitis symptoms 2
• Cystic fibrosis: Consider in children with nasal polyps or Pseudomonas colonization 2

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Surgical Management

Functional endoscopic sinus surgery should be considered for medically resistant sinusitis, particularly with localized persistent disease in the ostiomeatal complex 2, 1:

• Indicated after aggressive medical management fails 2
• Appropriate for obstructing nasal polyps unresponsive to oral corticosteroids 2
• Improves ventilation and facilitates drainage 7
• Medical treatment of underlying rhinitis must continue postoperatively 7

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Specialist Referral Indications

Consultation with allergist-immunologist or otolaryngologist is warranted when 2:

1. Sinusitis is refractory to usual antibiotic treatment
2. Recurrent sinusitis (≥3 episodes/year)
3. Need to clarify allergic or immunologic basis
4. Associated with unusual opportunistic infections
5. Significantly affects quality of life
6. Concomitant conditions present: chronic otitis media, asthma, nasal polyps, recurrent pneumonia, immunodeficiencies, aspirin sensitivity, allergic fungal disease