Treatment for Sinus Infection
Acute vs. Chronic Sinusitis: Critical Distinction
The treatment approach fundamentally differs based on whether you're dealing with acute sinusitis (symptoms <4 weeks) or chronic sinusitis (symptoms >3 months), with antibiotics being the mainstay for acute bacterial disease while intranasal corticosteroids and saline irrigation form the cornerstone for chronic disease. 1, 2, 3
Acute Bacterial Sinusitis Treatment
When to Start Antibiotics
Antibiotics are indicated only when bacterial infection is likely, specifically in patients with: 3, 4
- Persistent symptoms lasting >10 days without improvement 5
- Severe symptoms including high fever (≥39°C) and purulent nasal discharge for 3-4 consecutive days 5
- Worsening symptoms after initial improvement (double-worsening pattern) 5
Common pitfall: Do not treat patients with symptoms <7 days duration, as these are predominantly viral and resolve without antibiotics. 4
First-Line Antibiotic Therapy
Amoxicillin remains the first-line antibiotic choice for uncomplicated acute bacterial sinusitis in both adults and children. 1, 3
Adult dosing: 3
- Standard: 500 mg twice daily
- Severe infections: 875 mg twice daily
- Duration: 10-14 days (or until symptom-free for 7 days)
Pediatric dosing: 3
- Standard: 45 mg/kg/day in 2 divided doses
- High-dose (for resistant S. pneumoniae areas): 80-90 mg/kg/day in 2 divided doses
- Risk factors requiring high-dose: age <2 years, daycare attendance, recent antibiotic use
Alternative First-Line Options (Penicillin Allergy)
For true penicillin allergy, use cephalosporins: 3
- Cefuroxime
- Cefpodoxime
- Cefdinir
- Cefprozil
Critical warning: Azithromycin should NOT be used due to significant resistance patterns in S. pneumoniae and H. influenzae, despite being commonly prescribed. 3
Second-Line Therapy (Treatment Failure)
If no improvement after 3-5 days, switch to: 3
- Amoxicillin-clavulanate (provides β-lactamase coverage)
- Adult dose: 875 mg/125 mg twice daily
- Pediatric dose: 80-90 mg/kg/day of amoxicillin component
Special Situations: Complicated Sinusitis
For frontal, ethmoidal, or sphenoidal sinusitis (not maxillary), consider fluoroquinolones: 3, 6
- Levofloxacin 750 mg once daily for 5 days (FDA-approved regimen) 6
- Moxifloxacin (alternative)
Reserve fluoroquinolones for complicated cases or first-line treatment failure—not routine use. 3
Adjunctive Therapies for Acute Sinusitis
Intranasal corticosteroids should be added to antibiotic therapy to reduce inflammation and improve drainage. 3
Short-term oral corticosteroids (e.g., dexamethasone 4 mg) may be used for: 3
- Acute hyperalgic sinusitis (severe pain)
- Marked mucosal edema
- Failure to respond to initial treatment
Supportive measures: 3
- Adequate hydration
- Analgesics for pain
- Warm facial packs
- Sleep with head elevated
Chronic Sinusitis Treatment
First-Line Medical Management
Intranasal corticosteroids are the cornerstone of chronic sinusitis treatment due to their anti-inflammatory effects and documented efficacy. 2
Saline irrigation prevents crusting and facilitates mechanical mucus removal, with hypertonic saline potentially superior to normal saline for mucociliary clearance. 2
Role of Antibiotics in Chronic Disease
Antibiotics play a controversial role in non-infectious chronic sinusitis and should not be primary treatment. 2
For chronic infectious sinusitis with clear bacterial evidence: 2
- Longer duration therapy required (often weeks)
- Must cover anaerobic pathogens
- Consider broader spectrum agents
Common pitfall: Overuse of antibiotics without clear bacterial infection evidence should be avoided. 2
Adjunctive Therapies
Decongestants may provide symptomatic relief by widening ostia, but use cautiously due to potential systemic effects (hypertension, tachycardia). 2
Antihistamines are beneficial specifically for patients with concomitant allergic rhinitis component. 2
When Medical Management Fails
Surgical intervention (endoscopic sinus surgery) becomes the mainstay when conservative therapy fails, with combined medical-surgical treatment achieving >60% cure rates at 3 years. 1, 7
Refer to otolaryngology when: 2
- Sinusitis refractory to usual treatment
- Recurrent sinusitis (≥3 episodes per year)
- Significantly impaired quality of life
- Unusual opportunistic infections
Underlying Conditions to Address
Evaluate and treat: 2
- Allergic rhinitis
- Gastroesophageal reflux disease (GERD)
- Immunodeficiency
- Anatomic abnormalities
Key Clinical Pearls
Complete the full antibiotic course even after symptom improvement to prevent relapse and resistance. 3
The 70-80% clinical response rate with standard amoxicillin therapy remains comparable to broader-spectrum agents despite increasing β-lactamase-producing organisms (20% H. influenzae, 50-70% M. catarrhalis). 1
Imaging is not routinely recommended for diagnosis in primary care but may be helpful in selected cases or to confirm diagnosis in older children (>6 years) and adults. 5, 4