Treatment for Frontal Sinusitis
First-Line Antibiotic Therapy
For frontal sinusitis, fluoroquinolones active against pneumococci (levofloxacin 500-750 mg daily or moxifloxacin 400 mg daily) should be used as first-line therapy due to the high risk of serious complications, rather than reserving them for treatment failures. 1
Frontal sinusitis is specifically identified as a high-risk location requiring aggressive initial treatment because of the potential for life-threatening intracranial complications including meningitis, subdural empyema, brain abscess, and osteomyelitis of the frontal bone. 1, 2, 3, 4, 5
Recommended Antibiotic Regimens
Primary options:
- Levofloxacin 500 mg once daily for 10-14 days 1, 6
- Levofloxacin 750 mg once daily for 5 days (alternative shorter course) 6
- Moxifloxacin 400 mg once daily for 10 days 1, 7
These respiratory fluoroquinolones are specifically recommended for frontal sinusitis because they provide adequate coverage against Streptococcus pneumoniae (including multi-drug resistant strains), the most common pathogen, and penetrate well into sinus tissues. 1, 8, 6
Alternative first-line options if fluoroquinolones are contraindicated:
- Amoxicillin-clavulanate (high-dose) 1, 9
- Second-generation cephalosporins: cefuroxime-axetil 1, 9
- Third-generation cephalosporins: cefpodoxime-proxetil or cefotiam-hexetil 1, 9
- Pristinamycin (for beta-lactam allergies) 1, 10
Critical Distinction from Uncomplicated Sinusitis
The guidelines explicitly distinguish frontal sinusitis from maxillary sinusitis. While maxillary sinusitis can be treated with amoxicillin-clavulanate or cephalosporins as first-line, frontal sinusitis warrants immediate use of respiratory fluoroquinolones due to anatomic proximity to intracranial structures. 1, 8
Common pitfall: Do not use ciprofloxacin for frontal sinusitis—it has inadequate coverage against S. pneumoniae with an AUC-to-MIC ratio of only 10-20 versus the required 25-30. 8
Adjunctive Therapies
- Short-course corticosteroids may be beneficial as adjuvant therapy in acute hyperalgic (severe pain) frontal sinusitis 1, 10, 9
- NSAIDs at anti-inflammatory doses have NOT been proven effective and should not be relied upon 1, 10
- Supportive measures: adequate hydration, analgesics, warm facial packs, sleeping with head elevated 10
Indications for Immediate Hospitalization and Surgical Intervention
Hospitalize immediately and consult neurosurgery/ENT if any of the following develop:
- Neurological signs: altered mental status, focal deficits, seizures 10, 2, 5
- Visual disturbances suggesting orbital involvement 10, 4
- Signs of meningeal irritation 10, 5
- Severe, persistent headache despite treatment 10, 2
- Imaging showing intracranial extension or osteomyelitis 3, 4
Surgical drainage combined with IV antibiotics is required for complications including subdural empyema, brain abscess, epidural abscess, orbital abscess, or frontal bone osteomyelitis. 3, 4, 5 Even with modern antibiotics, these complications still occur and require aggressive combined medical-surgical management to prevent mortality. 3, 4
Treatment Duration and Monitoring
- Standard duration: 7-10 days for uncomplicated frontal sinusitis 1, 9
- Extended duration: 10-14 days may be needed for severe cases 1, 6
- Reassess at 3-5 days: If no clinical improvement, obtain imaging (CT or MRI) and consider ENT referral 8, 9
Microbiological Considerations
The most common pathogens in frontal sinusitis are Streptococcus pneumoniae (including MDRSP), Haemophilus influenzae, and Moraxella catarrhalis. 6 In complicated cases with osteomyelitis or abscess formation, Staphylococcus aureus and Streptococcus species are frequently isolated. 4
Obtain cultures via antral tap or surgical drainage when: