What is the treatment for sinusitis?

Treatment of Sinusitis

For acute bacterial sinusitis, start with amoxicillin as first-line therapy for 10-14 days, and for chronic sinusitis, use intranasal corticosteroids combined with daily high-volume saline irrigation as the foundation of treatment. 1

Acute Bacterial Sinusitis

When to Initiate Antibiotics

Antibiotics are indicated when patients meet specific criteria to avoid overtreatment 1:

• Persistent symptoms: Nasal congestion, purulent rhinorrhea, facial pain, or cough lasting 10-14 days without improvement 1, 2
• Severe presentation: High fever (≥39°C) with purulent nasal discharge for 3-4 consecutive days 2
• Worsening course: Initial improvement followed by symptom deterioration 2

First-Line Antibiotic Therapy

For mild disease in antibiotic-naive patients (no antibiotics in past 4-6 weeks): 3

• Amoxicillin 1.5-4 g/day (preferred first-line) 3, 1
• Amoxicillin-clavulanate 1.75-4 g/250 mg per day 3
• Alternative beta-lactams: cefpodoxime proxetil, cefuroxime axetil, or cefdinir 3

For penicillin-allergic patients: 3

• Doxycycline, trimethoprim-sulfamethoxazole, or macrolides (azithromycin, clarithromycin) may be used, but expect 20-25% bacteriologic failure rates 3

Escalation for Treatment Failures or Moderate Disease

If no improvement after 72 hours or for patients with recent antibiotic exposure (within 4-6 weeks): 3

• Respiratory fluoroquinolones (levofloxacin, moxifloxacin, gatifloxacin) - predicted efficacy 90-92% 3
• High-dose amoxicillin-clavulanate (4 g/250 mg per day) - predicted efficacy 90-92% 3
• Ceftriaxone 1 g IM/IV daily for 5 days 3

Duration and Follow-up

• Complete the full 10-14 day course to prevent relapse 1
• If partial response after initial course, continue for another 10-14 days 3
• If poor response after 21-28 days, consider broader-spectrum coverage including anaerobic agents (clindamycin or metronidazole) 3

Chronic Sinusitis (≥8 weeks duration)

First-Line Medical Management

Intranasal corticosteroids are the cornerstone of chronic sinusitis treatment: 1, 4

• Fluticasone propionate nasal spray: Adults start with 200 mcg once daily (two 50-mcg sprays per nostril), can be given as 100 mcg twice daily 5
• Pediatric patients (≥4 years): Start with 100 mcg once daily, increase to 200 mcg if inadequate response 5
• Maximum benefit may take several days; some improvement may occur within 12 hours 5
• Topical corticosteroids improve overall symptom scores (SMD -0.46), reduce polyp scores (SMD -0.73), and decrease polyp recurrence after surgery (RR 0.59) 6

Daily high-volume saline irrigation: 1, 4

• Improves symptom scores significantly (SMD 1.42) compared to no treatment 6
• Hypertonic saline may enhance mucociliary clearance more effectively than normal saline 4
• Prevents crusting and mechanically removes mucus 4

Adjunctive Therapies for Chronic Sinusitis

For patients with nasal polyps: 1

• Short course of systemic corticosteroids (1-3 weeks) reduces polyp size for up to 3 months (P<0.001) 6
• Doxycycline for 3 weeks reduces polyp size (P<0.001) 6
• Leukotriene antagonists improve nasal symptoms (P<0.01) 6

For chronic infectious sinusitis: 4

• Longer antibiotic courses may be required with attention to anaerobic pathogens 4
• Macrolide antibiotics (3-month course) may improve quality of life in patients without polyps at 24 weeks (SMD -0.43) 6

Decongestants and antihistamines: 4

• Decongestants provide symptomatic relief by widening ostia but use cautiously due to systemic effects 4
• Antihistamines are beneficial only for patients with concomitant allergic rhinitis 4

When to Consider Surgery

Functional endoscopic sinus surgery is indicated for: 1

• Medically resistant sinusitis despite aggressive medical management 1
• Significant anatomic obstruction (septal deviation compressing middle turbinate, obstructing nasal polyps) 3
• Localized persistent disease within the ostiomeatal complex 1

Recurrent Sinusitis (≥3 episodes/year)

Evaluate and address underlying risk factors: 3

• Allergic rhinitis: Test for IgE sensitization to inhalant allergens; treat with environmental control, pharmacotherapy, and consider immunotherapy 3
• Immunodeficiency: Measure quantitative IgG, IgA, IgM levels and specific antibody responses to tetanus toxoid or pneumococcal vaccine 3
• Anatomic abnormalities: Refer to otolaryngology for structural evaluation 3
• Associated conditions: Evaluate for asthma, GERD, and other comorbidities 4

Pediatric Considerations

For children with acute bacterial sinusitis: 3

• High-dose amoxicillin (90 mg/kg/day) or amoxicillin-clavulanate (90 mg/6.4 mg per kg per day) - predicted efficacy 91-92% 3
• Standard-dose amoxicillin (45 mg/kg/day) - predicted efficacy 82-87% 3
• Spontaneous resolution rate in untreated children is 63% 3

Common Pitfalls to Avoid

• Overdiagnosis and antibiotic overuse: Only prescribe antibiotics when symptoms persist ≥10-14 days or severe symptoms with fever and purulent discharge are present 1
• Premature discontinuation: Patients must complete the full antibiotic course to prevent relapse 1
• Ignoring underlying conditions: Failure to address allergies, anatomical abnormalities, or immunodeficiency leads to recurrent disease 1
• Inappropriate antihistamine use: Antihistamines are contraindicated in acute infectious sinusitis unless allergic rhinitis is symptomatic, as they may thicken secretions 7
• Neglecting non-infectious chronic sinusitis: Chronic hyperplastic eosinophilic rhinosinusitis does not respond to antibiotics and requires systemic corticosteroids 3

Specialist Referral Indications

Refer to allergist-immunologist for: 3

• Chronic or recurrent sinusitis with concomitant otitis media, bronchitis, or pneumonia 3
• Evaluation of unusual pathogens and immunodeficiency 3
• Treatment of underlying allergic factors 3

Refer to otolaryngologist for: 3, 4

• Refractory sinusitis despite optimal medical therapy 4
• Structural abnormalities requiring surgical correction 3
• Significantly impaired quality of life 4