What are the treatment options for sinusitis?

Treatment of Sinusitis

For acute sinusitis, start with amoxicillin for 10-14 days as first-line therapy, targeting the most common pathogens (S. pneumoniae, H. influenzae, M. catarrhalis), and switch to high-dose amoxicillin-clavulanate or cefuroxime if no improvement occurs within 3-5 days. 1

Acute Sinusitis Management

Antibiotic Therapy

First-line treatment:

• Amoxicillin is the drug of choice for both children and adults due to its effectiveness, low cost, and tolerability, with a 70-80% clinical response rate 1
• Duration should be 10-14 days total, continuing for 7 days after symptom resolution to ensure complete bacterial eradication 1
• For penicillin-allergic patients, use trimethoprim-sulfamethoxazole in adults, or second-generation cephalosporins (cefaclor) or macrolide/sulfonamide combinations (erythromycin-sulfisoxazole) 1

When to escalate therapy (after 3-5 days without improvement):

• Switch to high-dose amoxicillin-clavulanate or cefuroxime axetil 1
• These agents provide coverage against β-lactamase-producing organisms (20% of H. influenzae, 50-70% of M. catarrhalis) 1
• Alternative: Azithromycin 500 mg daily for 3 days achieves 88% clinical cure rates at Day 10 2

Indications for antibiotics:

• Symptoms persisting >10 days without improvement 3
• Severe symptoms with high fever and purulent discharge for 3-4 consecutive days 4
• Worsening symptoms after initial improvement 4

Adjunctive Therapies

Nasal corticosteroids:

• Should be used in all patients, especially those with marked mucosal edema, nasal polyps, or failure to respond to initial treatment 1
• Reduce inflammation and promote sinus drainage 1

Decongestants and drainage promotion:

• Oral or topical decongestants help widen ostia and reduce turbinate swelling 5
• Topical decongestants should not exceed 3 days to avoid rebound congestion 6
• Saline irrigation prevents crusting and facilitates mechanical mucus removal 5, 3

Oral corticosteroids:

• Consider as adjunct when patients fail initial treatment, have nasal polyposis, or marked mucosal edema 1

Common Pitfalls

• Do not use imaging routinely - plain radiographs have significant false-positive and false-negative results 1
• Avoid prescribing antibiotics for viral upper respiratory infections (viruses isolated in only 15% of cases) 1
• Ensure patients complete the full antibiotic course to prevent relapse 1

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Chronic Sinusitis Management

First-Line Approach

Intranasal corticosteroids are the cornerstone of chronic sinusitis treatment due to their anti-inflammatory effects and documented efficacy 5

Saline irrigation prevents secretion crusting and facilitates mechanical mucus removal, with hypertonic saline potentially superior to normal saline 5

Antibiotic Considerations

• Longer duration therapy may be required for chronic infectious sinusitis, with attention to anaerobic pathogens (Bacteroides, Peptostreptococcus, Fusobacterium, Veillonella) 1, 5
• Antibiotics should target both anaerobes and aerobes (viridans streptococci, S. pneumoniae, H. influenzae, M. catarrhalis) 1
• Antibiotics play a controversial role in non-infectious chronic sinusitis and should not be primary treatment 5
• Conservative medical therapy alone succeeds in only one-third of chronic cases 1

Surgical Intervention

• Surgery is the mainstay for refractory chronic sinusitis, facilitating drainage through artificial ostium creation and diseased tissue resection 1
• Combined medical and surgical treatment achieves >60% cure rate at 3 years 1

Special Considerations

Evaluate and treat underlying conditions:

• Allergic rhinitis (use antihistamines for patients with allergic component) 5
• Gastroesophageal reflux disease 5
• Immunodeficiency 5
• Asthma (sinusitis can trigger or worsen bronchial hyperresponsiveness) 1

Refer to specialist when:

• Sinusitis is refractory to standard treatment 5, 3
• Recurrent episodes (>3-4 per year) 3
• Complications present (facial swelling, visual changes, proptosis, periorbital inflammation, neurologic signs) 1
• Nasal polyps in children (evaluate for cystic fibrosis) 1

Critical Warning Signs

Immediately evaluate for complications:

• Facial swelling or erythema over involved sinus 1
• Visual changes or abnormal extraocular movements 1
• Proptosis or periorbital inflammation 1
• Any neurologic signs suggesting intracranial involvement 1