What is the best treatment for a 76-year-old female with acute sinusitis, presenting with chills, earache, and sinus symptoms, who has a history of responding well to steroid injections and has tried over-the-counter medications without relief?

Treatment Approach for Acute Sinusitis in a 76-Year-Old Female

For this patient with 3 weeks of sinus symptoms, bilateral middle ear effusions, and no fever, I recommend aggressive supportive therapy with intranasal corticosteroids, nasal antihistamine spray (Astepro), short-term nasal decongestant (3 days maximum), and intensive saline irrigation (2-3 times daily), while withholding antibiotics and systemic steroids at this time. 1, 2

Rationale for Avoiding Antibiotics Initially

• Most acute sinusitis is viral in origin, and antibiotics should be reserved for specific presentations: symptoms persisting beyond 10-14 days without improvement, severe symptoms (high fever with purulent discharge for 3-4 consecutive days), or worsening after initial improvement 1, 2, 3
• This patient has no fever and only chills, which does not meet criteria for bacterial sinusitis requiring immediate antibiotic therapy 1, 2
• Her previous course of amoxicillin 2 months ago did not provide lasting benefit, suggesting either viral etiology or underlying structural/inflammatory issues 1
• Antibiotics provide only modest benefit (number needed to treat of 10-15 people to get one additional person better), while carrying risks of resistance and side effects 1

Rationale for Avoiding Systemic Steroids

• Systemic corticosteroids as monotherapy are ineffective for acute sinusitis 4, 5
• When used as adjunctive therapy with antibiotics, oral steroids provide only modest benefit with a number needed to treat of 7, and this benefit is primarily seen in secondary care settings with radiologically confirmed disease 4, 5
• The patient specifically stated prednisone causes significant side effects ("runs me up," hip and foot pain), making the risk-benefit ratio unfavorable 4
• Short-term use of oral corticosteroids should only be considered when patients fail initial treatment, demonstrate nasal polyposis, or have marked mucosal edema 1

Recommended Supportive Therapy Regimen

Intranasal Corticosteroids

• Continue or optimize intranasal corticosteroid use (Flonase or Nasacort) with proper technique, as these provide clinically important benefits for symptom relief 1, 2
• The number needed to treat is 14 for intranasal steroids, which is reasonable given minimal side effects 1

Nasal Antihistamine Spray

• Add Astepro (azelastine) nasal spray as an antihistamine spray, which can be particularly helpful given her history of severe environmental allergies 2, 6
• This addresses the underlying allergic component that likely predisposes her to recurrent sinus issues 1, 6

Short-Term Nasal Decongestant

• Use topical nasal decongestant for maximum 3 days to powerfully open sinus passages and facilitate drainage 1, 2, 7
• Critical warning: Do not exceed 3 days to avoid rebound congestion (rhinitis medicamentosa) 2, 7

Intensive Saline Irrigation

• Increase nasal saline rinses to 2-3 times daily (currently doing once daily) to promote mucus clearance and reduce tissue edema 1, 2, 7
• This is a cornerstone of therapy with no side effects 1, 2

Analgesics

• Acetaminophen or ibuprofen for pain relief as needed for ear pain and facial discomfort 1, 2

Critical Red Flags Requiring Urgent Attention

This patient has unilateral left-sided symptoms that are worse, which raises concern for:

• Fungal sinusitis or tumor: Unilateral sinus disease frequently indicates these conditions and may require biopsy 8
• Fungus ball (mycetoma): Typically presents as unilateral maxillary sinus disease requiring surgical intervention 8
• The patient has chronic left-sided Eustachian tube dysfunction with persistent middle ear effusions that may indicate structural obstruction 8

Immediate Imaging and Referral Indications

• CT scan of sinuses is strongly recommended for this patient given unilateral predominance of symptoms, chronic recurrent nature, and persistent middle ear effusions 8
• ENT referral should be initiated now (she already has an established ENT in Clayton, Georgia) rather than waiting for treatment failure 8
• The combination of unilateral symptoms, 10-year history of left-sided problems, and persistent fluid behind both eardrums warrants direct visualization with nasal endoscopy 8

Follow-Up Timeline

• Return in 10 days if not improving or symptoms are stable but not resolving 1, 2
• Return immediately if worsening (high fever, severe facial pain, visual changes, periorbital swelling, neurological symptoms) 1
• If improved but not resolved at 10 days, continue supportive therapy and proceed with ENT referral 1, 2

When to Initiate Antibiotics

If the patient returns without improvement after 10 days of aggressive supportive therapy:

• Start high-dose amoxicillin-clavulanate (not plain amoxicillin, which failed previously) to cover β-lactamase-producing organisms 1, 3
• Alternative for penicillin allergy: doxycycline or trimethoprim-sulfamethoxazole 1, 2
• Duration: 10-14 days, continuing for 7 days after symptom resolution 1
• Reassess after 3-5 days of antibiotic therapy; if no improvement, switch to broader-spectrum coverage 1, 2

Addressing Underlying Predisposing Factors

• Severe environmental allergies documented by previous testing require ongoing management with daily intranasal corticosteroids and consideration of immunotherapy 1, 6
• Chronic left-sided anatomical issues may require functional endoscopic sinus surgery to improve ventilation and drainage 1
• Gastroesophageal reflux disease (patient on pantoprazole) can contribute to chronic sinusitis and should be optimally managed 1

Common Pitfalls to Avoid

• Do not use oral antihistamines (like the previously prescribed Allegra) unless actively treating allergic rhinitis, as they can thicken secretions and worsen sinus drainage 1, 2, 6
• Do not prescribe antibiotics reflexively for viral rhinosinusitis, which leads to unnecessary antibiotic resistance 1, 2
• Do not ignore unilateral symptoms, which require more aggressive workup than bilateral disease 8
• Do not use topical decongestants beyond 3 days, as this causes rebound congestion 2, 7
• Do not delay ENT referral in patients with recurrent sinusitis, unilateral disease, or chronic middle ear effusions 1, 8, 2