What is the recommended treatment for chronic sinusitis?

Treatment of Chronic Sinusitis

First-line treatment for chronic sinusitis consists of daily high-volume nasal saline irrigation combined with intranasal corticosteroid sprays, as this combination has the strongest evidence for improving symptoms and quality of life. 1, 2

Initial Medical Management

Primary Therapy (All Patients)

• Nasal saline irrigation should be performed daily using high-volume technique, as it significantly improves symptom scores compared to no treatment (standardized mean difference 1.42,95% CI 1.01-1.84) 1
• Intranasal corticosteroid sprays should be used continuously, as they improve overall symptom scores (standardized mean difference -0.46,95% CI -0.65 to -0.27) and are particularly effective in patients with nasal polyps 1, 2

Treatment Based on Polyp Status

For patients WITH nasal polyps:

• Continue saline irrigation and topical corticosteroids as maintenance therapy 1
• Consider a short course (1-3 weeks) of oral corticosteroids for acute exacerbations, as this reduces polyp size for up to 3 months (P < .001) 1
• Doxycycline 3-week course is an alternative option that reduces polyp size compared to placebo 1
• Leukotriene antagonists (e.g., montelukast) improve nasal symptoms compared to placebo (P < .01) and can be added as adjunctive therapy 1
• Topical corticosteroids reduce polyp recurrence after surgery by 41% (relative risk 0.59,95% CI 0.45-0.79) 1

For patients WITHOUT nasal polyps:

• Continue saline irrigation and topical corticosteroids as maintenance therapy 1, 2
• Consider a 3-month course of macrolide antibiotic (e.g., azithromycin, clarithromycin) if symptoms persist despite first-line therapy, as this improves quality of life at 24 weeks (standardized mean difference -0.43,95% CI -0.82 to -0.05) 1
• Note: Macrolides are used for their anti-inflammatory properties, not antimicrobial effects, in chronic sinusitis 1

Role of Antibiotics in Chronic Sinusitis

Critical Distinction

• Antibiotics should only be used for acute bacterial exacerbations superimposed on chronic sinusitis, not as routine maintenance therapy 2
• The role of bacterial infection in chronic sinusitis is controversial, and routine antibiotic use is not supported 3

When Acute Bacterial Exacerbation is Suspected:

• Use antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae 3
• Minimum 3-week course is recommended for acute exacerbations of chronic sinusitis 3
• First-line options include amoxicillin (500 mg twice daily) or amoxicillin-clavulanate (500-875 mg twice daily) 3
• For penicillin-allergic patients, use cephalosporins (cefuroxime, cefpodoxime, cefprozil) or fluoroquinolones (levofloxacin, moxifloxacin) 3, 4
• Azithromycin should NOT be used for acute bacterial exacerbations due to high resistance rates in S. pneumoniae and H. influenzae 4

Adjunctive Therapies

Decongestants

• Oral or topical decongestants may provide symptomatic relief, though evidence is limited 3, 5
• Topical decongestants (e.g., oxymetazoline) should not exceed 3-5 days to avoid rebound congestion (rhinitis medicamentosa) 3, 5

Antihistamines

• First-generation antihistamine/decongestant combinations may be beneficial if allergic rhinitis is an underlying factor 3
• Use minimum 3 weeks when treating chronic sinusitis with underlying allergic component 3
• Non-sedating antihistamines have no proven role in chronic sinusitis without allergic rhinitis 5, 6

Treatment Algorithm for Refractory Cases

Step 1: Optimize Medical Therapy (3 months minimum)

• Ensure compliance with high-volume saline irrigation and intranasal corticosteroids 1, 2
• Add polyp-specific or non-polyp-specific therapies as outlined above 1

Step 2: Evaluate for Underlying Conditions

• Allergic rhinitis: Test for IgE sensitization to inhalant allergens 7
• Immunodeficiency: Check quantitative IgG, IgA, IgM levels and specific antibody responses 7
• Anatomic abnormalities: Consider CT imaging if not already performed 2
• Other conditions: Vasculitides, granulomatous diseases, cystic fibrosis 2

Step 3: Referral Criteria

• Refer to otolaryngologist if symptoms persist after 3 months of optimal medical therapy 2
• Refer to allergist if allergic rhinitis or immunodeficiency suspected 7, 2
• Consider endoscopic sinus surgery for anatomic obstruction or medical therapy failure 3, 2

Common Pitfalls to Avoid

• Do not use antibiotic prophylaxis for chronic sinusitis—there is no evidence supporting this approach 7
• Do not use macrolides as first-line therapy for acute bacterial exacerbations due to weak activity against resistant organisms 7
• Do not reserve fluoroquinolones for first-line use—they should be second-line agents to prevent resistance 4, 7
• Do not use topical decongestants beyond 3-5 days to prevent rebound congestion 3, 5
• Do not treat viral upper respiratory infections with antibiotics—this is inappropriate and strongly discouraged 3
• Do not assume all chronic sinusitis requires antibiotics—the primary pathophysiology is inflammatory, not infectious 1, 2