What is the treatment for sinusitis?

Treatment of Sinusitis

For acute bacterial sinusitis, start amoxicillin 10-14 days as first-line therapy; for chronic sinusitis, use intranasal corticosteroids as primary treatment, reserving antibiotics only for acute bacterial exacerbations with systemic symptoms. 1, 2

Acute Bacterial Sinusitis

When to Start Antibiotics

Antibiotics are indicated only when patients meet specific criteria to avoid overdiagnosis and unnecessary treatment 3, 1:

• Persistent symptoms for 10-14 days without improvement 3, 1
• Severe symptoms including high fever (>39°C) with purulent nasal discharge, facial pain/tenderness, or periorbital swelling 3, 4
• Worsening symptoms after initial improvement from a viral upper respiratory infection 4

First-Line Antibiotic Therapy

Amoxicillin is the drug of choice for uncomplicated acute bacterial sinusitis 1:

• Standard dosing for 10-14 days 3, 1
• Effective, inexpensive, and well-tolerated 3
• Alternative: trimethoprim-sulfamethoxazole in adults (though resistance is more common in children) 3

Treatment Failure Protocol

If no improvement after 3-5 days, switch antibiotics 3, 1:

• High-dose amoxicillin-clavulanate (90 mg/kg amoxicillin and 6.4 mg/kg clavulanate, maximum 2g every 12 hours) 3, 2
• Alternative second-line agents: cefuroxime, cefpodoxime, cefprozil, or cefdinir 3
• For penicillin allergy: cephalosporins, macrolides, or quinolones 3, 1

Persistent Disease (21-28 days)

For sinusitis failing to improve after 21-28 days 3:

• Consider broader-spectrum agents: high-dose amoxicillin-clavulanate, cefuroxime, or cefpodoxime 3
• Add anaerobic coverage with clindamycin or metronidazole if needed 3
• Obtain sinus CT scan if not already done 3

Adjunctive Therapy for Acute Sinusitis

Intranasal corticosteroids may be helpful as adjunct to antibiotics, though efficacy is modest 3:

• Reasonable for patients failing initial treatment, those with nasal polyposis, or marked mucosal edema 3
• Short-term oral corticosteroids can be considered in these scenarios 3

Supportive measures 3:

• Adequate rest and hydration 3
• Analgesics as needed 3
• Warm facial packs, steamy showers 3, 5
• Sleep with head of bed elevated 3
• Saline nasal irrigation 5

Chronic Sinusitis (≥8 weeks of symptoms)

First-Line Treatment: NOT Antibiotics

Intranasal corticosteroids are the primary therapeutic intervention for chronic sinusitis 1, 2:

• European guidelines (EPOS 2020) show amoxicillin-clavulanate has no statistically significant benefit over placebo in chronic rhinosinusitis without nasal polyps 2
• Multiple randomized trials found no difference between antibiotics and alternative treatments 2

Daily high-volume saline irrigation is recommended as first-line therapy alongside intranasal corticosteroids 1, 6:

• Enhances mucociliary clearance 6
• Improves sinus drainage 6

When Antibiotics ARE Indicated in Chronic Sinusitis

Reserve antibiotics only for 2:

• Acute bacterial superinfection with systemic symptoms (high fever, severe facial pain, periorbital complications) 2
• Chronic infectious sinusitis requiring longer duration therapy with possible anaerobic coverage 3

If antibiotics are used: amoxicillin-clavulanate 875/125 mg twice daily for 10-14 days or until symptom-free for 7 days 2

Additional Chronic Sinusitis Management

For nasal polyps 1:

• Short course of systemic corticosteroids 1
• Consider doxycycline 1

For marked mucosal edema or severe symptoms failing intranasal corticosteroids 2:

• Short-term oral corticosteroids 2

Surgical intervention 1:

• Consider functional endoscopic sinus surgery for medically resistant disease 3, 1
• Particularly for localized persistent disease in the ostiomeatal complex 3, 1

Recurrent Sinusitis (≥3 episodes/year)

Evaluation for Underlying Causes

Patients with recurrent or chronic sinusitis require evaluation for 3, 1:

• Allergic rhinitis: Test for IgE sensitization to inhalant allergens 3
• Anatomic abnormalities: Septal deviation, middle turbinate deformity, accessory structures blocking drainage 3
• Immunodeficiency: Measure quantitative IgG, IgA, IgM; assess specific antibody responses to tetanus toxoid or pneumococcal vaccine 3
• Other rhinitic conditions: Vasomotor rhinitis, NARES, rhinitis medicamentosa 3
• GERD: Medical treatment may improve sinusitis symptoms 3

Specialist Referral Indications

Consult allergist-immunologist or otolaryngologist when 3, 6:

• Sinusitis refractory to usual antibiotic treatment 3
• Recurrent episodes (≥3 per year) 3
• Associated with chronic otitis media, bronchial asthma, nasal polyps, recurrent pneumonia 3
• Need to clarify allergic or immunologic basis 3
• Evaluation for unusual pathogens or immunodeficiency 3
• Structural abnormalities requiring surgical assessment 3

Critical Pitfalls to Avoid

Overuse of antibiotics 3, 1:

• Most "chronic sinusitis" does not benefit from antibiotics 2
• Appropriate antibiotic criteria: symptoms ≥10-14 days OR severe symptoms with fever and purulent discharge 3, 1

Failure to address underlying factors 1:

• Allergies, anatomical abnormalities, and immunodeficiency lead to recurrent disease if untreated 3, 1
• Chronic hyperplastic eosinophilic rhinosinusitis does not respond to antibiotics 3

Inadequate treatment duration 1:

• Patients must complete full 10-14 day course to prevent relapse 1
• Some physicians continue until symptom-free, then add 7 additional days 4

Missing non-infectious chronic sinusitis 3:

• Consider systemic corticosteroids for chronic hyperplastic sinusitis marked by eosinophils and mononuclear cells 3