What is the treatment for acute sinusitis?

Treatment of Acute Sinusitis

Initial Management: Symptomatic Treatment First

Most cases of acute sinusitis are viral and should be managed with symptomatic treatment alone—antibiotics are reserved only for specific clinical scenarios. 1

First-Line Symptomatic Therapy

• Analgesics (acetaminophen or NSAIDs) should be offered for pain relief in all patients 1
• Saline nasal irrigation promotes mucus clearance and temporarily reduces tissue edema 1
• Topical nasal decongestants may be used short-term (≤3-5 days) to relieve nasal congestion, but prolonged use leads to rebound congestion 1
• Intranasal corticosteroids provide modest but clinically important benefits with a number needed to treat of 14 1

When to Initiate Antibiotics

Antibiotics should only be started when patients meet specific criteria—not at initial presentation. 1

Three Clinical Scenarios Requiring Antibiotics:

1. Persistent symptoms: No improvement after 10-14 days of symptomatic treatment 1, 2
2. Severe symptoms at onset: High fever (≥101°F) with purulent nasal discharge for 3-4 consecutive days 3
3. Worsening symptoms: Initial improvement followed by clinical deterioration ("double-worsening") 1, 3

Antibiotic Selection

First-Line Antibiotic Choice:

• Amoxicillin is the preferred first-line antibiotic—it is generally effective, inexpensive, and well-tolerated 1

For Patients at Risk of Resistant Organisms:

• High-dose amoxicillin-clavulanate (875/125 mg twice daily) is recommended for patients with:
  • Recent antibiotic use (within 30 days)
  • Severe symptoms
  • Geographic areas with high rates of resistant Streptococcus pneumoniae 1, 3

For Penicillin-Allergic Patients:

• Doxycycline or trimethoprim-sulfamethoxazole are appropriate alternatives in adults 1, 2
• Levofloxacin 500 mg daily for 10-14 days or 750 mg daily for 5 days is FDA-approved for acute bacterial sinusitis due to Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis 4

Duration of Antibiotic Therapy:

• 10-14 days is the standard duration, or continue until symptom-free for 7 days 3
• 5-day regimens with higher-dose levofloxacin (750 mg daily) are FDA-approved and show equivalent efficacy 4

Treatment Monitoring and Failure

• If no improvement after 3-5 days of initial antibiotic therapy, switch to a different antibiotic or broader-spectrum coverage 1
• Consider resistant pathogens (Streptococcus pneumoniae, beta-lactamase-producing Haemophilus influenzae or Moraxella catarrhalis) in treatment failures 1, 3

Adjunctive Therapies

• Intranasal corticosteroids are beneficial when marked mucosal edema is present 1
• Short-term oral corticosteroids may be considered for patients who fail initial treatment, though evidence is limited 1
• Guaifenesin has theoretical benefits but insufficient evidence to support routine use 1
• Antihistamines should be avoided unless the patient has concurrent allergic rhinitis, as they may thicken secretions 1, 5

Red Flags Requiring Urgent Evaluation

Immediately refer or obtain imaging for suspected complications:

• Orbital involvement (periorbital edema, vision changes, ophthalmoplegia) 1, 2
• Intracranial extension (severe headache, altered mental status, focal neurologic signs) 1, 2
• Severe systemic toxicity 1

When to Refer to Otolaryngology:

• Sinusitis refractory to standard antibiotic treatment 1
• Recurrent sinusitis (≥3 episodes per year) 1
• Suspected anatomical abnormalities or underlying immunodeficiency 1

Common Pitfalls to Avoid

• Overdiagnosis of bacterial sinusitis leading to unnecessary antibiotic use—most cases are viral 1, 2
• Using antihistamines in non-allergic patients, which thickens secretions and impairs drainage 1, 5
• Prolonged topical decongestant use (>3-5 days) causing rebound congestion 1
• Failure to recognize complications such as orbital cellulitis or intracranial extension requiring urgent intervention 1, 2
• Routine imaging is not recommended for uncomplicated acute sinusitis 2