What is the recommended treatment for a patient with sinusitis?

SOAP Note for Sinusitis

Subjective

Key symptoms to document:

• Duration of symptoms (critical for classification: <4 weeks = acute, ≥8 weeks = chronic) 1, 2
• Persistent upper respiratory symptoms for ≥10 days without improvement (most common presentation) 1, 2
• Purulent rhinorrhea, nasal congestion, and postnasal drainage 1
• Facial or dental pain, headache, and cough (often worse at night) 1
• Fever, malaise, fatigue, halitosis, and hyposmia in some cases 1
• In children: irritability, vomiting with gagging on mucus 1

Red flag symptoms requiring immediate evaluation:

• Orbital swelling/pain, diplopia, or proptosis 1, 2
• Severe headache with high fever 2
• Neurological signs suggesting intracranial involvement 1

History of underlying conditions:

• Allergic rhinitis, asthma, nasal polyps 1, 3
• Recurrent sinusitis (≥3 episodes/year) 1, 2
• Prior antibiotic failures 1

Objective

Physical examination findings:

• Tenderness over sinuses, periorbital edema, dark circles under eyes 1
• Nasal examination: mucosal edema, purulent secretions 1
• Pharyngeal erythema and lymphoid hyperplasia 1
• Middle ear effusions (common association) 1
• Chest auscultation if cough present (rule out asthma exacerbation) 1, 3

Imaging considerations:

• Plain radiographs NOT routinely necessary for acute sinusitis diagnosis 1
• Consider CT scan only if: symptoms persist >21-28 days despite treatment, recurrent episodes, or suspected complications 1, 2
• Chronic sinusitis requires CT or MRI confirmation 2

Assessment

Acute Bacterial Sinusitis (presumed) when:

• Symptoms persist >10 days without improvement, OR 2, 4
• Severe symptoms (high fever ≥39°C + purulent discharge for 3-4 consecutive days), OR 2, 4
• "Double worsening" (initial improvement then worsening after 5-7 days) 4

Differential diagnoses to exclude:

• Viral upper respiratory infection (symptoms <10 days, improving) 1
• Allergic or non-allergic rhinitis 1
• Nasal polyps, dental infections 1

Plan

First-Line Antibiotic Therapy

For uncomplicated acute bacterial sinusitis:

Amoxicillin 1.5-4 g/day in divided doses for 10-14 days is the first-line choice 1, 5, 4. This provides adequate coverage for S. pneumoniae, H. influenzae, and M. catarrhalis at reasonable cost with good tolerability 1.

• Assess response at 3-5 days 1, 5, 6
• If improving: complete the full 10-14 day course (or continue until symptom-free for 7 days) 1, 5

Second-Line Therapy (if no improvement at 3-5 days)

Switch to high-dose amoxicillin-clavulanate (90 mg/kg amoxicillin component, up to 2g every 12 hours in adults) 1, 5, 6. Recent evidence suggests immediate-release formulations may provide faster symptom relief than extended-release, though with higher diarrhea rates 7.

Alternative options for penicillin allergy:

• Cefuroxime, cefpodoxime, or cefdinir 1, 5
• Respiratory fluoroquinolones (levofloxacin, moxifloxacin) in adults 1
• Azithromycin 500 mg daily × 3 days (FDA-approved dosing) 8, though macrolide resistance is increasing 1

Adjunctive Therapies

Intranasal corticosteroids (e.g., fluticasone, mometasone) to reduce inflammation and promote drainage 1, 5, 6. These are particularly helpful in patients with underlying allergic rhinitis or marked mucosal edema 1, 3.

Comfort measures:

• Adequate hydration and rest 1, 5
• Analgesics (acetaminophen, NSAIDs) for pain 5, 6
• Warm facial compresses 1, 5
• Sleep with head elevated 1, 5
• Saline nasal irrigation 6

Avoid routine use of:

• Oral decongestants (limited evidence, potential side effects) 1
• Antihistamines unless allergic rhinitis confirmed 1

Poor Response After 21-28 Days

Broaden antibiotic coverage:

• High-dose amoxicillin-clavulanate PLUS clindamycin or metronidazole (for anaerobic coverage) 1, 6
• Consider non-compliance, resistant pathogens, or structural abnormalities 1

Obtain sinus CT scan if not already done 1

Refer to specialist:

• Allergist-immunologist for: recurrent sinusitis (≥3 episodes/year), suspected immunodeficiency, evaluation for allergic triggers 1, 2, 6
• Otolaryngologist for: structural abnormalities, nasal polyps, consideration for functional endoscopic sinus surgery 1, 2, 6

Special Populations

Pediatric dosing (≥6 months):

• Acute bacterial sinusitis: 10 mg/kg once daily × 3 days 8
• Alternative: 10 mg/kg day 1, then 5 mg/kg days 2-5 8

Elderly patients:

• No dose adjustment needed with normal renal/hepatic function 8
• Monitor closely for drug interactions and atypical presentations 6
• Higher risk for cardiac arrhythmias with fluoroquinolones 8

Follow-Up

• Recheck in 3-5 days if not improving 5, 6
• No further evaluation needed if complete resolution 1
• For recurrent episodes: evaluate for underlying allergic rhinitis (IgE testing), immunodeficiency (quantitative immunoglobulins, vaccine titers), and anatomic abnormalities (CT scan) 1, 2, 6

Prevention of Recurrences

• Treat underlying allergic rhinitis aggressively (environmental control, pharmacotherapy, immunotherapy) 1, 5, 6
• Avoid cigarette smoke and other irritants 1
• Consider prophylactic intranasal corticosteroids during high-risk seasons 6

Common Pitfalls to Avoid

• Do not prescribe antibiotics for viral rhinosinusitis (symptoms <10 days and improving) 1, 4
• Do not use extended-release amoxicillin-clavulanate formulations if rapid symptom relief is desired (immediate-release may be more effective) 7
• Do not overlook underlying asthma - sinusitis can trigger bronchospasm and worsen asthma control 1, 3
• Do not assume chronic symptoms are infectious - chronic hyperplastic eosinophilic sinusitis requires corticosteroids, not prolonged antibiotics 1