What are the management options for sinusitis?

Management of Sinusitis

Acute Bacterial Sinusitis

Amoxicillin at 1.5-4 g/day for 10-14 days is the first-line antibiotic for uncomplicated acute bacterial sinusitis. 1, 2

When to Start Antibiotics

Antibiotics are indicated when patients meet specific criteria—not for all upper respiratory symptoms:

• Persistent symptoms: Nasal congestion, purulent rhinorrhea, postnasal drainage, facial/dental pain, headache, or cough lasting 10-14 days without improvement 1
• Severe presentation: High fever (≥39°C) with purulent nasal discharge and facial pain for 3-4 consecutive days 1, 3
• Worsening course: Initial improvement followed by symptom deterioration 3

Antibiotic Selection Algorithm

First-line therapy:

• Amoxicillin 1.5-4 g/day divided doses for 10-14 days 1, 2

If no improvement after 3-5 days:

• Switch to high-dose amoxicillin-clavulanate 2, 4

For penicillin allergy:

• Cephalosporins: cefuroxime, cefpodoxime, or cefdinir 1, 2, 3
• For serious penicillin allergy: clarithromycin or azithromycin 3
• Azithromycin dosing: 500 mg daily for 3 days 5

Critical pitfall: Avoid first-generation cephalosporins (cephalexin, cefadroxil) as they provide inadequate coverage against H. influenzae 4. Similarly, cefixime and ceftibuten are ineffective against penicillin-resistant S. pneumoniae 4.

Adjunctive Measures

• Intranasal corticosteroids reduce inflammation and complement antibiotic therapy 2
• Comfort measures: Adequate hydration, analgesics, warm facial compresses, steam inhalation, sleeping with head elevated 2, 6
• Avoid antihistamines unless concurrent allergic rhinitis is present and symptomatic, as they have no proven role in acute bacterial sinusitis otherwise 4, 6
• Topical decongestants (oxymetazoline) should not exceed 3-5 days to prevent rhinitis medicamentosa 4, 7

Chronic Sinusitis (Symptoms >8 Weeks)

Intranasal corticosteroids are first-line therapy for chronic sinusitis, not antibiotics. 1

Medical Management Strategy

Primary therapy:

• Daily intranasal corticosteroids (mometasone furoate, fluticasone propionate, or beclometasone dipropionate) 1, 7
• High-volume daily saline irrigation 1, 7

For chronic infectious sinusitis requiring antibiotics:

• Amoxicillin-clavulanate is preferred for prolonged therapy due to anaerobic coverage including Prevotella species 4
• Fluoroquinolones (levofloxacin or moxifloxacin) for documented infection refractory to amoxicillin-clavulanate, providing excellent coverage against resistant S. pneumoniae and H. influenzae 4
• Duration: Minimum 3 weeks of antibiotics required 4

For nasal polyps:

• Short course of systemic corticosteroids (oral prednisolone) 1, 7
• Alternative: doxycycline 1

Critical pitfall: Do not rely on antibiotics alone in chronic hyperplastic sinusitis—systemic corticosteroids are more appropriate 4.

Addressing Underlying Factors

Failure to identify and treat predisposing conditions leads to recurrent disease:

• Allergic rhinitis: Add antihistamines and allergen avoidance strategies 4, 7
• Gastroesophageal reflux: Consider evaluation and treatment 2
• Immunodeficiency: May require IVIG therapy 4
• Aspirin sensitivity: Aspirin desensitization shows benefit in aspirin-sensitive patients with concurrent asthma 4
• Environmental factors: Counsel on avoidance 2

Surgical Intervention

Functional endoscopic sinus surgery (FESS) should be considered when localized persistent disease within the ostiomeatal complex is documented despite maximal medical therapy (minimum 3 weeks antibiotics plus 3 months intranasal corticosteroids). 1, 4

Surgery aims to widen natural drainage openings, preserve ciliated epithelium, and restore normal sinus ventilation 8, 7. Medical treatment with intranasal corticosteroids must continue postoperatively, often long-term 7.

Specialist Referral Criteria

Refer to otolaryngology or allergy/immunology when:

• Sinusitis refractory to appropriate antibiotic trials 2, 4
• Recurrent sinusitis (≥3 episodes per year) 1, 2, 4
• Presence of nasal polyps or anatomical abnormalities 2
• Suspected immunodeficiency 2
• Complications: intraorbital or intracranial sepsis (requires urgent CT imaging, IV broad-spectrum antibiotics including anaerobic coverage, and surgical drainage) 8

Common Pitfalls to Avoid

• Overdiagnosis: Not every upper respiratory infection is bacterial sinusitis requiring antibiotics; strict adherence to diagnostic criteria (10-14 days persistent symptoms OR severe presentation) prevents unnecessary antibiotic use 1
• Incomplete antibiotic courses: Patients must complete the full 10-14 day course to prevent relapse 1
• Ignoring anatomical/allergic factors: These perpetuate chronic disease if unaddressed 1, 2
• Prolonged topical decongestants: Limit to 3-5 days maximum 4, 7