First-Line Treatment for Chronic Sinusitis
The first-line treatment for chronic sinusitis is daily high-volume saline irrigation combined with intranasal corticosteroid therapy, as this combination provides the strongest evidence for symptom improvement and disease control without the risks associated with systemic medications or surgery. 1, 2
Initial Medical Management
Primary Therapy (Start Here)
- Intranasal corticosteroids are the cornerstone of maintenance therapy, demonstrating significant improvement in overall symptom scores (SMD -0.46) and should be used continuously as first-line treatment 2
- High-volume saline irrigation should be performed daily, showing substantial symptom improvement (SMD 1.42) compared to no treatment 2
- This combination is recommended by the American Academy of Otolaryngology as the initial stepwise approach before escalating to other therapies 1
Important Distinction: Confirm the Diagnosis First
- You must confirm chronic rhinosinusitis with objective documentation of sinonasal inflammation using anterior rhinoscopy, nasal endoscopy, or CT scan before initiating treatment 3
- Chronic sinusitis requires symptoms lasting at least 12 consecutive weeks with at least two cardinal symptoms: facial pain/pressure, hyposmia/anosmia, nasal drainage, or nasal obstruction 4
- Distinguish chronic rhinosinusitis from recurrent acute bacterial rhinosinusitis, as treatment approaches differ significantly 3
When First-Line Therapy Is Insufficient
Assess for Nasal Polyps
- Determine presence or absence of nasal polyps, as this fundamentally changes management strategy 3
For patients WITH nasal polyps:
- Short-course systemic corticosteroids (7-21 days) significantly reduce polyp size and total symptom scores 1, 5
- Leukotriene antagonists improve nasal symptoms compared to placebo 2
- Short course of doxycycline (3 weeks) reduces polyp size for up to 3 months 2
For patients WITHOUT nasal polyps:
- Prolonged macrolide antibiotic therapy (3 months) may improve quality of life, though evidence shows benefit only at 24 weeks after therapy 2
- The 2006 CHEST guidelines describe a regimen of minimum 3 weeks of antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae, combined with older-generation antihistamine/decongestant therapy 3
Critical Pitfalls to Avoid
Do NOT Use Antibiotics Indiscriminately
- Do not prescribe antibacterial therapy if significant or persistent purulent nasal discharge is absent on examination 3
- The role of antibiotics in chronic sinusitis is unclear because CRS is primarily an inflammatory condition, not an infectious problem 3
- Conservative therapy with antibiotics alone (without surgical intervention) succeeds in only one-third of cases 3
Recognize When Medical Management Has Failed
- Surgical intervention becomes necessary when medical therapy fails to adequately control symptoms and improve quality of life 3, 1
- Combined medical and surgical treatment achieves cure rates >60% at 3 years for chronic maxillary sinusitis, compared to only 33% with medical therapy alone 3
Screen for Modifying Conditions
Assess for multiple chronic conditions that alter management:
- Asthma 3
- Cystic fibrosis 3
- Immunocompromised state 3
- Ciliary dyskinesia 3
- Aspirin-exacerbated respiratory disease (AERD) - consider aspirin desensitization 1
Microbiology Considerations
If antibiotics are warranted (evidence of active bacterial superinfection with purulent discharge):
- Chronic sinusitis pathogens differ from acute: anaerobic bacteria and Staphylococcus aureus predominate, along with viridans streptococci, S. pneumoniae, H. influenzae, and M. catarrhalis 3, 6
- Broad-spectrum coverage against respiratory anaerobes is essential 3
- Amoxicillin-clavulanate, clindamycin, or metronidazole plus penicillin are most effective for chronic sinusitis 6
Treatment Goals
The objectives are: