Treatment of Chronic Sinusitis According to CHEST Guidelines
For chronic sinusitis, the CHEST guideline recommends a minimum 3-week course of antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae, combined with 3 weeks of an older-generation antihistamine/decongestant (A/D) twice daily, 5 days of nasal decongestant twice daily, and continuation of intranasal corticosteroids for 3 months once cough resolves. 1
Understanding the CHEST Approach to Chronic Sinusitis
The CHEST (American College of Chest Physicians) guideline specifically addresses chronic sinusitis in the context of Upper Airway Cough Syndrome (UACS), previously called postnasal drip syndrome. 1 This is important because their treatment recommendations focus on patients presenting with chronic cough secondary to rhinosinus disease.
Key Distinction: Chronic vs. Acute Sinusitis
The CHEST guideline defines chronic sinusitis as lasting more than 3 weeks, acknowledging that the role of bacterial infection and antibiotic therapy remains controversial in this condition. 1 This contrasts with acute bacterial sinusitis where the most common organisms are Streptococcus pneumoniae and H. influenzae, with other organisms including anaerobes, streptococcal species, M. catarrhalis (especially in children), and S. aureus. 1
The CHEST Treatment Protocol for Chronic Sinusitis
Based on four prospective descriptive studies, the CHEST guideline provides this specific regimen: 1
Initial 3-Week Treatment Phase
- Antibiotics: Minimum 3 weeks with an agent effective against H. influenzae, mouth anaerobes, and S. pneumoniae 1
- Oral antihistamine/decongestant (A/D): Minimum 3 weeks of an older-generation (first-generation) preparation twice daily 1
- Nasal decongestant: 5 days of treatment (such as oxymetazoline hydrochloride) twice daily 1
Continuation Phase
- Intranasal corticosteroids: Continue for 3 months after cough disappears 1
Important Caveats About This Regimen
The evidence base is limited: The CHEST guideline acknowledges there are no prospective, randomized, double-blind studies proving that nasal or oral decongestants are efficacious in chronic sinusitis. 1 Additionally, no studies have investigated the efficacy of these medicines specifically on chronic cough related to sinusitis. 1
Intranasal corticosteroids have proven benefit: While decongestant evidence is weak, intranasal corticosteroids have been shown to be helpful in decreasing inflammation. 1
When Medical Therapy Fails
For patients with documented chronic sinus infection refractory to medical therapy AND anatomic obstruction amenable to correction, endoscopic sinus surgery should be considered. 1 This requires both conditions to be present: failure of medical management and surgically correctable anatomic obstruction.
CHEST Recommendations for Empiric Treatment
The CHEST guideline provides a Grade B recommendation (low evidence, substantial benefit) that: 1
When the cause of UACS-induced cough is apparent, institute specific therapy directed at that condition 1
For chronic cough patients, administer an empiric trial of therapy for UACS, as improvement or resolution of cough in response to specific treatment is the pivotal factor confirming the diagnosis 1
If a patient suspected of having UACS-induced cough does not respond to empiric A/D therapy with a first-generation antihistamine, obtain sinus imaging next 1 - This is critical because chronic sinusitis may cause a productive cough OR may be clinically silent with a relatively or completely nonproductive cough and none of the typical acute sinusitis findings 1
Reconciling CHEST with Other Guidelines
Important divergence: More recent guidelines from the American Academy of Otolaryngology (2015) take a different approach, recommending saline irrigation and intranasal corticosteroids as first-line therapy for chronic rhinosinusitis, with antibiotics NOT routinely recommended unless there is evidence of acute bacterial superinfection. 1 The 2015 AAO guideline specifically recommends AGAINST prescribing topical or systemic antifungal therapy (Grade A recommendation against). 1
The key difference: The CHEST guideline (2006) focuses specifically on chronic sinusitis presenting with cough and is based on four prospective descriptive studies showing efficacy of their antibiotic-based regimen. 1 The AAO guidelines (2015) address chronic rhinosinusitis more broadly and emphasize that the role of bacterial infection in chronic disease is controversial. 1
Practical Clinical Approach
Given the evolution of evidence since 2006, consider this algorithm:
For chronic sinusitis with prominent cough (UACS):
- Start with the CHEST protocol: first-generation A/D for 3 weeks, consider antibiotics for 3 weeks if bacterial infection suspected, nasal decongestant for 5 days, then intranasal corticosteroids for 3 months 1
For chronic rhinosinusitis without prominent cough:
- Start with saline irrigation and intranasal corticosteroids per AAO guidelines 1
- Reserve antibiotics for acute exacerbations with purulent discharge 1
Common pitfalls to avoid: