What is the treatment for sinusitis?

Treatment of Sinusitis

For acute bacterial sinusitis, start amoxicillin as first-line therapy for 10-14 days; for chronic sinusitis, use intranasal corticosteroids with daily high-volume saline irrigation as primary treatment, reserving antibiotics only for acute bacterial exacerbations with systemic symptoms. 1, 2

Acute Bacterial Sinusitis

When to Initiate Antibiotics

Antibiotics are appropriate only when patients meet specific criteria to avoid overdiagnosis and unnecessary treatment: 3, 1

• Persistent symptoms for 10-14 days without improvement 1, 4
• Severe presentation with high fever (≥39°C) plus purulent nasal discharge for 3-4 consecutive days 4
• Worsening symptoms after initial improvement (double-worsening pattern) 4

First-Line Antibiotic Therapy

Amoxicillin is the drug of choice for uncomplicated acute bacterial sinusitis in both children and adults due to efficacy, cost-effectiveness, and tolerability: 3, 1

• Standard dosing: 500 mg three times daily or 875 mg twice daily for adults 3
• High-dose regimen (for children or resistant organisms): 90 mg/kg/day divided twice daily 3
• Duration: 10-14 days, or continue until symptom-free for 7 days 2, 4

Alternative Antibiotics

For penicillin allergy or treatment failure after 3-5 days: 3, 1

• High-dose amoxicillin-clavulanate (875/125 mg twice daily or 90 mg/kg amoxicillin with 6.4 mg/kg clavulanate twice daily) 3, 2
• Cephalosporins: cefuroxime, cefpodoxime, cefprozil, or cefdinir 3
• Macrolides: clarithromycin or azithromycin (for serious penicillin allergy) 4
• Quinolones: levofloxacin or moxifloxacin (adults only) 3

Adjunctive Therapy for Acute Sinusitis

Intranasal corticosteroids may be added as adjunctive therapy, particularly for patients with underlying allergic rhinitis or marked mucosal edema: 3

• Fluticasone propionate 200 mcg daily (two 50-mcg sprays per nostril once daily) 5
• Mometasone furoate is also effective 2
• Benefits include reduced vascular permeability and inflammatory cell infiltration 3

Symptomatic measures to promote drainage and comfort: 3, 6

• Adequate hydration and rest 3
• Warm facial compresses and steam inhalation 3, 6
• Saline nasal irrigation 6
• Analgesics for pain control 3, 6
• Oral or topical decongestants (short-term use only) 3, 6
• Elevate head of bed during sleep 3

Management of Treatment Failure

Partial response (improved but not resolved after 10-14 days): 3

• Continue current antibiotic for another 10-14 days, OR
• Switch to broader-spectrum agent (high-dose amoxicillin-clavulanate, cefuroxime, or cefpodoxime) 3

Poor response (no improvement after 3-5 days): 3

• Switch immediately to alternative antibiotic covering resistant organisms 3
• Consider high-dose amoxicillin-clavulanate, second/third-generation cephalosporins, or respiratory fluoroquinolones 3

Persistent symptoms after 21-28 days: 3

• Consider broader-spectrum agents with or without anaerobic coverage (add clindamycin or metronidazole) 3
• Obtain CT scan if not already performed 3
• Evaluate for underlying risk factors (allergic rhinitis, anatomic abnormalities, immunodeficiency) 3
• Consider specialist consultation 3

Chronic Sinusitis (≥8 weeks duration)

First-Line Medical Management

The evidence strongly favors non-antibiotic therapy for chronic sinusitis: 2, 7

Intranasal corticosteroids are the primary therapeutic intervention: 1, 2, 7

• Fluticasone propionate 200 mcg daily or mometasone furoate 2, 5
• Improved overall symptom scores (SMD -0.46,95% CI -0.65 to -0.27) 7
• Reduced polyp scores and recurrence after surgery 7
• Should be continued long-term for maintenance 8

Daily high-volume saline irrigation: 1, 7

• Significantly improved symptom scores compared to no treatment (SMD 1.42,95% CI 1.01 to 1.84) 7
• Hypertonic saline may be more effective than normal saline for improving mucociliary clearance 3

Role of Antibiotics in Chronic Sinusitis

Antibiotics have limited evidence in chronic sinusitis and should be reserved for specific situations: 2

• European guidelines (EPOS 2020) show amoxicillin-clavulanate demonstrated no statistically significant benefit compared to placebo in chronic rhinosinusitis without nasal polyps 2
• Reserve antibiotics for acute bacterial exacerbations with systemic symptoms (high fever, severe facial pain, periorbital complications) 2
• If antibiotics are used: amoxicillin-clavulanate 875/125 mg twice daily for 10-14 days 2

Macrolide antibiotics (3-month course) may have anti-inflammatory benefits in patients without polyps: 7

• Improved quality of life at 24 weeks (SMD -0.43,95% CI -0.82 to -0.05) 7
• Mechanism likely anti-inflammatory rather than antimicrobial 7

Additional Therapies for Chronic Sinusitis with Nasal Polyps

Short-term systemic corticosteroids (1-3 weeks): 1, 7

• Reduced polyp size for up to 3 months after treatment (P < .001) 7
• Consider for marked mucosal edema or severe symptoms unresponsive to intranasal steroids 2

Doxycycline (3-week course): 1, 7

• Reduced polyp size compared to placebo for 3 months (P < .001) 7

Leukotriene antagonists: 7

• Improved nasal symptoms in patients with nasal polyps (P < .01) 7

Evaluation of Underlying Factors

Patients with recurrent (≥3 episodes/year) or chronic sinusitis require evaluation for: 3, 1

• Allergic rhinitis: IgE sensitization testing, treat with environmental control, pharmacotherapy, or immunotherapy 3
• Anatomic abnormalities: septal deviation, middle turbinate abnormalities, ostiomeatal complex obstruction 3
• Immunodeficiency: quantitative IgG, IgA, IgM levels; specific antibody responses to tetanus and pneumococcal vaccines 3
• Gastroesophageal reflux disease: may contribute to chronic sinusitis 3
• Aspirin sensitivity: particularly in patients with asthma and nasal polyps 3

Surgical Management

Functional endoscopic sinus surgery should be considered for: 3, 1

• Medically resistant sinusitis despite aggressive medical management 3, 1
• Localized persistent disease within the ostiomeatal complex 3, 1
• Obstructing nasal polyps after appropriate medical therapy including oral corticosteroids 3
• Significant anatomic obstruction (septal deviation compressing middle turbinate, accessory structures blocking drainage) 3

Common Pitfalls and Caveats

Antibiotic overuse: 3, 1

• Most "sinusitis" presentations are viral upper respiratory infections that resolve without antibiotics 3
• Strict adherence to diagnostic criteria (10-14 days persistent symptoms or severe presentation) prevents unnecessary antibiotic exposure 1

Premature discontinuation: 1

• Patients must complete the full 10-14 day course to prevent relapse and resistance 1

Failure to address underlying conditions: 1, 2

• Chronic sinusitis will recur without treating allergic rhinitis, anatomic abnormalities, or immunodeficiency 1
• Long-term intranasal corticosteroids are essential even after surgery 8

Antihistamine misuse: 6

• Antihistamines are indicated only when allergic rhinitis is symptomatic during allergy season 6
• May worsen sinusitis by thickening secretions if used inappropriately 6

Topical decongestant overuse: 3

• Limit use to 3-5 days to avoid rhinitis medicamentosa 3