What are the treatment options for sinus issues?

Treatment Options for Sinus Issues

For acute bacterial sinusitis, amoxicillin or amoxicillin-clavulanate (875 mg twice daily) is the first-line antibiotic treatment for 7-10 days, combined with intranasal corticosteroids to reduce inflammation and promote drainage. 1

Initial Assessment and Diagnosis

Before initiating treatment, confirm the diagnosis based on specific clinical criteria:

• Persistent symptoms (nasal discharge, congestion, facial pain, or cough) lasting >10 days without improvement 2
• Severe symptoms including high fever (>39°C) and purulent nasal discharge for 3-4 consecutive days 2
• Worsening symptoms after initial improvement from a viral upper respiratory infection 2
• Unilateral infraorbital pain that worsens when bending forward, often pulsatile and peaking in evening/night for maxillary sinusitis 3

Imaging is not required for uncomplicated acute sinusitis but should be considered if symptoms persist beyond 21-28 days or complications are suspected. 3, 4

First-Line Antibiotic Treatment

Standard Therapy for Adults

Amoxicillin is the preferred initial choice: 1

• Mild disease: 500 mg twice daily
• Moderate-severe disease: 875 mg twice daily
• Duration: 7-10 days (treat until symptom-free for 7 days) 3, 1

Amoxicillin-clavulanate (875 mg/125 mg twice daily) should be used for: 1

• Patients with recent antibiotic exposure (within 4-6 weeks)
• More severe infections
• Areas with high prevalence of resistant Streptococcus pneumoniae
• Treatment failure after 3-5 days of amoxicillin 3, 1

Penicillin-Allergic Patients

For documented penicillin allergy, use: 1

• Second-generation cephalosporins: Cefuroxime-axetil 3, 1
• Third-generation cephalosporins: Cefpodoxime-proxetil, cefdinir, or cefotiam-hexetil 3, 1
• Pristinamycin for true beta-lactam allergy 3

Critical pitfall: Do NOT use azithromycin or other macrolides due to 20-25% resistance rates in S. pneumoniae and H. influenzae. 1

Treatment Based on Anatomic Location

Maxillary sinusitis (most common): Standard first-line antibiotics as above 3, 1

Frontal, ethmoidal, or sphenoidal sinusitis require more aggressive therapy due to risk of serious complications: 3, 1

• Fluoroquinolones: Levofloxacin or moxifloxacin should be considered first-line for these locations 3, 1
• These sites have higher risk of intracranial complications and warrant closer monitoring 3

Adjunctive Therapies (Essential Components)

Intranasal Corticosteroids

Strongly recommended as adjunct to antibiotics in both acute and chronic sinusitis: 1

• Reduces mucosal inflammation and edema
• Promotes sinus drainage and ostial patency
• Examples: Fluticasone propionate 1-2 sprays per nostril daily 5
• Can be continued long-term for maintenance in recurrent cases 3

Supportive Measures

All patients should receive: 1

• Adequate hydration (increases mucus fluidity)
• Analgesics for pain control
• Warm facial compresses over affected sinuses
• Sleep with head elevated to promote drainage
• Oral decongestants (pseudoephedrine) to decrease nasal resistance 6
• Saline nasal irrigation to mechanically clear secretions

Short-term Oral Corticosteroids

Consider for: 1

• Marked mucosal edema on examination
• Severe pain (acute hyperalgic sinusitis) - dexamethasone 4 mg can be used 1
• Failure to respond to initial antibiotic therapy after 3-5 days 3, 1

Important: Oral corticosteroids should only be used as short-term adjunctive therapy, never as monotherapy for bacterial sinusitis. 1

Treatment Failure Protocol

Reassess at 3-5 Days

If no improvement after initial therapy: 3, 1

Switch to second-line antibiotics: 1

• High-dose amoxicillin-clavulanate (if not already used)
• Cefuroxime or cefpodoxime
• Respiratory fluoroquinolones (levofloxacin 500-750 mg daily or moxifloxacin 400 mg daily) 3, 1

Partial Response (Improved but Not Resolved)

• Continue current antibiotic for additional 10-14 days 3
• Add or optimize intranasal corticosteroids 1
• Consider short course of oral corticosteroids 3

Poor Response (Little to No Improvement)

After 21-28 days of treatment: 3

• Consider broader-spectrum coverage with anaerobic agents (add clindamycin or metronidazole) 3
• Obtain CT scan to evaluate for complications, anatomic abnormalities, or alternative diagnoses 3
• Refer to otolaryngology or allergy/immunology 3

Pediatric Dosing

Amoxicillin: 1

• Standard: 45 mg/kg/day in 2 divided doses
• High-dose: 80-90 mg/kg/day in 2 divided doses (for resistant S. pneumoniae)

Amoxicillin-clavulanate: 80-90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate in 2 divided doses 1

For penicillin allergy: Cefpodoxime proxetil 8 mg/kg/day in 2 doses 1

Chronic Sinusitis (Symptoms ≥8 Weeks)

This represents a different disease process: 3

• Consider non-infectious etiology: Chronic hyperplastic eosinophilic rhinosinusitis does not respond to antibiotics 3
• Systemic corticosteroids may be required for eosinophilic disease 3
• Evaluate underlying factors: 3
  • Allergic rhinitis (test for IgE sensitization to inhalants) 3
  • Immunodeficiency (measure IgG, IgA, IgM levels; assess antibody responses) 3
  • Anatomic abnormalities (septal deviation, polyps, ostiomeatal obstruction) 3
  • Gastroesophageal reflux disease 3
• CT imaging is indicated to define extent of disease and anatomy 3
• Functional endoscopic sinus surgery may be needed if medical management fails 3

When to Refer to Specialist

Immediate referral for: 3

• Signs of complications (meningeal signs, exophthalmos, palpebral edema, ocular mobility disorders, severe unrelenting pain) 3
• Frontal, ethmoidal, or sphenoidal sinusitis with poor response 3

Routine referral for: 3, 1

• Recurrent sinusitis (≥3 episodes per year) 3
• Chronic sinusitis refractory to 21-28 days of appropriate antibiotics 3, 1
• Suspected immunodeficiency (recurrent sinusitis with otitis media, bronchitis, pneumonia) 3
• Nasal polyps after trial of oral corticosteroids 3
• Need for allergy evaluation and immunotherapy 3

Critical Pitfalls to Avoid

• Do not use macrolides (azithromycin, clarithromycin) as first-line therapy due to high resistance rates 1
• Reserve fluoroquinolones for treatment failures or complicated sinusitis (frontal/ethmoidal/sphenoidal) to prevent resistance 3, 1
• Ensure adequate treatment duration - minimum 7-10 days; incomplete courses lead to relapse 3, 1
• Do not use oral corticosteroids alone for bacterial sinusitis - always combine with antibiotics 1
• Reassess if no improvement by 3-5 days - do not continue ineffective therapy 3, 1
• Consider underlying allergic rhinitis in 40-60% of sinusitis patients - treat concurrently with antihistamines and intranasal corticosteroids 3, 7