What is the recommended treatment for chronic sinusitis?

Treatment of Chronic Sinusitis

First-Line Maintenance Therapy

The cornerstone of chronic sinusitis treatment is daily high-volume nasal saline irrigation combined with intranasal corticosteroid sprays, not antibiotics. 1, 2

• Nasal saline irrigation significantly improves symptom scores (standardized mean difference 1.42) and should be performed daily with high-volume technique 2
• Intranasal corticosteroids improve overall symptom scores (standardized mean difference -0.46), reduce polyp scores (standardized mean difference -0.73), and decrease polyp recurrence after surgery by 41% 2
• These therapies work by enhancing mucociliary clearance, improving sinus drainage, and reducing local inflammation 3

Role of Antibiotics: Limited and Specific

Antibiotics should only be used for acute bacterial exacerbations superimposed on chronic sinusitis, never as routine maintenance therapy. 1

• The role of bacterial infection in chronic sinusitis itself is controversial, and routine antibiotic use is not supported 1
• When acute bacterial exacerbation is suspected (new onset purulent discharge, facial pain, fever), use antibiotics effective against H. influenzae, mouth anaerobes, and S. pneumoniae 1
• Minimum 3-week course is required for acute exacerbations of chronic sinusitis—significantly longer than the 10-14 days used for acute sinusitis 1

Antibiotic Selection for Acute Exacerbations

• First-line: Amoxicillin 500 mg twice daily OR amoxicillin-clavulanate 500-875 mg twice daily 1
• Penicillin allergy: Cephalosporins (cefuroxime, cefpodoxime, cefprozil) or fluoroquinolones (levofloxacin, moxifloxacin) 1
• Avoid azithromycin due to high resistance rates in S. pneumoniae and H. influenzae 1

Adjunctive Therapies for Symptom Relief

• Oral or topical decongestants may provide symptomatic relief, though evidence is limited 1
• Topical decongestants (oxymetazoline) must not exceed 3-5 days to avoid rebound congestion 1
• First-generation antihistamine/decongestant combinations may help if allergic rhinitis is an underlying factor 1

Advanced Medical Therapies for Patients with Nasal Polyps

When first-line therapy fails in patients with nasal polyps, consider:

• Short course of systemic corticosteroids (1-3 weeks) reduces polyp size for up to 3 months after treatment 2
• Oral doxycycline for 3 weeks reduces polyp size compared to placebo 2
• Leukotriene antagonists improve nasal symptoms in patients with polyps 2

Prolonged Macrolide Therapy: Specific Population Only

• 3-month course of macrolide antibiotic (not azithromycin due to resistance) may improve quality of life in patients without polyps at 24 weeks after therapy 2
• This is distinct from short-term antibiotic use for acute exacerbations 2

Algorithm for Refractory Cases

When patients fail first-line therapy, systematically evaluate:

1. Test for allergic rhinitis: IgE sensitization to inhalant allergens 1
2. Check for immunodeficiency: Quantitative IgG, IgA, IgM levels and specific antibody responses 1
3. Obtain CT imaging if not already performed to identify anatomic abnormalities 1
4. Consider other conditions: Vasculitides, granulomatous diseases, cystic fibrosis 1
5. Refer to otolaryngologist if medical management fails—endoscopic sinus surgery may be effective 3

Critical Pitfalls to Avoid

• Never use antibiotic prophylaxis for chronic sinusitis—there is no evidence supporting this approach 1
• Never use macrolides as first-line therapy for acute bacterial exacerbations due to weak activity against resistant organisms 1
• Reserve fluoroquinolones as second-line agents to prevent resistance development 1
• Do not extend topical decongestants beyond 3-5 days to prevent rebound congestion 1
• Do not treat viral upper respiratory infections with antibiotics—this is inappropriate and strongly discouraged 1