Treatment of Acute Sinusitis
For acute sinusitis, begin with symptomatic management (analgesics, saline irrigation, intranasal corticosteroids) and reserve antibiotics only for patients with severe symptoms, symptoms lasting >10-14 days without improvement, or worsening after initial improvement. 1
Initial Assessment and Risk Stratification
Before initiating treatment, evaluate for complications requiring urgent intervention:
- Facial swelling or erythema over involved sinuses, visual changes, abnormal extraocular movements, proptosis, periorbital inflammation, or any neurologic signs mandate immediate imaging and specialist consultation 2
- These red flags suggest orbital cellulitis, meningitis, or intracranial extension and require urgent intervention 1, 3
First-Line Symptomatic Management
Most cases of acute sinusitis are viral and self-limited, resolving within 7-10 days without antibiotics. 1, 3
Start all patients on:
- Analgesics (acetaminophen or NSAIDs) for pain relief 1
- Saline nasal irrigation to promote mucus clearance and reduce tissue edema 1
- Intranasal corticosteroids provide modest but clinically important benefits (number needed to treat = 14) 1
- Topical nasal decongestants may be used short-term (≤3-5 days) to relieve congestion, but avoid prolonged use due to rebound congestion 1
Additional comfort measures include adequate rest, hydration, warm facial packs, steamy showers, and sleeping with head elevated 2
When to Initiate Antibiotics
Antibiotics should be reserved for specific clinical scenarios: 1
Severe symptoms at presentation: High fever (>102°F/39°C), unilateral facial pain/pressure, and purulent nasal discharge with obstruction for ≥3 consecutive days 3
Persistent symptoms: Nasal symptoms or cough lasting >10-14 days without improvement 1, 3
Worsening symptoms: Initial improvement followed by clinical deterioration after 3-5 days (double-worsening) 1, 3
Common pitfall: Overdiagnosis of bacterial sinusitis leads to unnecessary antibiotic use—most cases are viral and do not benefit from antibiotics 1
Antibiotic Selection
First-Line Antibiotic Choice:
Amoxicillin is the preferred first-line agent—it is generally effective, inexpensive, and well-tolerated 2, 1
- Standard dosing for adults: 500 mg every 8 hours or 875 mg every 12 hours 4
- Pediatric dosing (≥12 weeks): 45 mg/kg/day divided every 12 hours for more severe infections 4
Studies demonstrate amoxicillin is as effective as amoxicillin-clavulanate for first-line treatment in patients without beta-lactam allergy 3
For Patients at Risk of Resistant Organisms:
High-dose amoxicillin-clavulanate is recommended when resistance is suspected: 2, 1
- Adults: 875 mg/125 mg every 12 hours or 500 mg/125 mg every 8 hours for respiratory infections 4
- Pediatric: 90 mg/kg amoxicillin component with 6.4 mg/kg clavulanate, not exceeding 2 g every 12 hours 2
- FDA-approved specifically for sinusitis caused by beta-lactamase-producing H. influenzae and M. catarrhalis 4
For Penicillin-Allergic Patients:
Alternative antibiotics include: 1, 3
- Doxycycline (adults)
- Trimethoprim-sulfamethoxazole (adults)
- Respiratory fluoroquinolones (adults)
- For children with non-type I hypersensitivity: clindamycin plus third-generation cephalosporin 3
Important caveat: Avoid using amoxicillin-clavulanate when susceptibility testing shows organisms susceptible to amoxicillin alone (no beta-lactamase production) 4
Duration of Antibiotic Therapy
Treat for 10-14 days total, or continue for 7 days after the patient becomes symptom-free 2, 5
- For acute otitis media specifically, 10 days is the studied and recommended duration 4
- Instruct patients to complete the full course to ensure complete eradication and prevent relapse 2
Treatment Monitoring and Adjustment
Reassess at 3-5 days after initiating antibiotics: 2, 1
If improving: Continue current antibiotic until patient is well for 7 days (typically 10-14 day total course) 2
If no improvement or worsening: Switch to a different antibiotic such as high-dose amoxicillin-clavulanate, cefuroxime axetil, cefpodoxime, or cefdinir 2, 1, 5
If marked mucosal edema or nasal polyposis: Consider adding short-term oral corticosteroids as adjunctive therapy 2, 1
Instruct patients to call immediately if symptoms worsen (especially headache or high fever) or fail to improve within 3-5 days 2
Adjunctive Therapies to Continue
Intranasal corticosteroids should be continued throughout treatment, especially when marked mucosal edema is present 1
Avoid antihistamines unless the patient has concurrent allergic rhinitis—they may thicken secretions in non-allergic patients 1
Guaifenesin has theoretical benefits but insufficient evidence to recommend routinely 1
When to Refer to Specialist
Consider otolaryngology consultation for: 1
- Sinusitis refractory to standard antibiotic treatment
- Recurrent sinusitis (multiple episodes)
- Complications such as orbital or intracranial involvement
- Significantly impaired quality of life
The most critical pitfall is failure to recognize complications requiring urgent intervention—maintain high suspicion for orbital cellulitis or intracranial extension in patients with periorbital symptoms or neurologic signs 1, 3