What is the treatment for sinusitis?

Treatment of Sinusitis

Acute Bacterial Sinusitis

Amoxicillin is the first-line antibiotic for uncomplicated acute bacterial sinusitis in both adults and children, prescribed for 10-14 days. 1

When to Start Antibiotics

Antibiotics are appropriate only when specific criteria are met to avoid overdiagnosis and unnecessary treatment: 1

• Persistent symptoms for 10-14 days without improvement 2, 1
• Severe presentation with high fever (≥39°C) plus purulent nasal discharge, facial pain/tenderness, or periorbital swelling 2, 1
• Worsening symptoms after initial improvement from a viral upper respiratory infection 3

First-Line Antibiotic Selection

Adults: 2, 1

• Amoxicillin (standard dosing) for 10-14 days
• Alternative: Trimethoprim-sulfamethoxazole (though resistance is increasing in children) 2

Children: 2, 1

• Amoxicillin is preferred
• Check local antibiogram profiles as resistance is more common in pediatric populations 2

Penicillin-allergic patients: 2, 1

• Cephalosporins (cefuroxime, cefpodoxime, cefdinir)
• Macrolides (clarithromycin, azithromycin) for serious drug allergy 3
• Quinolones (adults only)

Treatment Failure Protocol

If no improvement occurs after 3-5 days of initial therapy, switch antibiotics immediately: 2, 1

Second-line options for resistant organisms: 2

• High-dose amoxicillin-clavulanate (90 mg/kg amoxicillin + 6.4 mg/kg clavulanate, maximum 2g every 12 hours)
• Cefuroxime axetil
• Cefpodoxime or cefprozil
• Quinolones or ketolides (adults)

For persistent symptoms after 21-28 days: 2

• Consider broader-spectrum agents with anaerobic coverage (add clindamycin or metronidazole to high-dose amoxicillin-clavulanate)
• Obtain CT scan if not already done 2
• Evaluate for nasal polyps, anatomic abnormalities, or noncompliance 2

Adjunctive Therapies for Acute Sinusitis

Intranasal corticosteroids may be added to antibiotic therapy, particularly for patients with marked mucosal edema or those failing initial treatment: 2, 1

• Fluticasone propionate 200 mcg daily (2 sprays per nostril once daily) 4
• Mometasone furoate is also effective 5

Short-term oral corticosteroids are reasonable when: 2

• Patient fails initial antibiotic treatment
• Nasal polyposis is present
• Marked mucosal edema is demonstrated

Supportive measures (though not evidence-based, commonly used): 2, 6

• Adequate hydration and rest
• Analgesics for pain
• Warm facial compresses
• Saline nasal irrigation
• Sleeping with head elevated

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Chronic Sinusitis (≥8 weeks duration)

Intranasal corticosteroids are the primary first-line therapy for chronic sinusitis, NOT antibiotics. 1, 5

Evidence Against Routine Antibiotic Use

The European EPOS 2020 guidelines demonstrate that amoxicillin-clavulanate shows no statistically significant benefit over placebo in chronic rhinosinusitis without nasal polyps in multiple randomized trials. 5 This represents a critical distinction from acute bacterial sinusitis.

Recommended Treatment Algorithm

First-line therapy: 1, 5

• Intranasal corticosteroids (mometasone furoate or fluticasone propionate 200 mcg daily) 5, 4
• Daily high-volume saline irrigation 1

For acute exacerbations with bacterial superinfection: 5

• Reserve antibiotics only when systemic symptoms are present (high fever, severe facial pain, periorbital complications)
• If indicated: Amoxicillin-clavulanate 875/125 mg twice daily for 10-14 days 5

For nasal polyps: 1

• Short course of systemic corticosteroids
• Alternative: Doxycycline

For chronic infectious sinusitis (rare): 2, 1

• Longer antibiotic duration may be required
• Consider anaerobic coverage 2

For chronic hyperplastic eosinophilic sinusitis: 2

• This is a non-infectious inflammatory condition
• Does NOT respond to antibiotics 2
• Systemic corticosteroids should be considered 2

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Recurrent Sinusitis (≥3 episodes/year)

Patients with recurrent sinusitis require evaluation for underlying predisposing factors, not just repeated antibiotic courses. 2, 1

Mandatory Evaluation

Allergic rhinitis assessment: 2, 5

• Test for IgE sensitization to inhalant allergens
• Treat with environmental control, pharmacotherapy, and consider immunotherapy 2

Anatomic abnormalities: 2

• Septal deviation compressing middle turbinate
• Obstruction of ostiomeatal complex
• Accessory structures blocking sinus drainage
• Nasal polyps

Immunodeficiency screening (if indicated): 2

• Quantitative IgG, IgA, IgM levels
• Specific antibody responses to tetanus toxoid and pneumococcal vaccine
• Consider in patients with concurrent otitis media, bronchitis, bronchiectasis, or pneumonia 2

Other rhinitic conditions: 2

• Vasomotor rhinitis
• Nonallergic rhinitis with eosinophilia syndrome (NARES)
• Rhinitis medicamentosa

Consider GERD evaluation: 2

• Medical treatment of GERD has shown improvement in sinusitis symptoms in both children and adults 2

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Surgical Management

Functional endoscopic sinus surgery should be considered for medically resistant sinusitis after aggressive medical management has failed. 2, 1

Indications for surgical consultation: 2

• Persistent symptoms despite appropriate medical therapy
• Radiographic evidence of ostiomeatal obstruction
• Obstructing nasal polyps unresponsive to oral corticosteroids
• Significant anatomic abnormalities (septal deviation, middle turbinate deformity)
• Localized persistent disease within the ostiomeatal complex 1

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Critical Pitfalls to Avoid

Overdiagnosis and inappropriate antibiotic use: 2, 1

• Do NOT prescribe antibiotics for viral upper respiratory infections lasting <10 days
• Symptoms must meet specific criteria: 10-14 days duration OR severe presentation with fever and purulent discharge 1

Failure to address underlying conditions: 1, 5

• Untreated allergic rhinitis is the most common predisposing factor 2
• Anatomic abnormalities will cause recurrent infections if not corrected 2

Misuse of antibiotics in chronic sinusitis: 5

• Chronic sinusitis is primarily an inflammatory condition, not infectious
• Intranasal corticosteroids should be first-line, not antibiotics 5

Inadequate treatment duration: 1

• Patients must complete the full 10-14 day course to prevent relapse
• Some recommend continuing until symptom-free for 7 additional days 3

Antihistamine misuse: 6

• Only indicated in acute sinusitis when concomitant allergies are symptomatic during allergy season
• Should NOT be used as routine therapy as they can thicken secretions 6