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 indicated only when specific criteria are met to avoid overdiagnosis and unnecessary treatment: 2, 1

• Persistent symptoms: Nasal congestion, purulent rhinorrhea, or cough lasting 10-14 days without improvement 2, 1
• Severe presentation: High fever (≥39°C) with purulent nasal discharge, facial pain or tenderness, and periorbital swelling for 3-4 consecutive days 2, 3
• Worsening course: Initial improvement followed by symptom deterioration 3

Antibiotic Selection Algorithm

First-line therapy: 2, 1

• Amoxicillin (standard dose) for 10-14 days
• Alternative for penicillin-allergic adults: Trimethoprim-sulfamethoxazole 2

If no improvement after 3-5 days, switch to: 2, 1

• High-dose amoxicillin-clavulanate (90 mg/kg amoxicillin component, not exceeding 2g every 12 hours) 2
• Alternative second-line agents: cefuroxime, cefpodoxime, cefprozil, or cefdinir 2
• For penicillin allergy: cephalosporins (if no severe allergy), macrolides, or quinolones 2, 3

For persistent failure after 21-28 days: 2

• Broader-spectrum agents with or without anaerobic coverage (clindamycin or metronidazole) 2
• Consider CT imaging and specialist consultation 2

Adjunctive Therapies for Acute Sinusitis

Intranasal corticosteroids may be added as adjunctive therapy, though they are unlikely to reach the sinus interior; their benefit comes from reducing nasal congestion and inflammation at the ostia. 2

Short-term oral corticosteroids are reasonable when patients fail initial treatment, demonstrate nasal polyposis, or have marked mucosal edema. 2

Supportive measures include adequate hydration, analgesics, warm facial packs, steamy showers, and sleeping with head elevated. 2

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Chronic Sinusitis (≥8 weeks duration)

Intranasal corticosteroids are the primary first-line therapy for chronic sinusitis, NOT antibiotics. 1, 4

Evidence Against Routine Antibiotic Use

The European guidelines (EPOS 2020) demonstrate that amoxicillin-clavulanate shows no statistically significant benefit compared to other antibiotics or alternative treatments in chronic rhinosinusitis without nasal polyps. 4 This represents a critical distinction from acute sinusitis management.

Treatment Algorithm for Chronic Sinusitis

Primary therapy: 1, 4

• Intranasal corticosteroids (e.g., fluticasone propionate, mometasone furoate) daily 1, 4, 5
• High-volume saline irrigation daily 1

For nasal polyps: 1

• Short course of systemic corticosteroids 1
• Alternative: doxycycline 1

Reserve antibiotics only for: 4

• Acute bacterial superinfection with systemic symptoms (high fever, severe facial pain, periorbital complications) 4
• Chronic infectious sinusitis requiring longer duration therapy (potentially with anaerobic coverage) 2

For chronic hyperplastic eosinophilic rhinosinusitis: 2

• This non-infectious form does NOT respond to antibiotics 2
• Systemic corticosteroids should be considered 2

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Recurrent Sinusitis (≥3 episodes/year)

Patients require evaluation for underlying causes: 2, 1, 4

Allergic rhinitis: 2

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

Anatomic abnormalities: 2

• Septal deviation compressing middle turbinate 2
• Obstructing nasal polyps 2
• Consider otolaryngology consultation 2

Immunodeficiency: 2

• Measure quantitative IgG, IgA, IgM levels 2
• Assess specific antibody responses to tetanus toxoid or pneumococcal vaccine 2
• Particularly indicated if associated with recurrent otitis media, bronchitis, or pneumonia 2

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Surgical Management

Functional endoscopic sinus surgery should be considered for: 2, 1

• Medically resistant sinusitis after aggressive medical management 2
• Localized persistent disease within the ostiomeatal complex 2, 1
• Radiographic evidence of ostiomeatal obstruction despite medical therapy 2

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Critical Pitfalls to Avoid

Overuse of antibiotics: The most common error is prescribing antibiotics for viral upper respiratory infections or chronic sinusitis without bacterial superinfection. 2, 1 Antibiotics should only be used when symptoms persist ≥10-14 days or severe criteria are met. 2, 1

Inadequate treatment duration: Patients must complete the full 10-14 day course to prevent relapse and resistance. 1

Ignoring underlying factors: Failure to address allergic rhinitis, anatomic abnormalities, or immunodeficiency leads to recurrent disease requiring repeated antibiotic courses. 2, 1, 4

Misclassifying chronic sinusitis: Chronic sinusitis (≥8 weeks) requires intranasal corticosteroids as primary therapy, not prolonged antibiotics. 1, 4 The exception is proven chronic infectious sinusitis, which may require extended antibiotic therapy. 2