What is the treatment for chronic sinusitis?

Treatment of Chronic Sinusitis

For chronic sinusitis, initiate daily high-volume saline irrigation combined with intranasal corticosteroid sprays as first-line therapy, reserving antibiotics exclusively for acute bacterial exacerbations (minimum 3-week course with amoxicillin-clavulanate 500-875 mg twice daily). 1, 2

First-Line Maintenance Therapy

All patients with chronic sinusitis should receive:

• High-volume saline irrigation daily to enhance mucociliary clearance and improve sinus drainage, which demonstrates significant symptom improvement (standardized mean difference 1.42) 2, 3
• Intranasal corticosteroid sprays (mometasone, fluticasone, or beclomethasone) as the cornerstone of anti-inflammatory therapy, which improve overall symptom scores (standardized mean difference -0.46) and reduce polyp recurrence after surgery by 41% 2, 4

Role of Antibiotics: Critical Limitations

Antibiotics should NOT be used routinely in chronic sinusitis. 1 The bacterial role in chronic sinusitis remains controversial, and antibiotics are only indicated for acute bacterial exacerbations superimposed on the chronic condition. 1

When acute bacterial exacerbation is suspected (increased purulence, fever, worsening facial pain):

• First-line: Amoxicillin-clavulanate 500-875 mg twice daily for minimum 3 weeks targeting H. influenzae, S. pneumoniae, and mouth anaerobes 1
• Alternative first-line: Amoxicillin 500 mg twice daily for 3 weeks if cost is a concern 1
• For 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
• Avoid macrolides as first-line due to weak activity against resistant organisms 1

Treatment Based on Nasal Polyp Status

For patients WITH nasal polyps:

• Short-course systemic corticosteroids (oral prednisolone for 1-3 weeks) reduce polyp size for up to 3 months 2
• Oral doxycycline 100 mg daily for 3 weeks reduces polyp size 2
• Leukotriene antagonists (montelukast) improve nasal symptoms 2
• Topical corticosteroids improve polyp scores (standardized mean difference -0.73) 2

For patients WITHOUT nasal polyps:

• Prolonged macrolide therapy (3 months) may improve quality of life at 24 weeks, though this is considered second-line 2
• Focus remains on saline irrigation and intranasal corticosteroids 3

Adjunctive Symptomatic Therapies

Decongestants (use with caution):

• Topical decongestants (oxymetazoline) limited to 3-5 days maximum to prevent rebound congestion (rhinitis medicamentosa) 5, 1, 4
• Oral decongestants may provide modest symptomatic relief but lack strong evidence 5, 1

Antihistamines:

• Only beneficial if allergic rhinitis is an underlying factor 5, 1
• First-generation antihistamine/decongestant combinations may help when IgE sensitization to inhalant allergens is documented 1
• No role for antihistamines in chronic sinusitis without allergic component 5

Algorithm for Refractory Cases

If first-line therapy fails after 8-12 weeks, evaluate for:

1. Allergic rhinitis: Test for IgE sensitization to inhalant allergens 1
2. Immunodeficiency: Check quantitative IgG, IgA, IgM levels and specific antibody responses 1
3. Anatomic abnormalities: Obtain CT imaging if not already performed 1
4. Alternative diagnoses: Consider vasculitides, granulomatous diseases (sarcoidosis, granulomatosis with polyangiitis), cystic fibrosis 1, 3
5. Refer to otolaryngology for consideration of endoscopic sinus surgery if medical management fails 3

Critical Pitfalls to Avoid

• Never use antibiotic prophylaxis for chronic sinusitis—no evidence supports this approach 1
• Never treat viral upper respiratory infections with antibiotics—this is inappropriate and strongly discouraged 1
• Never use topical decongestants beyond 3-5 days—rebound congestion is inevitable 1, 6
• Never use fluoroquinolones as first-line—reserve as second-line agents to prevent resistance 1
• Never prescribe antibiotics for less than 3 weeks when treating acute exacerbations of chronic sinusitis—shorter courses are inadequate 1
• Alert patients on clindamycin (if used for anaerobic coverage) about pseudomembranous colitis risk and instruct them to report diarrhea or bloody stools immediately 5