What is the treatment for acute sinusitis?

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 (≥3 days), worsening after initial improvement, or persistent symptoms beyond 10-14 days without improvement. 1

Initial Management: Symptomatic Treatment First

Most cases of acute sinusitis are viral and self-limited, resolving within 7-10 days without antibiotics. 2 The American Academy of Otolaryngology-Head and Neck Surgery recommends starting with symptomatic measures: 1

Symptomatic therapies include:

• 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 for short-term use only (≤3-5 days) to avoid rebound congestion 1

Comfort measures that may help include adequate rest, hydration, warm facial packs, steamy showers, and sleeping with head elevated. 3

When to Initiate Antibiotics

Antibiotics are indicated only when: 1

• Symptoms persist >10-14 days without improvement
• Severe symptoms present (high fever >102°F, purulent discharge, unilateral facial pain) for ≥3 consecutive days 2
• Worsening symptoms after initial improvement (double sickening) 4

Common pitfall: Overdiagnosis of bacterial sinusitis leads to unnecessary antibiotic use—most cases are viral. 1

Antibiotic Selection Algorithm

First-Line Antibiotic Choice:

Amoxicillin is the drug of choice for both children and adults—it is generally effective, inexpensive, and well-tolerated. 3, 1

Dosing:

• Adults: Start with standard amoxicillin for 3-5 days 3
• Continue for 10-14 days total (or 7 days after symptom resolution) 3

If No Improvement After 3-5 Days:

Switch to high-dose amoxicillin-clavulanate for patients at risk of resistant organisms: 3, 1

• Adults: 875 mg/125 mg every 12 hours or 500 mg/125 mg every 8 hours 5
• Children: 90 mg/kg/day amoxicillin component (not to exceed 2 g every 12 hours) 3

FDA-approved indication: Amoxicillin-clavulanate is specifically indicated for sinusitis caused by beta-lactamase-producing H. influenzae and M. catarrhalis. 5

For Penicillin-Allergic Patients:

Alternatives include: 1, 2

• Doxycycline (adults)
• Trimethoprim-sulfamethoxazole (adults)
• Respiratory fluoroquinolones (adults)
• Cephalosporins (cefuroxime, cefpodoxime, cefdinir) if non-type I hypersensitivity 6

Avoid: Macrolides (clarithromycin, azithromycin) should be reserved only for serious drug allergies due to increasing resistance. 6

Adjunctive Therapies

Intranasal corticosteroids may be beneficial, especially when marked mucosal edema is present or when initial treatment fails. 3, 1

Short-term oral corticosteroids are reasonable adjuncts for patients who fail initial treatment, demonstrate nasal polyposis, or have marked mucosal edema. 3, 1

Avoid antihistamines unless concurrent allergic rhinitis is present—they may thicken secretions in non-allergic patients. 1

Monitoring Treatment Response

Assess response at 3-5 days: 3

• Improving: Continue current antibiotic until well for 7 days (typically 10-14 day total course) 3
• Not improving: Switch to different antibiotic (high-dose amoxicillin-clavulanate or alternative) 3, 1
• Worsening: Consider complications or resistant pathogens 1

Instruct patients to call if: 3

• Symptoms worsen (especially headache or high fever)
• No improvement within 3-5 days of treatment
• Development of facial swelling, visual changes, or neurologic symptoms

Red Flags Requiring Urgent Evaluation

Immediately evaluate for complications if: 3

• Facial swelling or erythema over involved sinus
• Visual changes or abnormal extraocular movements
• Proptosis or periorbital inflammation/edema/erythema
• Any suggestion of intracranial or CNS involvement
• Abnormal neurologic signs

These complications (orbital cellulitis, meningitis, abscess) are rare but require CT imaging and urgent specialist referral. 2

Common Pitfalls to Avoid

• Overusing antibiotics for viral sinusitis—reserve for appropriate indications only 1
• Prolonged topical decongestants (>3-5 days) cause rebound congestion 1
• Using antihistamines in non-allergic patients thickens secretions 1
• Failing to recognize complications requiring urgent intervention 1
• Inadequate antibiotic duration—complete the full 10-14 day course even if improved 3

Special Considerations

Consider specialist referral for: 1

• Sinusitis refractory to standard antibiotic treatment
• Recurrent sinusitis (≥4 episodes per year)
• Complications (orbital or intracranial involvement)
• Underlying factors (allergic rhinitis, immunodeficiency, anatomical abnormalities) 1