What is the treatment for chronic sinusitis?

Treatment of Chronic Sinusitis

First-line treatment for chronic sinusitis consists of daily intranasal corticosteroids combined with high-volume saline nasal irrigation, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery. 1

Initial Medical Management

Core Therapies (Use Together)

• Intranasal corticosteroids are the cornerstone of maintenance therapy, improving overall symptom scores (SMD -0.46), reducing polyp scores (SMD -0.73), and preventing polyp recurrence after surgery (relative risk 0.59). 2 These should be used daily as ongoing therapy. 1

• High-volume saline irrigation significantly improves symptom scores compared to no treatment (SMD 1.42) and enhances medication delivery to the sinonasal mucosa. 1, 2 This helps clear mucus and reduce inflammation. 1

Role of Antibiotics (Controversial and Limited)

The evidence for antibiotics in chronic sinusitis is weak, but they may be considered in specific situations:

• For acute exacerbations of chronic sinusitis with infectious etiology, use amoxicillin-clavulanate as the preferred agent, targeting H. influenzae, S. pneumoniae, and anaerobes. 3, 1

• Minimum 3-week course is required for chronic infectious sinusitis if antibiotics are used. 1 The 2005 guidelines note that appropriate duration is not well-defined, but chronic disease requires longer treatment than the 10-14 days used for acute sinusitis. 3

• Switch antibiotics within 3-5 days if no improvement is seen. 1

• Long-term macrolide therapy (3 months) may improve quality of life in patients WITHOUT nasal polyps, with benefit seen at 24 weeks after therapy. 2 This represents an anti-inflammatory rather than antimicrobial effect.

• Avoid routine antibiotic use - there is limited evidence supporting antibiotics in chronic sinusitis, and they should not be used prophylactically. 3, 1

Additional Medical Therapies Based on Phenotype

For patients WITH nasal polyps:

• Systemic corticosteroids (1-3 weeks) reduce polyp size for up to 3 months after treatment. 1, 2 This is particularly beneficial for chronic non-infectious sinusitis with polyps. 1

• Leukotriene antagonists improve nasal symptoms compared to placebo. 2

• Doxycycline (3 weeks) reduces polyp size for 3 months. 2

For patients WITHOUT nasal polyps:

• Consider 3-month course of macrolide antibiotics for improved quality of life. 2

Adjunctive Therapies (Weak Evidence)

• Decongestants (topical and oral) theoretically increase ostial patency by decreasing nasal resistance, but prospective studies are lacking. 3 Topical decongestants should not exceed 3 days to avoid rebound congestion (rhinitis medicamentosa). 3

• Antihistamines have no proven role in chronic sinusitis UNLESS the underlying risk factor is allergic rhinitis. 3 They are not recommended for routine use. 3

Address Underlying Contributing Conditions

Evaluate and treat predisposing factors that perpetuate chronic sinusitis:

• Allergic rhinitis - Consider allergen testing and appropriate management; antihistamines may be beneficial in this subset. 3, 1

• Immunodeficiency - Check immunoglobulin levels and functional antibody tests. 1

• GERD - Treat if present. 1

• Aspirin sensitivity - Identify and manage. 1

Surgical Intervention

Consider endoscopic sinus surgery for:

• Documented chronic sinus infection refractory to medical therapy 1
• Anatomic obstruction amenable to surgical correction 1
• Localized persistent disease within the ostiomeatal complex 1
• Nasal polyps unresponsive to medical therapy 1

Surgery should be functional, widening natural drainage openings while preserving ciliated epithelium. 4 Continue medical treatment post-operatively. 4

Referral Indications

Refer to otolaryngologist when sinusitis is refractory to first-line medical therapy, recurrent, or significantly affects quality of life. 1, 5

Refer to allergist or pulmonologist for suspected comorbidities including vasculitides, granulomatous diseases, cystic fibrosis, or immunodeficiency. 1, 5

Common Pitfalls

• Overuse of antibiotics - The role is controversial with limited supporting evidence; reserve for clear infectious exacerbations. 1
• Topical decongestant overuse - Limit to 3 days maximum to prevent rebound congestion. 3
• Treating without addressing underlying allergic rhinitis - This perpetuates the inflammatory cycle. 3, 1
• Inadequate antibiotic duration - If used for chronic infectious sinusitis, minimum 3 weeks is required, not the 10-14 days used for acute disease. 3, 1