What is the treatment approach for sinusitis and rhinosinusitis?

Sinusitis vs Rhinosinusitis: Treatment Approach

The terms "sinusitis" and "rhinosinusitis" are clinically interchangeable, with rhinosinusitis being the preferred modern terminology because sinusitis rarely occurs without concurrent nasal inflammation. 1

Why the Terminology Matters

The shift from "sinusitis" to "rhinosinusitis" reflects important clinical realities:

• Rhinitis typically precedes sinusitis, and sinusitis without rhinitis is rare 1
• The mucosa of the nose and sinuses are contiguous structures 1
• Symptoms of nasal obstruction and nasal discharge are prominent features in both conditions 1
• This unified terminology better guides treatment approaches that address both nasal and sinus inflammation 1

Classification and Diagnostic Criteria

Acute Bacterial Rhinosinusitis (ABRS)

ABRS requires specific diagnostic criteria before initiating treatment: 1

• Persistent symptoms (≥10 days) without improvement, OR
• Severe symptoms (high fever ≥39°C/102°F with purulent nasal discharge or facial pain for ≥3-4 consecutive days), OR
• Worsening symptoms after initial improvement (double-worsening) 1

Chronic Rhinosinusitis (CRS)

CRS is diagnosed when at least two of the following symptoms persist for ≥12 weeks: 1

• Mucopurulent drainage (anterior, posterior, or both)
• Nasal obstruction/congestion
• Facial pain-pressure-fullness
• Decreased sense of smell

Plus objective evidence of inflammation documented by purulent mucus/edema in the middle meatus, nasal polyps, or radiographic evidence of sinus inflammation 1

Recurrent Acute Rhinosinusitis

Defined as ≥4 episodes per year of ABRS without symptoms between episodes 1

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Treatment Algorithm for Acute Bacterial Rhinosinusitis

Step 1: Determine Severity and Duration

For mild-to-moderate symptoms <7 days: Observation with symptomatic treatment is preferred over antibiotics 1

For symptoms 7-10 days: Continue observation unless severe features develop 1

For symptoms ≥10 days OR severe presentation OR worsening after initial improvement: Consider antibiotic therapy 1

Step 2: Initial Symptomatic Management (All Patients)

Intranasal corticosteroids provide modest but clinically important benefit (number needed to treat = 14): 1

• Fluticasone propionate 200 mcg once daily reduces sinus pain/pressure and nasal congestion 2, 3
• Benefits appear within the first day, with full effectiveness building over several days 2
• Does not cause rebound effect unlike topical decongestants 2
• Safe for up to 6 months in patients ≥12 years, or up to 2 months/year in ages 4-11 2

Saline nasal irrigation is strongly recommended: 1

• Improves mucociliary function and mechanically rinses infectious debris 1
• Use 2-3 times daily for optimal benefit 4
• Relieves sinonasal symptoms and may reduce reliance on other medications 1

Analgesics for facial pain/pressure: 1

• Acetaminophen or NSAIDs as needed for symptom relief 1

Step 3: Antibiotic Selection (When Indicated)

First-line antibiotic: Amoxicillin 1

• Narrow-spectrum coverage targeting Streptococcus pneumoniae and Haemophilus influenzae 1
• Most favorable clinical outcomes result from natural history, not antibiotics, so expensive alternatives are not superior 1

Consider risk factors for antibiotic-resistant bacteria: 1

• Recent antibiotic use within past month
• Contact with children in daycare
• In these cases, consider amoxicillin-clavulanate or alternative agents 1

Step 4: Avoid Ineffective or Harmful Interventions

Do NOT routinely use: 1

• Antihistamines in non-atopic patients (questionable efficacy) 1
• Systemic corticosteroids (unproven efficacy for ABRS) 1
• Topical decongestants beyond 3-5 days (risk of rhinitis medicamentosa) 1, 4

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Treatment Algorithm for Chronic Rhinosinusitis

First-Line Medical Management

Intranasal corticosteroids are the cornerstone of CRS treatment: 5, 6

• Long-term treatment reduces inflammation, polyp size, and improves nasal blockage, rhinorrhea, and smell 6
• Continue indefinitely as maintenance therapy 5, 6
• Use lowest effective dose, particularly in children 1

Saline nasal irrigation (2-3 times daily): 1, 5

• Enhances mucociliary clearance and improves sinus drainage 5
• Should be continued long-term alongside intranasal corticosteroids 1

Second-Line Options

Intranasal corticosteroid drops (if spray fails): 6

• May provide better delivery to affected areas when standard spray is ineffective 6

Short courses of oral corticosteroids: 6

• Reserved for severe CRS with nasal polyps or when rapid symptomatic improvement is needed 6
• Not for routine or long-term use 6

Antibiotics (limited role): 5

• Only indicated when evidence of superimposed acute bacterial infection exists 5
• Not effective for chronic inflammation without active infection 1

When to Consider Surgical Referral

Refer to otolaryngology when: 1, 5

• Medical management fails after appropriate trial (typically 8-12 weeks) 1
• Significant anatomic obstruction (septal deviation compressing middle turbinate, obstructing nasal polyps) 1
• Radiographic evidence of ostiomeatal obstruction despite aggressive medical therapy 1

Endoscopic sinus surgery goals: 1

• Promote drainage and aeration 1
• Improve access for topical medications 5
• Continue intranasal corticosteroids postoperatively 1, 6

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Treatment for Recurrent Acute Rhinosinusitis

Prevention Strategies

Primary prevention (reduce VRS episodes that precede ABRS): 1

• Hand hygiene with soap or alcohol-based rub when exposed to ill individuals 1
• Smoking cessation counseling (smoking increases sinusitis risk) 1

Secondary prevention (minimize symptoms and exacerbations): 1

• Regular saline nasal irrigation 1
• Consider treating gastroesophageal reflux if present (limited evidence but may prevent CRS) 1

Acute Episode Management

Treat each episode according to ABRS guidelines above 1

Consider evaluation for underlying causes: 1

• Allergy evaluation if allergic rhinitis suspected 1
• Immunologic assessment if immunodeficiency suspected (IgG subclasses, specific antibody responses to tetanus/pneumococcal vaccine) 1
• Nasal endoscopy to identify anatomic abnormalities 1

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Critical Pitfalls to Avoid

Do not prescribe antibiotics for viral rhinosinusitis: 1

• Only 0.5-2% of acute rhinosinusitis episodes are bacterial 1
• Approximately 60% of presumed ABRS resolves spontaneously without antibiotics 1
• Mucus color alone does not indicate bacterial infection (reflects neutrophils, not bacteria) 1

Do not use topical decongestants beyond 3-5 days: 1, 4

• Risk of rhinitis medicamentosa (rebound congestion) 1, 4
• Further dries nasal mucosa in chronic conditions 4

Do not use oral antihistamines in non-allergic rhinosinusitis: 1, 4

• Anticholinergic effects worsen nasal dryness 4
• No proven benefit in non-atopic patients 1

Do not rely on sinus radiography for diagnosis: 1

• High prevalence of abnormal findings in viral rhinosinusitis 1
• Limited diagnostic value for uncomplicated cases 1

In chronic rhinosinusitis, do not assume infection is the primary problem: 1

• Chronic hyperplastic eosinophilic rhinosinusitis does not respond to antibiotics 1
• Marked by eosinophils and mononuclear cells, not neutrophils 1
• Requires corticosteroid therapy, not antimicrobials 1