What is the recommended treatment for chronic sinusitis?

Treatment of Chronic Sinusitis

Intranasal corticosteroids combined with daily high-volume saline nasal irrigation should be the first-line treatment for all patients with chronic sinusitis, regardless of polyp status. 1, 2, 3

First-Line Medical Therapy

Intranasal Corticosteroids

• Intranasal corticosteroids are the cornerstone of chronic sinusitis management, reducing inflammation, decreasing nasal polyp size, and improving nasal blockage, rhinorrhea, and loss of smell. 1, 2
• These agents should be continued indefinitely as maintenance therapy and postoperatively after sinus surgery to maintain symptom control. 2
• Specific agents include mometasone furoate, fluticasone propionate, and beclometasone dipropionate. 4

Saline Nasal Irrigation

• High-volume saline irrigation (not just nasal spray) significantly improves symptom scores compared to no treatment (standardized mean difference 1.42,95% CI 1.01-1.84). 3
• Saline irrigation clears mucus, reduces inflammation, and improves medication delivery to the sinonasal mucosa. 1, 2
• The combination of intranasal corticosteroids with saline irrigation provides enhanced effectiveness compared to either treatment alone. 2

Role of Antibiotics in Chronic Sinusitis

The use of antibiotics in chronic sinusitis is controversial with limited evidence supporting routine use. 1

When to Consider Antibiotics

• For chronic infectious sinusitis with evidence of bacterial infection, consider a minimum 3-week course of antibiotics effective against H. influenzae, anaerobes, and S. pneumoniae. 5, 1
• Appropriate antibiotic choices include amoxicillin-clavulanate, ciprofloxacin, clarithromycin, or trimethoprim-sulfamethoxazole. 4, 6
• If no improvement occurs within 3-5 days of antibiotic therapy, switch to an alternative antibiotic. 1

Macrolide Antibiotics for Non-Polyp Disease

• A 3-month course of macrolide antibiotics (such as clarithromycin) may improve quality of life in patients without nasal polyps (standardized mean difference -0.43,95% CI -0.82 to -0.05). 3
• This represents a prolonged anti-inflammatory effect rather than traditional antimicrobial therapy. 3

Critical Caveat

• Conservative therapy with antibiotics alone (without surgical intervention when indicated) is successful in only one-third of chronic sinusitis cases. 5

Systemic Corticosteroids for Nasal Polyps

For patients with nasal polyps, a short course (1-3 weeks) of systemic corticosteroids reduces polyp size for up to 3 months after treatment. 1, 3

• Oral prednisolone or dexamethasone for 3 weeks significantly reduces polyp size compared to placebo (P < 0.001). 3
• Systemic corticosteroids are particularly beneficial for patients with chronic non-infectious sinusitis and nasal polyps. 1

Alternative Medical Therapies

Leukotriene Antagonists

• Leukotriene antagonists improve nasal symptoms in patients with nasal polyps compared to placebo (P < 0.01). 3

Doxycycline

• A 3-week course of doxycycline reduces polyp size for up to 3 months after treatment in patients with nasal polyps (P < 0.001). 3

Adjunctive Therapies to Avoid Long-Term

• Topical decongestants cause rebound hyperemia (rhinitis medicamentosa) when used beyond a few days, so limit use to short-term only. 2
• Oral decongestants may cause hypertension, CNS stimulation, insomnia, and urinary retention. 2

Surgical Intervention

Endoscopic sinus surgery should be considered when medical therapy fails after an adequate trial (typically 8-12 weeks of optimal medical management). 1, 2

Specific Indications for Surgery

• Documented chronic sinus infection refractory to medical therapy 1, 2
• Anatomic obstruction amenable to surgical correction 1, 2
• Localized persistent disease within the ostiomeatal complex 1, 2
• Nasal polyps that don't respond to medical therapy 1, 2

Surgical Approach

• Surgery should be functional, involving widening of natural drainage openings while preserving ciliated epithelium as much as possible. 4
• For nasal polyposis, more aggressive removal of diseased polypous mucosa is required. 4
• Combined medical and surgical treatment achieves cure rates >60% after 3 years of follow-up, compared to only one-third with medical therapy alone. 5

Evaluation for Underlying Conditions

Always evaluate and treat underlying conditions that perpetuate chronic sinusitis: 1, 2

• Allergic rhinitis: Consider allergen testing and appropriate management, including antihistamines if allergic rhinitis is contributing. 1
• Immunodeficiency: Obtain immunoglobulin measurements and functional antibody tests in refractory cases. 1
• Gastroesophageal reflux disease (GERD): Treat if present. 1, 2
• Aspirin sensitivity: Identify and manage appropriately. 1, 2

When to Refer to a Specialist

Refer to an otolaryngologist when: 1, 7

• Sinusitis is refractory to first-line medical therapy (intranasal corticosteroids plus saline irrigation for 8-12 weeks) 7
• Recurrent sinusitis occurs (≥3 episodes per year) 1
• Quality of life is significantly affected despite treatment 1
• Unusual opportunistic infections are suspected 1

Consider referral to an allergist or pulmonologist for patients with suspected vasculitides, granulomatous diseases, cystic fibrosis, or immunodeficiency. 7

Treatment Algorithm Summary

1. Start all patients on intranasal corticosteroids plus high-volume saline irrigation 1, 2, 3
2. If nasal polyps present: Add short course (1-3 weeks) of systemic corticosteroids or doxycycline, or consider leukotriene antagonist 1, 3
3. If evidence of active bacterial infection: Add 3-week course of appropriate antibiotics (amoxicillin-clavulanate, ciprofloxacin, or clarithromycin) 5, 1, 4
4. If no polyps but refractory: Consider 3-month course of macrolide antibiotics 3
5. If medical therapy fails after 8-12 weeks: Refer for endoscopic sinus surgery 1, 2, 7
6. Always evaluate for and treat underlying conditions (allergic rhinitis, immunodeficiency, GERD, aspirin sensitivity) 1, 2