What is the treatment for chronic sinusitis?

Treatment of Chronic Sinusitis

First-line treatment for chronic sinusitis consists of daily high-volume saline irrigation combined with intranasal corticosteroid sprays, as antibiotics should only be reserved for acute bacterial exacerbations, not routine maintenance therapy. 1, 2, 3

Initial Medical Management

Core Maintenance Therapy

• Nasal saline irrigation (high-volume, hypertonic or normal saline) significantly improves symptom scores compared to no treatment (standardized mean difference 1.42) and should be performed daily 2
• Topical corticosteroid sprays (e.g., flunisolide, mometasone) improve overall symptom scores, reduce polyp size, and decrease polyp recurrence after surgery by 41% 2, 4
• This combination addresses the underlying inflammatory pathophysiology by enhancing mucociliary clearance and reducing sinonasal inflammation 3

Role of Antibiotics in Chronic Sinusitis

Antibiotics are NOT indicated for routine chronic sinusitis management but should only be used when acute bacterial exacerbation is suspected (new onset purulent drainage, facial pain, fever) 1

When acute bacterial exacerbation occurs:

• Minimum 3-week course is required (longer than acute sinusitis) 1
• First-line choice: Amoxicillin 500 mg twice daily OR amoxicillin-clavulanate 500-875 mg twice daily 1
• Target pathogens: H. influenzae, S. pneumoniae, and mouth anaerobes 1
• Avoid azithromycin due to high resistance rates in key pathogens 1

For penicillin-allergic patients:

• Cephalosporins (cefuroxime, cefpodoxime, cefprozil) OR
• Fluoroquinolones (levofloxacin, moxifloxacin) as second-line agents 1

Treatment Based on Polyp Status

Patients WITH Nasal Polyps

Beyond saline irrigation and topical corticosteroids 2:

• Short-course systemic corticosteroids (1-3 weeks) reduce polyp size for up to 3 months post-treatment 2
• Doxycycline 3-week course provides similar polyp reduction 2
• Leukotriene antagonists (e.g., montelukast) improve nasal symptoms 2

Patients WITHOUT Nasal Polyps

• Prolonged macrolide therapy (3 months) may improve quality of life at 24 weeks, though this is a single time-point benefit 2
• Note: This contradicts the recommendation against azithromycin for acute exacerbations; long-term macrolides likely work through anti-inflammatory rather than antimicrobial mechanisms 1, 2

Adjunctive Symptomatic Therapies

Decongestants (Limited Evidence)

• Oral decongestants may provide symptomatic relief but lack strong evidence 1
• Topical decongestants (oxymetazoline): Maximum 3-5 days to prevent rebound congestion (rhinitis medicamentosa) 5, 1
• First-generation antihistamine/decongestant combinations may help if allergic rhinitis is present 1

Evaluation for Refractory Cases

When symptoms persist despite 8+ weeks of appropriate medical therapy 5:

Identify Underlying Causes

• Allergic rhinitis: Test for IgE sensitization to inhalant allergens; treat with environmental control, pharmacotherapy, and consider immunotherapy 5, 1
• Immunodeficiency: Check quantitative IgG, IgA, IgM levels and specific antibody responses to tetanus toxoid or pneumococcal vaccine, especially if concurrent otitis media, bronchitis, or pneumonia 5, 1
• Anatomic abnormalities: Obtain coronal sinus CT with cuts through ostiomeatal complex to assess for septal deviation compressing middle turbinate, obstructing polyps, or sinus outflow obstruction 5, 1
• Other conditions: Consider vasculitides, granulomatous diseases (sarcoidosis, Wegener's), cystic fibrosis, or fungal disease 1, 3

Specialist Referral Indications

• Otolaryngology consultation: Structural abnormalities, obstructing nasal polyps after trial of oral corticosteroids, or ostiomeatal obstruction despite aggressive medical management 5, 3
• Allergy/Immunology consultation: Recurrent sinusitis with other infections, suspected immunodeficiency, or need for allergen immunotherapy 5, 1
• Endoscopic sinus surgery may be effective when medical management fails 3

Critical Pitfalls to Avoid

• Never use antibiotic prophylaxis for chronic sinusitis—no evidence supports this approach 1
• Never use macrolides as first-line for acute bacterial exacerbations due to resistance 1
• Never extend topical decongestants beyond 3-5 days 1
• Never treat viral upper respiratory infections with antibiotics 1
• Never use fluoroquinolones as first-line agents; reserve as second-line to prevent resistance 1
• Recognize that chronic hyperplastic eosinophilic rhinosinusitis does not respond to antibiotics and may require systemic corticosteroids 5