What is the treatment for sinusitis?

Treatment of Sinusitis

Acute Bacterial Sinusitis

Amoxicillin is the first-line antibiotic for uncomplicated acute bacterial sinusitis in both adults and children, prescribed for 10-14 days. 1, 2

When to Start Antibiotics

Antibiotics should only be initiated when acute bacterial sinusitis is confirmed by one of three clinical patterns: 2

• Persistent symptoms ≥10 days without clinical improvement (nasal congestion, purulent rhinorrhea, postnasal drainage, facial/dental pain, headache, or cough) 1, 3
• Severe symptoms for ≥3 consecutive days (high fever with purulent nasal discharge and facial pain) 4, 2
• "Double sickening" - worsening symptoms after initial improvement from a viral upper respiratory infection 2, 3

Antibiotic Selection

First-line therapy: 4, 1

• Amoxicillin 500 mg twice daily for mild disease
• High-dose amoxicillin 875 mg twice daily (or 90 mg/kg in children) for moderate disease or areas with high prevalence of resistant S. pneumoniae 2

If no improvement after 3-5 days, switch antibiotics: 4

• High-dose amoxicillin-clavulanate (90 mg/kg amoxicillin and 6.4 mg/kg clavulanate, not to exceed 2g every 12 hours) 4
• Cefuroxime, cefpodoxime, cefprozil, or cefdinir 4
• Quinolones or macrolides (clarithromycin, azithromycin) for serious penicillin allergy 4, 3

For poor response after 21-28 days: 4

• Consider broader-spectrum agents with or without anaerobic coverage (clindamycin or metronidazole) 4
• Evaluate for resistant pathogens, nasal polyps, or noncompliance 4

Adjunctive Therapies for Acute Sinusitis

Intranasal corticosteroids (e.g., fluticasone propionate 200 mcg daily) should be added as adjunctive therapy to reduce inflammation and improve drainage: 4, 2, 5

• Symptom improvement may begin within 12 hours but maximum benefit takes several days 5
• Particularly helpful when patients fail initial treatment or demonstrate marked mucosal edema 4

Supportive measures: 4, 2

• Adequate rest and hydration
• Analgesics as needed
• Warm facial packs and steamy showers
• Sleeping with head of bed elevated
• Saline nasal irrigation 2

Chronic Sinusitis (Symptoms ≥8 weeks)

Intranasal corticosteroids are first-line therapy for chronic sinusitis, combined with daily high-volume saline irrigation. 1, 2

Treatment Approach

Primary therapies: 1, 2

• Intranasal corticosteroids (fluticasone propionate 100-200 mcg daily) as maintenance therapy 1, 5
• Daily high-volume saline irrigation to facilitate drainage 1
• Longer duration antibiotic therapy (minimum 3 weeks) for chronic infectious sinusitis 2

For chronic non-infectious (hyperplastic eosinophilic) sinusitis: 4

• Consider systemic corticosteroids as this form does not respond to antibiotics 4
• Marked by eosinophils and mononuclear cells with relative paucity of neutrophils 4

For nasal polyps: 1

• Short course of systemic corticosteroids or doxycycline 1

When to Refer to a Specialist

Refer to otolaryngologist or allergist-immunologist for: 4, 2

• Sinusitis refractory to usual antibiotic treatment after 21-28 days 4, 2
• Recurrent sinusitis (≥3 episodes per year) 4, 1, 2
• Suspected complications (orbital or intracranial involvement) 2
• Need to evaluate underlying allergic rhinitis, immunodeficiency, or anatomic abnormalities 4
• Consideration for functional endoscopic sinus surgery for medically resistant disease 4, 1

Recurrent Sinusitis

Patients with recurrent sinusitis require evaluation for underlying causes: 4

• Allergic rhinitis - test for IgE sensitization to inhalant allergens; treat with environmental control, pharmacotherapy, and consider allergen immunotherapy 4
• Immunodeficiency - measure quantitative IgG, IgA, IgM levels and assess specific antibody responses to tetanus toxoid or pneumococcal vaccine 4
• Anatomic abnormalities - consider CT scan if not already done; evaluate for septal deviation, middle turbinate abnormalities, or ostiomeatal obstruction 4
• Gastroesophageal reflux disease (GERD) - medical treatment of GERD may result in significant improvement 4

Critical Pitfalls to Avoid

Overdiagnosis and inappropriate antibiotic use: 1, 2

• Do not prescribe antibiotics for viral upper respiratory infections lasting <10 days without severe symptoms 1
• Ensure patients complete the full 10-14 day course to prevent relapse 1

Failure to address underlying factors: 1

• Untreated allergic rhinitis, anatomical abnormalities, or immunodeficiency will lead to recurrent disease 4, 1
• Continue intranasal corticosteroids long-term for chronic rhinitis even after acute infection resolves 4

Missing complications: 2

• Watch for orbital or intracranial involvement requiring urgent evaluation and IV antibiotics 2
• Instruct patients to call immediately if symptoms worsen with severe headache or high fever 4