What is the treatment for chronic maxillary sinusitis?

Treatment of Chronic Maxillary Sinusitis

For chronic maxillary sinusitis, medical management with amoxicillin-clavulanate (875 mg/125 mg twice daily for 10-14 days) combined with intranasal corticosteroids is the first-line approach, but functional endoscopic sinus surgery (FESS) should be considered when symptoms persist despite multiple courses of appropriate antibiotics or when anatomic obstruction of the ostiomeatal complex is identified. 1, 2

Distinguishing Chronic from Acute Disease

• Chronic sinusitis is defined as inflammation lasting >3 months with compatible radiographic abnormalities on CT imaging 1
• Confirmation should ideally include endoscopic sinoscopy with direct visualization, microbiologic sampling, and histopathologic evaluation when possible 1
• Evaluate for underlying causes including environmental factors, allergic rhinitis, immunodeficiency, and anatomic abnormalities that perpetuate the disease 1, 2

Medical Management Algorithm

First-Line Antibiotic Therapy

• Amoxicillin-clavulanate 875 mg/125 mg twice daily for 10-14 days is the preferred first-line antibiotic for chronic maxillary sinusitis 1, 2, 3
• This provides coverage against β-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis, which are increasingly prevalent in chronic disease 2
• Treatment duration should extend until symptom-free for 7 days, typically requiring 10-14 days total 2

Alternative Options for Penicillin Allergy

• Second-generation cephalosporins: Cefuroxime-axetil 500 mg twice daily for 10-14 days 1, 2, 3
• Third-generation cephalosporins: Cefpodoxime-proxetil or cefdinir with superior activity against H. influenzae 1, 2, 3
• Pristinamycin for patients with true β-lactam allergy 1

Second-Line Therapy for Treatment Failure

• Reserve fluoroquinolones (levofloxacin 500 mg once daily or moxifloxacin 400 mg once daily for 10-14 days) for situations where first-line therapy fails or major complications are threatened 1, 2
• Fluoroquinolones provide 90-92% predicted clinical efficacy against drug-resistant Streptococcus pneumoniae and β-lactamase-producing organisms 2
• These should not be used as routine first-line therapy to prevent resistance development 1, 2

Essential Adjunctive Medical Therapies

Intranasal Corticosteroids (Strongly Recommended)

• Intranasal corticosteroids (mometasone, fluticasone, or budesonide twice daily) are recommended as adjunct therapy in both acute and chronic sinusitis 2
• These reduce mucosal inflammation and improve symptom resolution with strong evidence from multiple randomized controlled trials 2
• Continue long-term in chronic disease to maintain patency and reduce inflammation 2

Short-Term Oral Corticosteroids (Selective Use)

• Consider short-term oral corticosteroids (typically 5 days) for patients with marked mucosal edema or who fail initial treatment 1, 2
• These should always be combined with appropriate antibiotic therapy, never used as monotherapy 2

Supportive Measures

• Saline nasal irrigation provides symptomatic relief 2
• Adequate hydration, analgesics, and warm facial packs 2
• Decongestants (pseudoephedrine) may provide symptomatic relief, though evidence is limited 2

When to Refer for Surgical Evaluation

Indications for Specialist Referral

• Symptoms persisting for several months or recurring 2-3 times per year despite appropriate medical treatment 1
• Recurrent or persistent infectious sinusitis despite multiple courses of antibiotics chosen to cover anticipated pathogens 1
• Nasal polyps obstructing sinus drainage that persist despite medical treatment 1
• Anatomic defects obstructing the ostiomeatal complex identified on CT imaging 1
• Quality of life significantly affected with chronic loss of school or work 1
• Complications including asthma, bronchiectasis, or recurrent otitis 1

Surgical Approach: Functional Endoscopic Sinus Surgery (FESS)

• FESS has become the surgical standard of care for chronic infectious sinusitis with mechanical blockage of the ostiomeatal complex 1
• The endoscopic approach is minimally invasive, associated with less morbidity, and provides stable long-term results 4, 5
• Surgery focuses on restoring ventilation and drainage by removing diseased tissue and enlarging the natural ostium 1, 5
• Incidence of severe surgical complications is approximately 0.5% 1

Important Surgical Considerations

• Patients who continue to smoke after surgery have significantly worse long-term outcomes 1
• Advantages and disadvantages of elective surgery should be carefully weighed in active smokers 1
• Fungal sinusitis (fungus balls, allergic fungal sinusitis, invasive disease) generally requires surgical intervention 1
• Unilateral polypoid disease requires biopsy to exclude fungal disease or tumor (inverted papilloma) 1

Special Situations

Chronic Maxillary Sinusitis of Dental Origin (CMSDO)

• Requires simultaneous management of both the diseased maxillary sinus and the dental source of infection 4, 5
• Combined endoscopic and intra-oral approach is the treatment of choice 4, 5
• First surgical step treats the odontogenic source (extraction, fistula closure, foreign body removal) 5
• Second step is FESS with opening and calibration of the maxillary natural ostium 5
• This multi-disciplinary approach between maxillofacial surgeons and otolaryngologists is essential 4

Pediatric Chronic Maxillary Sinusitis

• Amoxicillin-clavulanate 80 mg/kg/day in three doses (not exceeding 3 g/day) for 7-10 days 1, 3
• For penicillin-allergic children: Cefpodoxime-proxetil 8 mg/kg/day in two doses 1
• Adenoidal hypertrophy should be evaluated as a contributing factor to ostiomeatal obstruction 1

Critical Pitfalls to Avoid

• Do not use azithromycin or other macrolides due to resistance rates of 20-25% for both S. pneumoniae and H. influenzae 2
• Never use clindamycin as monotherapy as it lacks activity against H. influenzae and M. catarrhalis 2
• Avoid fluoroquinolone overuse by reserving them strictly for treatment failures or complicated disease 1, 2
• Ensure adequate treatment duration (minimum 10-14 days) to prevent relapse 2
• Reassess at 3-5 days: if no improvement, switch antibiotics or re-evaluate diagnosis 2
• Do not continue ineffective medical therapy indefinitely without considering surgical evaluation 1

Monitoring and Follow-Up

• Reassess response to treatment after 3-5 days of antibiotic therapy 2
• If no improvement after adequate medical management, obtain CT imaging to evaluate for anatomic obstruction 1
• Consider referral to otolaryngology after failure of two courses of appropriate antibiotics 2
• Long-term management requires addressing underlying inflammatory conditions (allergic rhinitis, asthma) and environmental exposures 1