Treatment of Chronic Sinusitis
Start with intranasal corticosteroids combined with daily saline nasal irrigation as first-line therapy for all patients with chronic sinusitis. 1, 2
First-Line Medical Management
Intranasal Corticosteroids
- Intranasal corticosteroids are the cornerstone of chronic sinusitis treatment, reducing inflammation, decreasing nasal polyp size, and improving nasal blockage, rhinorrhea, and loss of smell 2, 3
- Use fluticasone propionate or similar agents daily; relief may begin within the first day, but full effectiveness requires several days of consistent use 4
- Continue for up to 6 months in patients age 12 or older, or up to 2 months per year in children ages 4-11 4
- No rebound effect occurs with intranasal corticosteroids, unlike topical decongestants which cause rhinitis medicamentosa with extended use 2, 4
Saline Nasal Irrigation
- High-volume saline irrigation clears mucus, reduces inflammation, and improves medication delivery to the sinonasal mucosa 1, 2
- Saline irrigation improved symptom scores significantly compared with no treatment (standardized mean difference 1.42) 5
- Combined use of intranasal corticosteroids with saline irrigation provides enhanced effectiveness compared to either treatment alone 2
Antibiotic Therapy (Selective Use)
When to Consider Antibiotics
- Use antibiotics only for chronic infectious sinusitis with evidence of active bacterial infection, not routinely for all chronic sinusitis 1
- Prescribe a minimum 3-week course targeting H. influenzae, anaerobes, and S. pneumoniae 1, 2
- If no improvement within 3-5 days, switch to alternative antibiotics 1, 2
- Consider macrolide antibiotics (3-month course) specifically for patients without nasal polyps, as this improved quality of life at 24 weeks (standardized mean difference -0.43) 5
Common Pitfall
- Avoid routine antibiotic use in chronic sinusitis, as evidence supporting their use is limited and controversial 1
Systemic Corticosteroids (Short-Term)
- Use short courses (1-3 weeks) of oral corticosteroids for patients with nasal polyps or when rapid symptomatic improvement is needed 1, 3, 5
- Systemic corticosteroids reduce polyp size for up to 3 months after treatment 1
- Particularly beneficial in severe chronic rhinosinusitis with nasal polyps 3
Additional Adjunctive Therapies
For Patients with Nasal Polyps
- Consider leukotriene antagonists for patients with nasal polyps, as they improve nasal symptoms compared to placebo 5
- Consider 3-week course of doxycycline for polyp reduction 5
Medications to Avoid Long-Term
- Never use topical decongestants beyond 3 days, as they cause rebound hyperemia (rhinitis medicamentosa) 2
- Oral decongestants may cause hypertension, CNS stimulation, insomnia, and urinary retention 2
Surgical Intervention
Consider endoscopic sinus surgery for patients meeting any of these criteria: 1, 2
- Documented chronic sinus infection refractory to medical therapy
- Anatomic obstruction amenable to surgical correction
- Localized persistent disease within the ostiomeatal complex
- Nasal polyps unresponsive to medical therapy
Continue intranasal corticosteroids postoperatively to maintain symptom control and reduce polyp recurrence (relative risk 0.59 for recurrence with continued use) 2, 5
Evaluation for Underlying Conditions
Evaluate and treat these contributing conditions: 1, 2
- Allergic rhinitis (consider allergen testing and antihistamines)
- Immunodeficiency (check immunoglobulin levels and functional antibody tests)
- Gastroesophageal reflux disease (GERD)
- Aspirin sensitivity
When to Refer
Refer to otolaryngology when: 1, 2, 6
- Symptoms persist after one week of appropriate first-line therapy
- Sinusitis is refractory to usual treatment
- Recurrent episodes occur
- Quality of life is significantly affected
- Severe sinus pain or thick nasal discharge suggests possible sinus infection requiring evaluation
Consider referral to allergist or pulmonologist for patients with suspected vasculitides, granulomatous diseases, cystic fibrosis, or immunodeficiency 6