Sinusitis Treatment and Management
For acute bacterial sinusitis, initiate amoxicillin 1.5-4 g/day for 10-14 days as first-line therapy, reserving broader-spectrum antibiotics for treatment failures after 3-5 days, while intranasal corticosteroids serve as essential adjunctive therapy to reduce inflammation. 1, 2
Distinguishing Bacterial from Viral Sinusitis
Before initiating antibiotics, confirm the diagnosis of acute bacterial rhinosinusitis (ABRS) using specific criteria:
- Symptoms persisting ≥10 days without improvement 3, 2
- "Double worsening": symptoms that initially improve then worsen within 10 days 3, 2
- Severe presentation: high fever (>38.3°C) with purulent discharge for ≥3 consecutive days in the first 3-4 days 3
Most acute sinusitis cases are viral and resolve without antibiotics—antibacterial treatment is only indicated for patients meeting these bacterial criteria. 2, 4
First-Line Antibiotic Therapy
Amoxicillin remains the antibiotic of choice at doses of 1.5-4 g/day for 10-14 days. 1, 2 This recommendation persists despite newer broad-spectrum agents because meta-analyses demonstrate no significant superiority of expensive alternatives over narrow-spectrum agents for uncomplicated cases. 4
For Treatment Failures or High-Resistance Areas:
- Switch to amoxicillin-clavulanate (high-dose) if no improvement after 3-5 days 1
- Alternative agents for penicillin allergy: cefuroxime, cefpodoxima, or cefdinir 1
- Reassess at 7 days to confirm diagnosis, exclude complications, and rule out alternative causes 2
Essential Adjunctive Therapy
Intranasal corticosteroids (e.g., fluticasone propionate) are recommended as complementary therapy to reduce mucosal inflammation and promote drainage. 1, 5, 6 Fluticasone propionate decreases nasal mucosal eosinophils in 66% of patients and promotes drainage by reducing inflammation and white blood cell influx. 5, 6
Additional Supportive Measures:
- Analgesics based on pain severity (mandatory assessment) 2
- High-volume saline irrigation 7
- Adequate hydration, warm compresses, steam inhalation, sleeping with head elevated 1, 8
- Oral and topical decongestants to reduce tissue edema and maintain ostial patency 9, 8
Important Caveat on Antihistamines:
Avoid antihistamines in acute sinusitis unless the patient has concomitant active allergic rhinitis, as they can thicken secretions and impair drainage. 8
Chronic Sinusitis Management
The cornerstone of chronic sinusitis treatment is intensive medical management with high-volume saline irrigation plus intranasal corticosteroids, combined with mandatory smoking cessation. 7
Critical First Step - Smoking Cessation:
Defer functional endoscopic sinus surgery until smoking cessation is achieved, as patients who continue smoking after surgery have significantly worse long-term outcomes. 7, 10 This is the single most important intervention before considering definitive treatment. 7
Evaluate Underlying Contributing Factors:
- Allergic rhinitis: obtain IgE testing to inhalant allergens 3, 7
- Gastroesophageal reflux disease (GERD): medical treatment of GERD results in significant improvement in sinusitis symptoms 7
- Anatomic abnormalities: assess via CT imaging and nasal endoscopy 3
- Immunodeficiency: consider in recurrent or refractory cases 3
Role of Antibiotics in Chronic Sinusitis:
Reserve antibiotics for evidence of superimposed acute bacterial infection. 7 When treating chronic infectious sinusitis, longer duration therapy (potentially 3 months) may be required with attention to anaerobic pathogens. 7
Surgical Indications
Functional endoscopic sinus surgery (FESS) is the standard of care for chronic infectious sinusitis with mechanical blockage of the ostiomeatal complex, but only after failed medical management. 10
Specific Surgical Indications:
- Nasal polyps obstructing drainage despite medical treatment 10
- Recurrent/persistent infectious sinusitis despite adequate antibiotic trials 10
- Anatomic defects obstructing the ostiomeatal complex 10
- Fungal sinusitis (fungus balls, allergic fungal sinusitis, invasive fungal sinusitis) 10
- Threatened complications (brain abscess, meningitis, cavernous sinus thrombosis) 10
Important: FESS results in significant improvement in the majority of patients, but optimal outcomes require combining surgical intervention with intensive postoperative local management and appropriate medical therapy. 10, 7
When to Refer to Specialists
Refer to Allergist-Immunologist:
- Chronic sinusitis persisting several months or recurring 2-3 times per year despite treatment 10, 7
- Quality of life significantly affected or chronic work/school loss 10
- Suspected immunodeficiency or need for immune function assessment 10
- Complications: otitis, asthma, bronchiectasis, nasal polyps, bronchitis 10
Refer to Otolaryngologist:
- First-line medical therapy failure 7
- Structural abnormalities or nasal polyps 3
- Consideration for surgical intervention 3
- Need for biopsy to rule out granulomatous disease, neoplasms, ciliary dyskinesia, or fungal infections 10
Common Pitfalls to Avoid
Do not obtain imaging studies (CT/X-ray) for routine acute sinusitis diagnosis—imaging is only indicated when complications or alternative diagnoses are suspected. 2 Sinus imaging is over-utilized and contributes to over-diagnosis. 4
Avoid observation without antibiotics unless the patient has mild illness (mild pain, temperature <38.3°C) with assured follow-up and meets criteria for uncomplicated ABRS. 2
Do not prescribe broad-spectrum antibiotics as first-line therapy—this contributes to resistance without improving outcomes compared to amoxicillin. 4