What is the treatment for post-sinusitis cough?

Treatment of Post-Sinusitis Cough

For post-sinusitis cough, initiate treatment with a first-generation antihistamine-decongestant combination (such as dexbrompheniramine 6 mg or azatadine 1 mg plus sustained-release pseudoephedrine 120 mg, both twice daily), as this has been proven effective in controlled studies and works through anticholinergic properties to reduce secretions and cough. 1

Initial Treatment Approach

The primary treatment strategy targets the underlying mechanism of upper airway cough syndrome (UACS) following sinusitis:

• First-line therapy: Use older-generation antihistamine-decongestant (A/D) combinations, which have demonstrated consistent efficacy in both randomized controlled trials and prospective studies of chronic cough 1
• The anticholinergic properties of first-generation antihistamines are crucial for effectiveness in post-viral rhinosinusitis, making them superior to newer non-sedating antihistamines 1
• Most patients show improvement within days to 2 weeks of initiating therapy 1

Alternative and Adjunctive Therapies

If the standard A/D combination is contraindicated or ineffective:

• Ipratropium bromide nasal spray can be used as an alternative, particularly in patients with glaucoma or symptomatic benign prostatic hypertrophy where anticholinergic oral agents are contraindicated 1
• Guaifenesin may provide symptomatic relief as an expectorant, though evidence for clinical efficacy in sinusitis specifically is limited 1, 2. However, it has been shown to reduce cough reflex sensitivity in patients with upper respiratory infections 3
• Nasal saline irrigation helps prevent crusting of secretions and facilitates mechanical removal of mucus 1, 2

When Cough Persists Despite Initial Treatment

For refractory post-sinusitis cough:

• Inhaled ipratropium should be considered as it may attenuate persistent cough 1
• Inhaled corticosteroids can be tried when cough adversely affects quality of life and persists despite ipratropium 1
• Short-course oral corticosteroids (prednisone 30-40 mg daily) may be considered for severe paroxysms after ruling out other common causes of chronic cough 1
• Central antitussive agents (codeine or dextromethorphan) should be reserved for when other measures fail 1

Critical Pitfalls to Avoid

• Do not use antibiotics for post-viral sinusitis cough, as the cause is not bacterial infection and antibiotics have no role 1, 2
• Avoid newer-generation antihistamines (such as terfenadine or loratadine) for post-viral rhinosinusitis, as studies have shown them to be ineffective for this condition 1
• Limit topical decongestants to ≤3-5 days maximum to prevent rhinitis medicamentosa (rebound congestion) 2

Reassessment Criteria

Consider bacterial sinusitis requiring antibiotics only if:

• Symptoms persist beyond 10 days and worsen or fail to improve 2
• High fever (≥39°C), severe facial pain, or purulent discharge develop for ≥3 consecutive days 2
• In these cases, amoxicillin or high-dose amoxicillin-clavulanate becomes appropriate 1

Supportive Measures

Recommend these adjunctive comfort measures:

• Adequate rest and hydration 1
• Warm facial packs and steamy showers 1
• Sleeping with head of bed elevated 1
• Analgesics as needed for discomfort 1, 2