What is the recommended treatment for chronic sinusitis?

Treatment of Chronic Sinusitis

Intranasal corticosteroids combined with daily high-volume saline irrigation should be the first-line treatment for all patients with chronic sinusitis, regardless of polyp status. 1, 2

First-Line Medical Therapy

Intranasal corticosteroids are the cornerstone of chronic sinusitis management and should be used continuously as maintenance therapy:

• Reduce inflammation, decrease nasal polyp size, and improve nasal symptoms including blockage, rhinorrhea, and loss of smell 2
• Improve overall symptom scores (standardized mean difference -0.46) and polyp scores (standardized mean difference -0.73) 3
• Reduce polyp recurrence after surgery by 41% (relative risk 0.59) 3
• Should be continued postoperatively to maintain symptom control 2

Saline nasal irrigation (high-volume, daily) provides significant benefit:

• Clears mucus, reduces inflammation, and improves medication delivery to sinonasal mucosa 1, 2
• Improves symptom scores compared with no treatment (standardized mean difference 1.42) 3
• Combined use with intranasal corticosteroids provides enhanced effectiveness compared to either treatment alone 2

Role of Antibiotics in Chronic Sinusitis

The use of antibiotics in chronic sinusitis is controversial with limited supporting evidence. 1 The approach differs based on whether you're treating chronic infectious sinusitis versus an acute exacerbation:

For Chronic Infectious Sinusitis:

• A minimum 3-week course of antibiotics effective against H. influenzae, anaerobes, and S. pneumoniae may be beneficial 1, 2
• High-dose amoxicillin-clavulanate is a reasonable first choice 4
• If no improvement within 3-5 days, switch to alternative antibiotics such as cefuroxime, cefpodoxime, or fluoroquinolones 4, 1
• For patients without nasal polyps, a 3-month course of macrolide antibiotics may improve quality of life 3

For Acute Exacerbations:

• Recent high-quality evidence suggests antibiotics may not provide additional benefit when added to intranasal corticosteroids and saline irrigation 5
• A 2017 randomized, placebo-controlled trial found amoxicillin-clavulanate for 14 days did not change clinical course compared to placebo when both groups received intranasal steroids and saline 5
• Consider antibiotics only when there is clear evidence of superimposed acute bacterial infection 6

Additional Medical Therapies for Specific Situations

For Patients with Nasal Polyps:

• Short course of systemic corticosteroids (1-3 weeks, such as oral prednisolone) reduces polyp size for up to 3 months 1, 3
• Oral doxycycline for 3 weeks reduces polyp size compared to placebo 3
• Leukotriene antagonists improve nasal symptoms in patients with polyps 3

Adjunctive Therapies (Use with Caution):

• Oral decongestants: May provide symptomatic relief but can cause systemic side effects including increased blood pressure, CNS stimulation, insomnia, and urinary retention 2
• Topical decongestants (e.g., oxymetazoline): Can temporarily improve sinus aeration but should not be used for more than 3 days to avoid rebound hyperemia (rhinitis medicamentosa) 4, 2

When to Consider Surgery

Endoscopic sinus surgery should be considered for patients who fail medical therapy with the following indications: 1, 2

• Documented chronic sinus infection refractory to appropriate medical therapy
• Anatomic obstruction amenable to surgical correction
• Localized persistent disease within the ostiomeatal complex
• Nasal polyps that don't respond to medical therapy

Surgery should be functional, aimed at widening natural drainage openings while preserving ciliated epithelium 7

Evaluation for Underlying Contributing Conditions

Always evaluate and treat underlying conditions that perpetuate chronic sinusitis: 1, 2

• Allergic rhinitis: Consider allergen testing and appropriate management; antihistamines may have a role if allergic rhinitis is present 4
• Immunodeficiency: Consider immunoglobulin measurements and functional antibody tests 1
• Gastroesophageal reflux disease (GERD) 1
• Aspirin sensitivity 1

When to Refer to a Specialist

Refer to an otolaryngologist when: 2, 6

• Sinusitis is refractory to first-line medical therapy
• Sinusitis is recurrent
• Quality of life is significantly affected

Consider referral to allergist or pulmonologist for patients with history suggestive of vasculitides, granulomatous diseases, cystic fibrosis, or immunodeficiency 6

Common Pitfalls to Avoid

• Overuse of antibiotics: Most chronic sinusitis benefits more from anti-inflammatory therapy than prolonged antibiotics 1, 5
• Extended topical decongestant use: Never exceed 3 days to prevent rhinitis medicamentosa 2
• Treating without addressing underlying allergic rhinitis: This perpetuates the inflammatory cycle 4, 1
• Discontinuing intranasal corticosteroids after surgery: These should be continued postoperatively 2