What is the initial treatment for chronic sinus infections?

Initial Treatment for Chronic Sinus Infections

Intranasal corticosteroids and saline irrigation are the cornerstones of chronic sinusitis management—antibiotics should NOT be routinely prescribed and should only be used when significant purulent nasal discharge is present on examination. 1

Understanding Chronic vs. Acute Sinusitis

Chronic rhinosinusitis (CRS) is fundamentally different from acute bacterial sinusitis—it is primarily an inflammatory condition rather than an infectious disease. 1 This distinction is critical because it completely changes the treatment approach. While acute sinusitis responds to antibiotics, chronic sinusitis requires anti-inflammatory therapy as the foundation of treatment. 1

First-Line Treatment: Anti-Inflammatory Therapy

Intranasal Corticosteroids (Primary Treatment)

• Intranasal corticosteroids should be the first-line therapeutic intervention due to their anti-inflammatory effects and documented efficacy. 1
• Options include mometasone, fluticasone, or budesonide administered twice daily. 2
• These medications reduce mucosal inflammation and improve symptom resolution with strong evidence from multiple randomized controlled trials. 2

Saline Nasal Irrigation (Essential Adjunct)

• Saline nasal irrigation facilitates mechanical removal of mucus and prevents crusting of secretions. 1
• This should be performed regularly as part of the treatment regimen. 1
• Saline irrigation has been beneficial in chronic sinusitis with no serious adverse effects. 3, 4

When Antibiotics May Be Considered (Limited Role)

Antibiotics should only be prescribed when purulent nasal discharge is present on direct examination—not based on symptoms alone. 1 The evidence supporting antibiotic use in chronic sinusitis is notably poor, with multiple systematic reviews indicating data are limited in quantity and quality. 1

If Antibiotics Are Indicated:

• Amoxicillin-clavulanate 875/125 mg twice daily for 10-14 days is the appropriate choice when documented purulent exacerbations occur. 1
• Treatment duration should be 10-14 days or until symptom-free for 7 days. 1
• Target organisms include respiratory anaerobes, viridans streptococci, S. pneumoniae, H. influenzae, and M. catarrhalis. 1
• Conservative therapy with antibiotics alone is successful in only one-third of chronic sinusitis cases. 1

Important Evidence on Antibiotic Efficacy:

A 2017 randomized, placebo-controlled trial demonstrated that amoxicillin-clavulanate for 14 days did not change the clinical course of acute exacerbation of chronic rhinosinusitis compared with placebo when both groups received intranasal corticosteroids and saline irrigation. 5 Both groups exhibited overall improvement of symptoms, particularly nasal secretion and nasal obstruction, with no difference between antibiotic and placebo groups. 5

Critical Pitfalls to Avoid

• Do not prescribe antibiotics routinely or indiscriminately unless there is clear evidence of bacterial infection with purulent discharge on examination. 1
• Overuse of antibiotics is associated with limited efficacy and high potential for side effects. 1
• Topical decongestants should not exceed 3-5 days to avoid rhinitis medicamentosa. 6
• Do not rely on antibiotics alone in chronic hyperplastic sinusitis—systemic corticosteroids are more appropriate. 6

Confirming the Diagnosis Before Treatment

Before initiating any treatment, confirm the diagnosis with objective documentation of sinonasal inflammation using anterior rhinoscopy, nasal endoscopy, or CT scan. 1 This ensures you are treating true chronic rhinosinusitis rather than another condition.

When to Escalate Treatment

Consider Short-Term Oral Corticosteroids:

• For marked mucosal edema or treatment failure, consider short-term oral corticosteroids before adding antibiotics. 1
• Oral corticosteroids are reasonable for patients who fail to respond to initial treatment, demonstrate nasal polyposis, or have marked mucosal edema. 2
• Typical duration is 5 days based on research evidence. 2

When to Refer to a Specialist:

Refer to an otolaryngologist or allergist/immunologist when: 6

• Sinusitis is refractory to usual treatment after appropriate trials (minimum 3 weeks of antibiotics plus 3 months of intranasal corticosteroids). 6
• Recurrent sinusitis occurs (≥3 episodes per year). 6
• Symptoms are refractory to two courses of appropriate antibiotics. 2
• Suspected complications such as orbital cellulitis or meningitis develop. 2

Evaluate for Underlying Causes

Before considering surgical intervention or prolonged antibiotic therapy, evaluate for: 6

• Allergic rhinitis, which may require antihistamines and allergen avoidance. 6
• Immunodeficiency, which may require IVIG therapy. 6
• Aspirin sensitivity, as aspirin desensitization has shown benefit in aspirin-sensitive patients with sinusitis and asthma. 6
• Anatomic obstruction that may be amenable to endoscopic correction. 6

Surgical Consideration

Functional endoscopic sinus surgery (FESS) should be considered when localized persistent disease within the ostiomeatal complex is documented despite maximal medical therapy, or when anatomic obstruction is present that is amenable to endoscopic correction. 6 Surgery should only be considered after medical management has failed following appropriate duration (minimum 3 weeks of antibiotics plus 3 months of intranasal corticosteroids). 6