From the Guidelines
Chronic sinusitis management should prioritize saline nasal irrigation and topical intranasal corticosteroids for symptom relief, as recommended by the most recent and highest quality study 1.
Key Components of Management
- Daily saline nasal irrigation using a neti pot or squeeze bottle to flush out mucus and irritants
- Intranasal corticosteroids like fluticasone (Flonase) 1-2 sprays per nostril daily or mometasone (Nasonex) to reduce inflammation
Additional Considerations
- For acute flare-ups, oral antibiotics such as amoxicillin-clavulanate (875/125 mg twice daily for 10-14 days) may be considered if bacterial infection is suspected, as suggested by older studies 1
- Antihistamines like loratadine (10 mg daily) or cetirizine (10 mg daily) can help if allergies contribute to symptoms
- Environmental modifications are crucial, including use of air purifiers, avoidance of known allergens, maintenance of optimal humidity (40-50%), and quitting smoking
Surgical Options
- If symptoms persist despite 3 months of appropriate medical therapy, consultation with an ENT specialist to consider surgical options like functional endoscopic sinus surgery (FESS) may be necessary, as indicated by studies 1
- Surgical intervention may be considered for anatomic defects, recurrent or persistent infectious sinusitis, or other specific indications, as outlined in the studies 1
From the Research
Chronic Sinusitis Management
- Chronic sinusitis is a common inflammatory condition defined by persistent symptomatic inflammation of the sinonasal cavities lasting longer than 3 months 2.
- The management of chronic sinusitis involves the use of medical therapies to optimize patient quality of life and daily functioning, and minimize the risk of acute inflammatory exacerbations 2.
Medical Therapies
- Saline irrigation has been shown to improve symptom scores compared to no treatment, with a standardized mean difference (SMD) of 1.42 [95% CI, 1.01 to 1.84] 2.
- Topical corticosteroid therapy has been shown to improve overall symptom scores (SMD, -0.46 [95% CI, -0.65 to -0.27]), improve polyp scores (SMD, -0.73 [95% CI, -1.0 to -0.46]), and reduce polyp recurrence after surgery (relative risk, 0.59 [95% CI, 0.45 to 0.79]) 2.
- Systemic corticosteroids and oral doxycycline have been shown to reduce polyp size compared to placebo for 3 months after treatment (P < .001) 2.
- Leukotriene antagonists have been shown to improve nasal symptoms compared to placebo in patients with nasal polyps (P < .01) 2.
- Macrolide antibiotic for 3 months has been associated with improved quality of life at a single time point (24 weeks after therapy) compared to placebo for patients without polyps (SMD, -0.43 [95% CI, -0.82 to -0.05]) 2.
Recommendations
- Daily high-volume saline irrigation with topical corticosteroid therapy is recommended as a first-line therapy for chronic sinusitis 2.
- A short course of systemic corticosteroids (1-3 weeks), short course of doxycycline (3 weeks), or a leukotriene antagonist may be considered in patients with nasal polyps 2.
- A prolonged course (3 months) of macrolide antibiotic may be considered for patients without polyps 2.
- Oral steroids are strongly recommended for short-term management of chronic rhinosinusitis with nasal polyps (CRSwNP) and for management of allergic fungal sinusitis (AFS) 3.
- Oral steroid use in chronic rhinosinusitis without nasal polyps (CRSsNP) is optional due to insufficient strong evidence 3.
Diagnostic Criteria
- Clinicians should distinguish presumed acute bacterial rhinosinusitis (ABRS) from acute rhinosinusitis caused by viral upper respiratory infections and noninfectious conditions 4.
- The management of ABRS should include an assessment of pain, with analgesic treatment based on the severity of pain 4.
- Radiographic imaging is not recommended for patients who meet diagnostic criteria for acute rhinosinusitis, unless a complication or alternative diagnosis is suspected 4.