What are the treatment options for sinus symptoms?

Treatment of Sinus Symptoms

For acute sinus symptoms, start with symptomatic relief using analgesics, nasal saline irrigation, and intranasal corticosteroids, reserving antibiotics only for bacterial sinusitis confirmed by symptoms lasting ≥10 days without improvement or severe symptoms from onset. 1, 2

Initial Assessment and Symptom Management

Distinguishing Viral from Bacterial Disease

Most sinus symptoms are viral and resolve without antibiotics. 2 Consider bacterial sinusitis only when:

• Symptoms persist for ≥10 days without improvement 1, 2
• Severe symptoms present from onset (high fever ≥39°C with purulent nasal discharge for 3-4 consecutive days) 2, 3
• Worsening symptoms after initial improvement ("double-worsening") 3

Do not prescribe antibiotics for symptoms lasting less than 10 days unless severe criteria are met. 1, 2

First-Line Symptomatic Treatment (All Patients)

Regardless of viral versus bacterial etiology, provide symptomatic relief:

Analgesics:

• Acetaminophen or ibuprofen for facial pain, headache, and fever 1, 2
• Pseudoephedrine plus acetaminophen provides effective relief of sinus pressure and pain 4

Nasal Saline Irrigation:

• High-volume nasal irrigation with physiologic or hypertonic saline relieves symptoms and is well-tolerated 1, 2
• Provides cleansing and modest symptom improvement 2

Intranasal Corticosteroids:

• Recommended as adjunctive therapy for both acute and chronic sinusitis 1, 2
• Reduces inflammation and improves nasal congestion and facial pain 1
• Number needed to treat is 14 for modest benefit, but adverse events are rare 1
• Not FDA-approved for acute viral rhinosinusitis but evidence supports use 1

Decongestants:

• Oral decongestants (pseudoephedrine) provide symptomatic relief if no contraindications exist (hypertension, anxiety) 1, 5, 6
• Topical decongestants may be used but limit to 3-5 days maximum to avoid rebound congestion and rhinitis medicamentosa 1, 6

Antibiotic Therapy for Bacterial Sinusitis

First-Line Antibiotic Choice

Amoxicillin is the first-line antibiotic for acute bacterial sinusitis in both children and adults. 1, 2, 7

• Standard dosing: 500 mg three times daily for adults 7
• High-dose amoxicillin (80-90 mg/kg/day in children; 1000 mg three times daily in adults) for areas with high penicillin-resistant Streptococcus pneumoniae 8, 3
• Duration: 10-14 days, or continue until symptom-free plus 7 additional days 1, 8, 2

Rationale: Amoxicillin is effective, inexpensive, well-tolerated, and covers the most common pathogens (S. pneumoniae, Haemophilus influenzae, Moraxella catarrhalis). 2, 7

Second-Line Antibiotics

Switch to second-line therapy if:

• No improvement after 3-5 days of first-line treatment 1, 8, 2
• Recent antibiotic use within past 6 weeks 7
• Moderate to severe disease 7
• High local resistance to penicillin 3

Amoxicillin-clavulanate is the preferred second-line agent:

• High-dose formulation (amoxicillin component 80-90 mg/kg/day) 8, 3
• Provides coverage against beta-lactamase-producing organisms 8, 7

Alternative second-line options:

• Respiratory fluoroquinolones (levofloxacin, moxifloxacin) for beta-lactam allergy or treatment failure 7
• Cefuroxime, cefpodoxime, or cefdinir 3

For penicillin allergy:

• Mild disease: Trimethoprim-sulfamethoxazole or doxycycline 7
• Moderate disease: Fluoroquinolone 7

Critical Reassessment Point

Reassess all patients at 3-5 days after starting antibiotics. 1, 8, 2 If no improvement or worsening occurs, switch antibiotics or pursue imaging (CT scan) to evaluate for complications. 8, 2

Adjunctive Therapies

Intranasal corticosteroids should be used as adjunct to antibiotics in bacterial sinusitis. 1, 2 They reduce inflammation and promote sinus drainage. 1

Avoid ineffective therapies:

• Antihistamines have no proven benefit in non-allergic patients 1, 7
• Guaifenesin (expectorants) lack evidence of efficacy 1
• Systemic corticosteroids are not routinely recommended for acute bacterial sinusitis 1

Chronic Sinusitis Considerations

For chronic sinusitis (symptoms >12 weeks):

• Longer antibiotic courses may be required with attention to anaerobic pathogens 1
• Intranasal corticosteroids are particularly helpful 1
• Consider systemic corticosteroids for chronic non-infectious (hyperplastic) sinusitis 1
• Evaluate for underlying conditions: allergic rhinitis, immunodeficiency, anatomical abnormalities, gastroesophageal reflux disease 1, 8

When to Refer or Escalate Care

Consider specialist referral (ENT or allergy/immunology) for:

• No improvement after 48-72 hours of appropriate antibiotic therapy 8
• Recurrent episodes of sinusitis 8
• Presence of complications (periorbital edema, severe headache, neurological symptoms) 1, 8, 2
• Immunocompromised patients 8
• Anatomical abnormalities 8

Imaging (CT scan) is indicated when:

• Symptoms are vague or physical findings equivocal 1
• Clinical disease persists despite optimal medical therapy 1
• Complications are suspected 8

Common Pitfalls to Avoid

• Overdiagnosis and unnecessary antibiotic use: Most sinus symptoms are viral and resolve without antibiotics. 1
• Topical decongestant overuse: Never exceed 3-5 days to prevent rebound congestion. 1, 6
• Inadequate treatment duration: Complete the full 10-14 day course even if symptoms improve earlier. 1, 2
• Missing underlying conditions: In recurrent cases, evaluate for allergic rhinitis (present in 26% of chronic sinusitis), immunodeficiency, or GERD. 1