What is the initial treatment for chronic sinusitis?

Initial Treatment for Chronic Sinusitis

The initial treatment for chronic sinusitis consists of intranasal corticosteroids combined with saline nasal irrigation, both used daily as first-line therapy. 1, 2, 3

First-Line Medical Therapy

Intranasal Corticosteroids

• Intranasal corticosteroids are the cornerstone of treatment due to their anti-inflammatory effects and documented efficacy in relieving nasal congestion, improving overall symptom scores (standardized mean difference -0.46), and reducing polyp size when present. 1, 2, 3
• Fluticasone propionate nasal spray can be used daily for up to 6 months in patients age 12 or older, or up to 2 months per year in children ages 4-11. 4
• These medications work locally in the nose with less than 1% systemic absorption, minimizing side effects even at higher doses. 5
• Relief may begin on the first day, but full effectiveness requires several days of consistent daily use. 4

Saline Nasal Irrigation

• High-volume saline irrigation should be used daily to prevent crusting of secretions and facilitate mechanical removal of mucus. 1, 2, 3
• Hypertonic saline may improve mucociliary clearance more effectively than normal saline. 2
• Saline irrigation improved symptom scores with a standardized mean difference of 1.42 compared to no treatment. 3

Role of Antibiotics

When to Consider Antibiotics

• Antibiotics should NOT be the primary treatment for chronic sinusitis unless there is clear evidence of an active, superimposed acute bacterial infection. 2, 6
• For chronic infectious sinusitis with documented bacterial infection, longer duration therapy (typically 3-4 weeks) may be required with attention to anaerobic pathogens. 1, 2
• Amoxicillin or high-dose amoxicillin-clavulanate are reasonable first choices when bacterial infection is confirmed. 1
• A 3-month course of macrolide antibiotics may be considered specifically for patients WITHOUT nasal polyps who fail first-line therapy. 3

Critical Pitfall to Avoid

• Overuse of antibiotics should be avoided unless there is clear evidence of bacterial infection, as antibiotics play a controversial role in non-infectious chronic sinusitis. 2, 6

Adjunctive Therapies for Symptom Relief

Decongestants

• Topical nasal decongestants (like oxymetazoline) may provide temporary symptomatic relief by widening ostia and reducing turbinate swelling. 2, 7
• Limit use to short-term only (maximum 3 days) to avoid rebound congestion—note that intranasal corticosteroids do NOT cause rebound effects and can be used long-term. 4

Antihistamines

• Consider antihistamines specifically for patients with documented allergic rhinitis as a contributing factor. 2, 7

When to Escalate Treatment

Systemic Corticosteroids

• A short course (1-3 weeks) of oral corticosteroids may be considered for patients with nasal polyps or those failing initial therapy. 1, 3
• Oral prednisolone provides rapid symptomatic improvement and reduces polyp size for approximately 3 months after treatment. 3, 7

Specialist Referral Indications

• Refer to an otolaryngologist when symptoms fail to improve after one week of appropriate first-line therapy, when sinusitis is recurrent, or when it significantly affects quality of life. 2, 4, 6
• Consider referral to an allergist or pulmonologist for patients with suspected underlying conditions such as vasculitides, granulomatous diseases, cystic fibrosis, or immunodeficiency. 6

Treatment Approach Based on Polyp Status

With Nasal Polyps

• Confirm presence or absence of nasal polyps as this is a critical modifying factor for treatment decisions. 1
• Patients with polyps benefit most from intranasal corticosteroids (polyp score improvement standardized mean difference -0.73) and may require systemic corticosteroids or leukotriene antagonists. 1, 3

Without Nasal Polyps

• Focus on intranasal corticosteroids and saline irrigation. 1, 3
• If medical management fails, consider a 3-month course of macrolide antibiotics before surgical intervention. 3

Therapies to AVOID

Antifungal Therapy

• Do NOT prescribe topical or systemic antifungal therapy for chronic sinusitis—multiple randomized controlled trials show lack of efficacy with significant cost and adverse effects. 1