What are the treatment options for sinus pain?

Treatment of Sinus Pain

For sinus pain relief, start with over-the-counter analgesics (acetaminophen or NSAIDs) combined with nasal saline irrigation and intranasal corticosteroid sprays, reserving antibiotics only for confirmed bacterial sinusitis lasting more than 10 days or with severe/worsening symptoms. 1

First-Line Symptomatic Treatment

Pain relief is the primary goal and should be addressed immediately regardless of whether the sinusitis is viral or bacterial 1:

• Acetaminophen or ibuprofen are usually sufficient to relieve facial pain and are the analgesics of choice 1
• Narcotics are rarely necessary and should be actively discouraged due to potential adverse events 1

Adjunctive Therapies for Symptom Relief

Intranasal Corticosteroids

• Provide modest but clinically meaningful benefit with a number needed to treat of 14 (improving symptom resolution from 66% to 73% at 15-21 days) 1
• Side effects are minor (epistaxis, headache, nasal itching) and rare 1
• Particularly helpful when there is marked mucosal edema or underlying allergic rhinitis 2
• Can be used for both viral and bacterial sinusitis 1

Nasal Saline Irrigation

• May improve quality of life, decrease symptoms, and reduce medication use, especially in patients with frequent sinusitis 1
• Buffered hypertonic saline (3%-5%) showed modest benefit and may have superior anti-inflammatory effects compared to isotonic saline 1
• Low risk of adverse reactions makes this a safe adjunctive option 1

Decongestants

• Oral decongestants may provide symptomatic relief and should be considered unless contraindicated by hypertension or anxiety 1
• Topical decongestants (xylometazoline) reduce sinus and nasal mucosal congestion but must be limited to 3-5 consecutive days maximum to avoid rebound congestion and rhinitis medicamentosa 1

Therapies to AVOID

Critical pitfall: Do not routinely use antihistamines or oral steroids 1:

• Antihistamines have no role in non-allergic patients with sinusitis and may worsen congestion by drying nasal mucosa 1
• Exception: In allergic patients with confirmed sinusitis, loratadine as an adjunct to antibiotics showed benefit 1
• Oral steroids as monotherapy show no benefit over placebo 1
• When oral steroids are combined with antibiotics, there is only modest short-term benefit (NNT of 7) with significant risk of attrition bias and mild adverse events (nausea, vomiting, gastric complaints) 1
• Guaifenesin lacks evidence of clinical efficacy 1

When to Consider Antibiotics

Antibiotics are indicated only for bacterial sinusitis, defined by 2, 3:

• Symptoms persisting ≥10 days without improvement (persistent pattern)
• Severe symptoms (high fever ≥39°C and purulent nasal discharge) for 3-4 consecutive days
• Worsening symptoms after initial improvement (double-worsening pattern)

First-line antibiotic choice: Amoxicillin or amoxicillin-clavulanate for 10-14 days 2, 3

Reassess at 3-5 days: If not improving, switch to high-dose amoxicillin-clavulanate or broader-spectrum agents 2, 3

Treatment Algorithm Summary

1. All patients with sinus pain: Start analgesics (acetaminophen or NSAIDs) immediately 1
2. Add intranasal corticosteroids for modest symptom improvement (discuss cost vs. benefit with patient) 1
3. Recommend nasal saline irrigation (hypertonic preferred) 1
4. Consider short-term oral or topical decongestants if significant nasal congestion (limit topical to 3-5 days) 1
5. Reserve antibiotics only for confirmed bacterial sinusitis patterns (≥10 days persistent, severe onset, or double-worsening) 2, 3
6. Avoid antihistamines unless documented allergic component 1
7. Avoid routine oral steroids due to limited benefit and adverse effects 1

Important Caveats

• Most acute sinusitis is viral and resolves without antibiotics; symptoms lasting <7 days are unlikely to be bacterial 2
• Radiographic imaging is not indicated for uncomplicated sinusitis due to high false-positive rates 1
• Unilateral symptoms warrant heightened concern for fungal infection or tumor, requiring CT imaging and possible ENT referral 4
• Patients should be instructed to return if symptoms worsen (especially with severe headache or high fever) or fail to improve within 3-5 days 2