What is the recommended treatment for a patient with chronic sinusitis, presenting with persistent nasal congestion, facial pressure, and discharge, and potentially complicated by allergies?

Treatment of Chronic Sinusitis

For chronic sinusitis (symptoms ≥8 weeks), initiate daily high-volume saline irrigation combined with intranasal corticosteroids as first-line therapy, while simultaneously evaluating for underlying causes including allergic rhinitis, anatomic abnormalities, and immunodeficiency. 1, 2

Initial Medical Management

First-Line Therapy

• Start intranasal corticosteroids (fluticasone 200 mcg daily or 100 mcg twice daily) as the cornerstone of treatment to reduce mucosal inflammation and improve sinus drainage 3, 2
• Implement daily high-volume saline irrigation which significantly improves symptom scores (standardized mean difference 1.42) compared to no treatment 2
• Continue intranasal corticosteroids at regular intervals for optimal effect, as maximum benefit may take several days 3

Role of Antibiotics in Chronic Sinusitis

The role of bacterial infection in chronic sinusitis is less certain than in acute disease 1. However:

• For chronic infectious sinusitis with neutrophilic inflammation, consider prolonged antibiotic therapy (21-28 days) with high-dose amoxicillin-clavulanate, cefuroxime, or cefpodoxime 1, 4
• Add anaerobic coverage with clindamycin or metronidazole if sinusitis fails to improve after initial antibiotic treatment 1, 4
• For patients without nasal polyps, consider a 3-month course of macrolide antibiotics (e.g., clarithromycin), which improved quality of life at 24 weeks in systematic review 2

Adjunctive Measures

• Adequate hydration, analgesics for facial pain, warm facial compresses, and sleeping with head elevated 4
• Short-term topical decongestants (oxymetazoline) may temporarily improve sinus aeration, but avoid prolonged use to prevent rhinitis medicamentosa 5

Distinguishing Chronic Infectious vs. Eosinophilic Sinusitis

This distinction is critical as treatment differs fundamentally:

Chronic Hyperplastic Eosinophilic Sinusitis

• Characterized by eosinophils and mononuclear cells with few neutrophils; does not respond to antibiotics 1
• Often associated with nasal polyps, asthma, and aspirin sensitivity 1
• Requires systemic corticosteroids: Consider oral prednisolone for 1-3 weeks, which reduces polyp size for up to 3 months 1, 2
• Add leukotriene antagonists in patients with nasal polyps, as they improve nasal symptoms compared to placebo 2
• Consider doxycycline 3-week course for anti-inflammatory effects in polyp disease 2

Management of Underlying Conditions

Allergic Rhinitis Evaluation and Treatment

• Test for IgE sensitization to inhalant allergens in all patients with chronic or recurrent sinusitis 1
• If allergic rhinitis is confirmed, add antihistamines to the regimen 5, 6
• Implement environmental control measures and consider allergen immunotherapy in selected patients 1

Anatomic Abnormalities

• Obtain coronal sinus CT with extra cuts through the ostiomeatal complex if symptoms persist despite 4 weeks of appropriate medical therapy 1
• Look specifically for: significant nasal septal deviation compressing the middle turbinate, middle turbinate deformity, accessory structures blocking drainage, or obstructing nasal polyps 1

Immunodeficiency Screening

• Refer to allergist-immunologist if chronic sinusitis is associated with recurrent otitis media, bronchitis, bronchiectasis, or pneumonia 1
• Evaluation should include quantitative serum IgG, IgA, and IgM levels and assessment of specific antibody responses to tetanus toxoid or pneumococcal vaccine 1

When Medical Therapy Fails

Indications for Specialist Referral

Refer to allergist-immunologist for:

• Evaluation and management of underlying allergic factors 1
• Assessment for unusual pathogens and immunodeficiency 1
• Patients with chronic symptoms despite aggressive medical management 1

Refer to otolaryngologist for:

• Structural abnormalities (septal deviation, turbinate deformity, accessory structures) 1
• Obstructing nasal polyps that persist after trial of oral corticosteroids 1
• Radiographic evidence of ostiomeatal obstruction despite aggressive medical management 1

Surgical Intervention

• Every effort should be made to maximize medical treatment before proceeding with surgery 1
• Contemporary surgical therapy involves functional endoscopic sinus surgery aimed at widening natural drainage openings while preserving ciliated epithelium 1, 5
• Most patients benefit from continued individualized medical therapy, including allergy management, after surgery 1

Treatment Algorithm Summary

1. Confirm diagnosis: Symptoms ≥8 weeks with abnormal CT or MRI findings 1
2. Initiate first-line therapy: Daily saline irrigation + intranasal corticosteroids 3, 2
3. Determine subtype: Infectious (neutrophilic) vs. eosinophilic pattern 1
4. For infectious pattern: Add prolonged antibiotics (21-28 days) with anaerobic coverage if needed 1, 4
5. For eosinophilic pattern/polyps: Add systemic corticosteroids (1-3 weeks), consider leukotriene antagonists and doxycycline 2
6. Evaluate underlying factors: Test for allergies, obtain CT if not improving after 4 weeks, screen for immunodeficiency if indicated 1
7. Refer to specialists: Allergist for allergy/immunology workup; ENT for structural issues or surgical consideration 1

Common Pitfalls to Avoid

• Do not use antihistamines as monotherapy—they have no role in treating sinusitis itself and may thicken secretions unless allergic rhinitis is confirmed 7
• Avoid prolonged topical decongestants beyond a few days to prevent rebound rhinitis medicamentosa 1, 5
• Do not proceed to surgery without maximizing medical therapy first, including treatment of underlying rhinitis 1
• Do not treat chronic eosinophilic sinusitis with antibiotics alone—it requires corticosteroids 1