What is the best nasal spray for an adult patient with sinusitis and no significant underlying health conditions?

Best Nasal Spray for Sinusitis

For an adult with sinusitis, intranasal corticosteroids—specifically mometasone furoate 200 µg twice daily or fluticasone propionate 200 µg once daily—are the most effective nasal spray options, providing modest but clinically meaningful symptom reduction with minimal adverse effects. 1

Primary Recommendation: Intranasal Corticosteroids

Intranasal corticosteroids are the gold standard nasal spray for sinusitis because they directly address the underlying inflammatory process, reducing mucosal inflammation, vascular permeability, and inflammatory mediator release. 1, 2

Specific Agent Selection

• Mometasone furoate 200 µg twice daily demonstrated significant symptom improvements versus both amoxicillin and placebo in multiple high-quality trials, with a number needed to treat of 14 for symptom improvement. 1

• Fluticasone propionate 200 µg once daily is equally effective and offers the convenience of once-daily dosing, which may improve compliance. 1, 3

• Triamcinolone acetonide is available over-the-counter and represents a cost-effective alternative, though it has not been studied as extensively for acute bacterial rhinosinusitis specifically. 1

Evidence Quality and Effect Size

The 2020 European Position Paper on Rhinosinusitis concluded that intranasal corticosteroids effectively reduce total symptom scores in adults with acute post-viral rhinosinusitis, though the effect size is small. 1 The American Academy of Otolaryngology-Head and Neck Surgery's 2015 guideline found that intranasal steroids increased symptom improvement rates from 66% to 73% after 15-21 days. 1

Safety Profile

Minor adverse effects include epistaxis (nosebleed), headache, and nasal itching, but these are generally mild and do not require treatment discontinuation. 1 Long-term use does not affect systemic cortisol levels or cause hypothalamic-pituitary-adrenal axis suppression. 1

Important Adjunctive Therapy: Nasal Saline Irrigation

Nasal saline irrigation should be used alongside intranasal corticosteroids, not as a replacement. 1, 2

• Buffered hypertonic saline (3-5%) showed modest benefit in clinical trials and may have superior anti-inflammatory effects compared to isotonic saline. 1

• Saline irrigation improves quality of life, decreases symptoms, and reduces medication use, particularly in patients with frequent sinusitis. 1, 2

What NOT to Use as Primary Nasal Spray

Topical Decongestants (Oxymetazoline, Xylometazoline)

These should NEVER be used for more than 3-5 consecutive days due to the risk of rebound congestion and rhinitis medicamentosa, which worsens the original problem. 1, 2, 4 While they provide rapid symptom relief, they are appropriate only for short-term use in severe congestion. 1, 2

Antihistamine Nasal Sprays (Azelastine)

Azelastine is FDA-approved for allergic rhinitis and vasomotor rhinitis, not for infectious sinusitis. 5 Antihistamines have no role in symptomatic relief of acute bacterial rhinosinusitis in non-allergic patients and may worsen congestion by drying nasal mucosa. 1 They should only be considered if there is a clear allergic component with sneezing and itching. 1, 2

Treatment Algorithm

1. Start immediately with intranasal corticosteroid (mometasone 200 µg twice daily OR fluticasone 200 µg once daily) + nasal saline irrigation (hypertonic preferred). 1, 2

2. Add analgesics (acetaminophen or ibuprofen) for facial pain and sinus pressure. 1, 2

3. If severe congestion persists, consider adding topical decongestant for MAXIMUM 3-5 days OR oral pseudoephedrine (if no cardiovascular contraindications). 1, 2

4. If symptoms persist beyond 10 days without improvement or worsen after initial improvement ("double sickening"), consider bacterial sinusitis and antibiotic therapy. 2

Critical Pitfalls to Avoid

• Never extend topical decongestant use beyond 3-5 days—this causes rebound congestion that is worse than the original condition. 1, 2, 4

• Do not routinely prescribe antihistamine nasal sprays unless there is clear evidence of allergic rhinitis with sneezing and itching. 1, 2

• Avoid oral corticosteroids for routine sinusitis—they showed no benefit as monotherapy and have systemic side effects; reserve for severe or intractable cases only. 1

• Do not use guaifenesin or other mucolytics—evidence of clinical efficacy is lacking. 4