What are the treatment options for chronic sinusitis?

From the Guidelines

Chronic sinusitis treatment should prioritize saline nasal irrigation and topical intranasal corticosteroids for symptom relief, as recommended by the most recent and highest quality studies 1.

Treatment Overview

Chronic sinusitis treatment typically involves a combination of medications and self-care strategies to reduce inflammation, clear infection, and improve sinus drainage.

• Initial treatment includes saline nasal irrigation (using a neti pot or squeeze bottle) 1-2 times daily to flush out mucus and irritants.
• Intranasal corticosteroids like fluticasone (Flonase) or mometasone (Nasonex), used as 1-2 sprays per nostril daily, reduce inflammation and are often the cornerstone of treatment.

Medical Management

For acute bacterial exacerbations, antibiotics such as amoxicillin-clavulanate (875/125 mg twice daily for 10-14 days) or doxycycline (100 mg twice daily for 10-14 days) may be necessary, as suggested by older studies 1.

• Oral decongestants like pseudoephedrine can provide temporary relief but shouldn't be used longer than 3-5 days to avoid rebound congestion.
• For patients with allergic components, antihistamines may help.
• In cases resistant to medical therapy, a short course of oral corticosteroids (prednisone 20-40 mg daily for 5-7 days) might be prescribed.

Surgical Options

Surgical options like endoscopic sinus surgery may be considered for patients who don't respond to medical treatment after 6-12 weeks, with a focus on functional endoscopic sinus surgery as the contemporary surgical standard of care 1.

Lifestyle Modifications

Lifestyle modifications including avoiding irritants, managing allergies, and using a humidifier can complement medical treatment by creating an environment that promotes sinus health. These treatments work by targeting the underlying inflammation, infection, and mucus buildup that characterize chronic sinusitis, with the goal of improving morbidity, mortality, and quality of life outcomes.

From the FDA Drug Label

What if I’m having severe sinus pain If you feel severe pain in your face, have thick nasal discharge, or think you may have a sinus infection, stop using Fluticasone Propionate Nasal Spray, USP and see your doctor. Your doctor may want to consider if other medicines are needed.

• Chronic sinusitis treatment with Fluticasone Propionate Nasal Spray, USP may not be sufficient if severe sinus pain or suspected sinus infection occurs.
• The patient should stop using Fluticasone Propionate Nasal Spray, USP and consult a doctor for further evaluation and potential additional treatment.
• The doctor may consider alternative or additional medicines to manage the condition 2.

From the Research

Treatment Options for Chronic Sinusitis

• Medical treatment is the first line of therapy for chronic rhinosinusitis, including nasal polyps, and mainly consists of topical intranasal and oral corticosteroids 3
• Long-term treatment with corticosteroid nasal spray reduces inflammation and nasal polyp size, and improves nasal symptoms such as nasal blockage, rhinorrea, and the loss of smell 3
• Saline irrigation and topical corticosteroid therapy are recommended as a first-line therapy for chronic sinusitis 4
• A short course of systemic corticosteroids, short course of doxycycline, or a leukotriene antagonist may be considered in patients with nasal polyps 4
• A prolonged course of macrolide antibiotic may be considered for patients without polyps 4

Role of Corticosteroids in Treatment

• Intranasal corticosteroids should be continued postoperatively after endoscopic sinus surgery 3
• The addition of fluticasone to antibiotic therapy improves clinical success rates and accelerates recovery of patients with a history of chronic rhinitis or recurrent sinusitis who present for treatment of acute rhinosinusitis 5
• However, treatment with fluticasone propionate aqueous nasal spray for 1 year after functional endoscopic sinus surgery does not reduce the recurrence rate of nasal polyps and chronic rhinosinusitis 6
• Budesonide respules delivered via a mucosal atomization device may be more effective than traditional nasal steroids, such as fluticasone, in patients with chronic rhinosinusitis with nasal polyposis after endoscopic sinus surgery 7

Considerations for Specific Patient Populations

• Care should be taken when using intranasal corticosteroids in selected populations such as children, pregnant women, and elderly patients, especially in those patients with comorbid conditions such as asthma 3
• The overall steroid intake should be considered in patients with asthma, as they may be taking both intranasal and inhaled corticosteroids 3