Treatment of Non-Infectious Sinusitis
For non-infectious sinusitis causing headache and ear pressure, prescribe intranasal corticosteroids (mometasone 200 mcg twice daily or fluticasone 200 mcg twice daily) as first-line therapy to reduce inflammation and alleviate symptoms. 1
Primary Treatment: Intranasal Corticosteroids
Mometasone furoate nasal spray 200 mcg twice daily is the preferred regimen, demonstrating significant symptom improvements in headache, facial pain, and congestion compared to placebo in multiple high-quality trials. 1
Fluticasone propionate 200 mcg once daily is an equally effective alternative, providing significant relief of sinus pain, pressure, and nasal congestion. 2
Treatment duration should be 15-21 days initially, with continuation as needed for symptom control. 1
The European Position Paper on Rhinosinusitis (2020) confirms that intranasal corticosteroids effectively reduce total symptom scores in post-viral rhinosinusitis, though the effect size is modest. 1
Important Caveats About Efficacy
While intranasal corticosteroids are effective for symptom reduction, the clinical benefit is small to moderate and they have not been shown to improve quality of life measures significantly. 1
The EPOS2020 guidelines advise prescribing intranasal corticosteroids only when symptom reduction is considered necessary, recognizing that post-viral rhinosinusitis is self-limiting. 1
The number needed to treat is approximately 14 for clinically important benefit. 3
Adjunctive Symptomatic Measures
Saline nasal irrigation should be recommended to promote mucus clearance and reduce tissue edema. 3, 4
Analgesics (acetaminophen or NSAIDs) for pain management based on severity of headache and facial pressure. 3, 4
Warm facial compresses and steamy showers may provide comfort. 3
When to Consider Oral Corticosteroids
A short 5-7 day course of oral corticosteroids may be appropriate for very severe or intractable symptoms with marked mucosal edema. 1, 3
This is particularly relevant for chronic hyperplastic eosinophilic rhinosinusitis, which does not respond to antibiotics and is characterized by eosinophil predominance. 1, 5
Single or recurrent parenteral corticosteroid administration is contraindicated due to greater potential for long-term side effects. 1
Dosing Considerations for Severe Cases
For chronic sinusitis with eosinophils that fails standard dosing, fluticasone propionate can be increased to 800 mcg per day (double the usual dose) with minimal systemic absorption (<1%). 6
Higher doses of intranasal corticosteroids may be necessary when rapid symptomatic improvement is needed. 5
What NOT to Use
Oral antihistamines are not effective for non-allergic, non-infectious sinusitis and should be avoided. 1
Antibiotics have no role in non-infectious sinusitis and should not be prescribed. 1, 4
Intranasal anticholinergics may reduce rhinorrhea but have minimal effects on congestion or pressure symptoms. 1
Monitoring and Reassessment
Reassess at 3-5 days: if no improvement, re-evaluate the diagnosis to ensure this is truly non-infectious. 3, 4
If symptoms persist beyond 7-10 days despite appropriate intranasal corticosteroid therapy, consider whether bacterial superinfection has developed. 4
For chronic symptoms (>8 weeks), evaluate for underlying conditions including allergic rhinitis, anatomic abnormalities, or chronic hyperplastic eosinophilic rhinosinusitis. 1, 7
When to Refer
Refer to an allergist-immunologist if intranasal corticosteroids are ineffective or produce adverse events. 1
Refer to otolaryngology if obstructing nasal polyps are present after appropriate medical therapy including a trial of oral corticosteroids. 1
Refer for evaluation if recurrent episodes (≥3 per year) occur despite treatment. 1, 4
Consider referral if symptoms significantly impair quality of life, sleep, or work/school performance. 1