What is the recommended management for a patient with chronic maxillary sinusitis?

Management of Chronic Maxillary Sinusitis

For chronic maxillary sinusitis, initiate treatment with daily high-volume saline irrigation combined with intranasal corticosteroids as first-line therapy, reserving surgical intervention for patients who fail appropriate medical management. 1, 2

Initial Medical Management

First-Line Therapy

• Begin with nasal saline irrigation (high-volume) plus topical intranasal corticosteroids (mometasone, fluticasone, or budesonide twice daily) as the cornerstone of chronic rhinosinusitis management 1, 2, 3
• Saline irrigation significantly improves symptom scores compared with no treatment (standardized mean difference 1.42,95% CI 1.01-1.84) 2
• Topical corticosteroids improve overall symptom scores (standardized mean difference -0.46,95% CI -0.65 to -0.27) and reduce inflammation 2, 4
• Continue this regimen for at least 8-12 weeks before considering treatment failure 1, 3

Role of Antibiotics in Chronic Disease

• Do not prescribe antibacterial therapy unless significant or persistent purulent nasal discharge is present on examination 1
• The role of antibiotics in chronic sinusitis is far less clear than in acute disease, with conservative medical therapy (without surgery) successful in only one-third of cases 1
• When antibiotics are indicated for chronic sinusitis, they should have broad-spectrum activity against respiratory anaerobes, viridans streptococci, S. pneumoniae, H. influenzae, and M. catarrhalis 1
• Consider a 3-month course of macrolide antibiotics (such as clarithromycin or azithromycin) for patients without nasal polyps who have failed initial therapy, as this may improve quality of life (standardized mean difference -0.43,95% CI -0.82 to -0.05) 2

Adjunctive Medical Therapies

• For patients with nasal polyps, consider a short course (1-3 weeks) of systemic corticosteroids, which reduce polyp size for up to 3 months after treatment (P < 0.001) 2, 4
• Oral doxycycline 100 mg daily for 20-21 days may provide modest benefit in chronic rhinosinusitis with nasal polyps, particularly in asthmatic patients 5
• Leukotriene antagonists improve nasal symptoms compared with placebo in patients with nasal polyps (P < 0.01) 2

When Medical Management Fails

Defining Treatment Failure

• Avoid rigid, predetermined protocols for "adequate" or "maximal" medical therapy before considering surgery 1
• Treatment failure should be determined based on persistent symptoms despite appropriate medical therapy tailored to disease subtype, tolerability, and expected effectiveness 1
• Approximately 70-80% of chronic rhinosinusitis patients respond adequately to appropriate medical treatment 6

Surgical Management

• Surgical procedures to facilitate sinus drainage through creation of an artificial ostium and submucosal resection of diseased tissue are the mainstays of treatment for chronic sinusitis that fails medical management 1
• With combined medical and surgical treatment, the cure rate for chronic maxillary sinusitis exceeds 60% after 3 years of follow-up 1
• Endoscopic sinus surgery should include full exposure of the sinus cavity and removal of diseased tissue, not just balloon or manual ostial dilation alone 1, 6
• Continue intranasal corticosteroids postoperatively, as they reduce polyp recurrence after surgery (relative risk 0.59,95% CI 0.45-0.79) 2, 4, 3

Special Considerations

Chronic Maxillary Sinusitis of Dental Origin

• When dental pathology is the source (odontogenic cysts, oroantral fistula, peri-implantitis, foreign bodies), contemporary treatment requires addressing both the odontogenic source and performing endoscopic sinus surgery with opening and calibration of the maxillary natural ostium 7
• The endoscopic approach is associated with less morbidity and lower complication rates compared with traditional approaches 7

Fungal Ball

• Fungal ball requires exclusively surgical treatment—medical therapy is not beneficial 1
• This demonstrates why homogenous medical treatment protocols for all chronic rhinosinusitis are inappropriate 1

Critical Pitfalls to Avoid

• Do not delay appropriate surgical intervention by requiring arbitrary durations of medical therapy when the patient has failed to respond to individualized medical management 1
• Do not use first-generation cephalosporins (cephalexin) for chronic sinusitis, as they lack adequate coverage against H. influenzae 5
• Avoid using azithromycin or macrolides as routine first-line antibiotics due to resistance rates of 20-25% for both S. pneumoniae and H. influenzae 5
• Do not prescribe antibiotics indiscriminately without evidence of bacterial infection (purulent discharge on examination) 1
• Recognize that chronic rhinosinusitis lasting >8 weeks requires fundamentally different management than acute disease 5, 8

When to Refer to Specialist

• Sinusitis refractory to two courses of appropriate antibiotics 5, 8
• Recurrent sinusitis (≥3 episodes per year) requiring evaluation for underlying allergic rhinitis, immunodeficiency, or anatomic abnormalities 5, 8
• Suspected complications (orbital cellulitis, meningitis, brain abscess) 5
• Need to clarify allergic or immunologic basis for chronic disease 5
• Presence of nasal polyps or anatomic abnormalities requiring surgical correction 8