What is the best management approach for a patient with sinusitis, possibly with a history of allergic rhinitis and asthma?

Management of Sinusitis

Distinguishing Acute Bacterial from Viral Rhinosinusitis

The cornerstone of sinusitis management is distinguishing acute bacterial rhinosinusitis (ABRS) from viral upper respiratory infections, as this determines whether antibiotics are indicated. 1, 2

• Diagnose ABRS when symptoms persist 10-14 days or more without improvement, or when symptoms worsen within 10 days after initial improvement (double worsening) 1, 2
• Appropriate criteria for antibiotics include: fever with purulent nasal discharge, facial pain or tenderness, and periorbital swelling 1
• Viral rhinosinusitis typically resolves within 7-10 days and should be managed with symptomatic relief only 2

First-Line Treatment for Acute Bacterial Sinusitis

Amoxicillin is the antibiotic of choice for most adults with ABRS, prescribed for 10-14 days. 1, 2

• If no improvement occurs within 3-5 days, switch to an alternative antibiotic 1
• Observation without antibiotics is acceptable for patients with mild illness (mild pain and temperature <38.3°C) who have reliable follow-up 2

Adjunctive Therapies for Acute Sinusitis

Intranasal corticosteroids as adjunct to antibiotic therapy improve outcomes in acute and recurrent sinusitis. 1, 3

• Fluticasone propionate 200 mcg daily (two 50-mcg sprays per nostril once daily) is FDA-approved for rhinitis management and provides symptom relief within 12 hours, with maximum effect in several days 4
• Nasal saline irrigation provides symptomatic benefit and facilitates drainage 1, 5
• Oral or topical decongestants may provide temporary relief but should be used cautiously in patients with hypertension, cardiac disease, or glaucoma 1
• Topical decongestants must be limited to 3-5 days maximum to prevent rhinitis medicamentosa 1, 3

Management of Chronic Rhinosinusitis

For chronic rhinosinusitis (CRS), intranasal corticosteroids are the most effective monotherapy and should be first-line treatment. 3, 6, 7

• The role of antibiotics in chronic sinusitis is controversial; longer courses (3-4 weeks) may be required for chronic infectious sinusitis with attention to anaerobic pathogens 1
• For chronic non-infectious (hyperplastic) sinusitis, systemic corticosteroids should be considered 1
• A short 5-7 day course of oral corticosteroids may be appropriate for very severe or intractable symptoms, but recurrent parenteral corticosteroids are contraindicated due to long-term side effects 1, 6

Special Considerations for Patients with Allergic Rhinitis and Asthma

Patients with recurrent or chronic sinusitis should be evaluated for underlying allergic rhinitis, as up to 60% have substantial allergic sensitivities. 1

• Treatment of allergic rhinitis with intranasal corticosteroids may improve both sinus and asthma control 1
• Medical or surgical management of sinusitis results in objective and subjective improvement of asthma 1
• Allergen immunotherapy should be considered for patients with documented specific IgE antibodies to clinically relevant allergens who fail pharmacotherapy, as it is the only disease-modifying treatment 1, 3

When to Refer to a Specialist

Consultation with an allergist/immunologist or otolaryngologist is indicated when: 1

• Sinusitis is refractory to usual antibiotic treatment after 7 days 1, 2
• Sinusitis is recurrent (≥4 episodes per year) 1
• There is need to clarify allergic or immunologic basis 1
• Concomitant conditions complicate management (chronic otitis media, asthma, nasal polyps, immunodeficiencies, aspirin sensitivity) 1
• Medically resistant sinusitis may require functional endoscopic sinus surgery 1

Critical Pitfalls to Avoid

• Never overdiagnose sinusitis or prescribe antibiotics for viral upper respiratory infections lasting <10 days 1, 2
• Avoid prolonged use of topical decongestants beyond 3-5 days 1, 3
• Do not use antihistamines in acute sinusitis unless the patient has concomitant symptomatic allergic rhinitis 1, 8
• Avoid recurrent parenteral corticosteroids due to greater potential for long-term adverse effects 1, 6
• Do not perform radiographic imaging (CT) for uncomplicated acute sinusitis unless complications or alternative diagnoses are suspected 2