What is the recommended treatment for a patient with chronic sinusitis, possibly with a history of bacterial infections or underlying conditions such as allergies or asthma?

Treatment for Chronic Sinusitis

First-line treatment for chronic sinusitis is daily high-volume saline irrigation combined with intranasal corticosteroid sprays, with mandatory smoking cessation if applicable. 1, 2

Define Chronic Sinusitis First

Chronic sinusitis requires at least two of four cardinal symptoms (facial pain/pressure, hyposmia/anosmia, nasal drainage, nasal obstruction) persisting for ≥12 consecutive weeks, plus objective evidence on endoscopy or CT imaging. 3 This distinguishes it from acute bacterial sinusitis, which requires fundamentally different management. 4

Mandatory First Step: Address Smoking

If the patient smokes, smoking cessation is the single most important intervention before any definitive treatment, particularly surgery. 1 Active smokers have significantly worse surgical outcomes compared to non-smokers, and functional endoscopic sinus surgery should be deferred until smoking cessation is achieved. 1

First-Line Medical Therapy

High-Volume Saline Irrigation

• Use daily high-volume saline irrigation (not just nasal spray) as it improves symptom scores significantly compared to no treatment (standardized mean difference 1.42,95% CI 1.01-1.84). 2
• High-volume irrigation provides superior paranasal sinus penetration compared to low-volume sprays. 5
• Saline irrigation enhances mucociliary clearance, removes mucus, and improves sinus drainage. 3

Intranasal Corticosteroids

• Prescribe intranasal corticosteroid sprays (mometasone, fluticasone, or budesonide) twice daily as they improve overall symptom scores (SMD -0.46,95% CI -0.65 to -0.27) and reduce polyp scores if present (SMD -0.73,95% CI -1.0 to -0.46). 2
• Topical corticosteroids reduce sinonasal inflammation and improve mucociliary clearance. 6
• For patients with more severe disease or post-surgical management, consider off-label budesonide or mometasone nasal irrigations (mixed with saline irrigation solution) for improved paranasal distribution and absorption. 6

Evaluate and Treat Underlying Contributing Factors

Allergic Rhinitis

• Assess for allergic rhinitis, which augments bacterial sinusitis in many patients. 4, 1
• If allergic rhinitis is present, add antihistamines and consider allergy testing/immunotherapy. 4
• Nasal cytology can help identify eosinophilic nonallergic rhinitis (found in 26% of chronic sinusitis patients). 4

Gastroesophageal Reflux Disease (GERD)

• Evaluate for GERD, as medical treatment of GERD results in significant improvement in sinusitis symptoms. 4, 1
• GERD has been suggested as a cause of chronic sinusitis in both children and adults. 4

Asthma

• If the patient has asthma, recognize that medical or surgical management of sinusitis results in objective and subjective improvement of asthma. 4
• No direct causal factor exists, but the association is well-established. 4

Role of Antibiotics in Chronic Sinusitis

The role of antibiotics in chronic sinusitis is controversial and should be reserved for specific situations. 4, 3

When to Use Antibiotics

• For chronic infectious sinusitis with evidence of active bacterial infection, use longer duration therapy (potentially 3 months) with attention to anaerobic pathogens. 4, 1
• Consider amoxicillin-clavulanate 875 mg/125 mg twice daily for 3-4 weeks as initial therapy if bacterial infection is suspected. 5
• For chronic non-infectious sinusitis (chronic hyperplastic sinusitis), do NOT use antibiotics; instead consider systemic corticosteroids. 4

Macrolide Antibiotics for Non-Polyp Disease

• For patients WITHOUT nasal polyps who fail first-line therapy, consider a prolonged course (3 months) of macrolide antibiotic (e.g., azithromycin 250 mg three times weekly), which improved quality of life at 24 weeks after therapy (SMD -0.43,95% CI -0.82 to -0.05). 2
• This is used for anti-inflammatory effects, not antimicrobial action. 7

Additional Medical Therapies Based on Polyp Status

For Patients WITH Nasal Polyps

• Short course of systemic corticosteroids (1-3 weeks) reduces polyp size compared to placebo for 3 months after treatment (p<0.001). 2
• Short course of doxycycline 100 mg daily for 3 weeks reduces polyp size compared to placebo. 2
• Leukotriene antagonists (montelukast 10 mg daily) improve nasal symptoms compared to placebo in patients with nasal polyps (p<0.01). 2
• Consider aspirin desensitization for aspirin-sensitive patients with sinusitis and asthma. 4

For Patients WITHOUT Nasal Polyps

• Avoid systemic corticosteroids and doxycycline as they lack evidence in non-polyp disease. 2
• Focus on prolonged macrolide therapy if first-line treatment fails. 2

When to Refer to a Specialist

Refer to an otolaryngologist when: 4, 1, 3

• First-line medical therapy (saline irrigation + intranasal corticosteroids) fails after 8-12 weeks
• Quality of life is significantly affected
• Sinusitis is recurrent (≥3 episodes per year)
• Sinusitis is refractory to usual treatment
• Need to clarify allergic or immunologic basis for sinusitis
• Sinusitis is associated with unusual opportunistic infections
• Chronic sinusitis persists for several months or recurs 2-3 times per year despite treatment

Consider referral to allergist-immunologist when: 4

• Need to evaluate for allergic rhinitis or immunodeficiency
• Recurrent sinusitis suggests underlying immune dysfunction
• Tests for immunodeficiency (quantitative immunoglobulins, functional antibody tests, HIV testing) may be indicated

Surgical Considerations

Functional endoscopic sinus surgery may be considered for medically resistant sinusitis, particularly with localized persistent disease within the ostiomeatal complex. 4, 1

Important Surgical Caveats

• Surgery should be deferred until smoking cessation is achieved. 1
• Optimal outcomes require combination of appropriate surgical intervention with intensive postoperative local management and appropriate medical therapy. 1
• Topical corticosteroids reduce polyp recurrence after surgery (relative risk 0.59,95% CI 0.45-0.79). 2

Special Diagnostic Considerations

When to Pursue Advanced Testing

• For children with nasal polyps or colonization with Pseudomonas species, consider quantitative sweat chloride tests and genetic testing for cystic fibrosis. 4
• For recurrent sinusitis, consider tests for immunodeficiency including quantitative immunoglobulin measurement, functional antibody tests, and HIV testing. 4
• Sinus secretions for culture should be obtained by aspiration (not swab) in adults via maxillary sinus aspiration or endoscopically directed catheter at middle meatus; in children, aspiration only. 4

Common Pitfalls to Avoid

• Do not use antibiotics as first-line therapy for chronic sinusitis without evidence of active bacterial infection, as most chronic sinusitis is inflammatory rather than infectious. 3, 7
• Do not use low-volume saline nasal sprays instead of high-volume irrigation, as penetration into paranasal sinuses is inadequate. 2, 6
• Do not prescribe systemic corticosteroids or doxycycline for patients without nasal polyps, as evidence supports use only in polyp disease. 2
• Do not proceed with elective sinus surgery in active smokers without first achieving smoking cessation. 1