What is the best treatment approach for a patient with chronic sinusitis, presenting with sinus congestion, maxillary sinus tenderness, purulent nasal discharge, and turbinate hypertrophy for 1 month?

Treatment of Chronic Sinusitis

This patient requires prolonged antibiotic therapy (4-8 weeks) combined with intranasal corticosteroids and nasal saline irrigation as first-line treatment, with consideration for ENT referral if symptoms persist despite 4 weeks of optimal medical therapy. 1

Diagnostic Confirmation

This presentation meets criteria for chronic sinusitis (symptoms ≥8 weeks with purulent discharge, facial pain/tenderness, and nasal congestion). 1 The presence of maxillary sinus tenderness, purulent nasal discharge, and turbinate hypertrophy on examination supports the diagnosis without requiring imaging initially. 1

• CT imaging should be obtained if symptoms persist after 4 weeks of appropriate medical therapy to confirm the diagnosis and assess for ostiomeatal complex obstruction. 1
• Coronal sinus CT with cuts through the ostiomeatal complex is the imaging modality of choice. 1

Medical Management Algorithm

First-Line Therapy

Intranasal corticosteroids are the cornerstone of maintenance therapy for chronic sinusitis:

• Fluticasone propionate 200 mcg daily (2 sprays per nostril once daily) or 100 mcg twice daily. 2
• Maximum benefit may take several days; continue for at least 4-8 weeks. 2, 3

Nasal saline irrigation should be used concurrently to promote drainage and mucosal healing. 3

Antibiotic Therapy

The role of antibiotics in chronic sinusitis differs from acute disease:

• For chronic infectious sinusitis: Prolonged antibiotic course (4-8 weeks minimum) is required, targeting broader spectrum organisms including Staphylococcus aureus, Pseudomonas aeruginosa, and anaerobes in addition to typical respiratory pathogens. 1
• First-line antibiotic: Amoxicillin-clavulanate 500mg three times daily provides coverage for beta-lactamase producing organisms and anaerobes. 1, 4
• Alternative agents for penicillin allergy: Fluoroquinolones (moxifloxacin 400mg daily) or doxycycline 100mg daily. 1, 5

Adjunctive Measures

• Oral decongestants may help restore sinus drainage but should be used cautiously and for limited duration. 1
• Avoid topical decongestant sprays beyond 3-5 days to prevent rhinitis medicamentosa. 1

When Antibiotics May Not Be Indicated

Chronic hyperplastic eosinophilic sinusitis (non-infectious chronic sinusitis) does not respond to antibiotics and requires different management:

• Consider this diagnosis if there is poor response to prolonged antibiotics. 1
• Oral corticosteroids (prednisone 30-60mg daily for 5-7 days) may be required to reduce mucosal inflammation and polyp burden. 1
• Maintenance with intranasal corticosteroids is essential after oral steroid taper. 3

Evaluation for Underlying Factors

Patients with chronic sinusitis require assessment for predisposing conditions:

• Allergic rhinitis: Test for IgE sensitization to inhalant allergens if suspected. 1
• Anatomic obstruction: Septal deviation compressing the middle turbinate or ostiomeatal complex obstruction. 1
• Immunodeficiency: Consider if recurrent infections or poor response to therapy (quantitative immunoglobulins, functional antibody testing). 1
• GERD: May contribute to chronic sinusitis; treat if suspected. 1

Indications for ENT Referral

Refer to otolaryngology if any of the following are present:

• Failure to improve after 4 weeks of optimal medical therapy (antibiotics + intranasal corticosteroids + saline irrigation). 1
• CT evidence of ostiomeatal complex obstruction despite aggressive medical management. 1
• Obstructing nasal polyps that persist after trial of oral corticosteroids. 1
• Significant septal deviation or middle turbinate abnormalities causing obstruction. 1
• Suspected fungal sinusitis, neoplasia, or granulomatous disease requiring biopsy. 1

Functional endoscopic sinus surgery provides an adjunctive option for difficult-to-treat cases, but continued medical therapy is typically required postoperatively. 1, 3

Critical Pitfalls to Avoid

• Do not treat chronic sinusitis with short 10-14 day antibiotic courses as used for acute sinusitis—this is inadequate and promotes resistance. 1
• Do not rely on plain radiographs for chronic sinusitis diagnosis; CT is far superior when imaging is needed. 6, 3
• Do not assume all chronic sinusitis is infectious—eosinophilic disease requires corticosteroids, not prolonged antibiotics. 1
• Turbinate hypertrophy alone is not an indication for surgery if medical therapy has not been maximized. 1

Reassessment Timeline

• Evaluate response at 3-5 days: If worsening or no improvement, consider broader spectrum antibiotics or oral corticosteroids. 4
• Reassess at 4 weeks: If symptoms persist, obtain CT imaging and consider ENT referral. 1
• Long-term maintenance: Continue intranasal corticosteroids and saline irrigation indefinitely for symptom control. 3