What is the best primary care treatment for an adult patient with sinus pressure and no severe underlying health conditions?

Best Primary Care Treatment for Sinus Pressure

For an adult with sinus pressure, start with intranasal corticosteroids (fluticasone, mometasone, or budesonide) once daily combined with saline nasal irrigation, as this combination provides the most effective symptomatic relief with minimal side effects and is supported by the highest quality evidence. 1, 2

First-Line Treatment Approach

Intranasal Corticosteroids

• Prescribe fluticasone propionate, mometasone furoate, or fluticasone furoate as first-line therapy because they have negligible systemic bioavailability, require only once-daily dosing, and are the safest options. 1
• Start with 200 mcg daily (two 50-mcg sprays per nostril once daily) for adults, with symptom improvement typically beginning within 12 hours and maximum effect achieved within several days. 3
• These agents reduce mucosal edema, inflammatory cell infiltration, and provide direct anti-inflammatory effects at the site of symptoms. 2
• Proper administration technique is critical: patients must look down, use opposite hand for each nostril, aim toward the outer nasal wall (not the septum), and avoid sniffing hard to prevent epistaxis and maximize drug delivery. 1

Saline Nasal Irrigation

• Recommend high-volume saline irrigation (not spray) as it is significantly more effective at expelling secretions, improving mucous clearance, enhancing ciliary activity, and disrupting biofilms and inflammatory mediators. 1, 2, 4
• Irrigation can be performed with isotonic or hypertonic solution—either is acceptable as evidence does not support superiority of one over the other. 1
• Patients should use proper technique with devices such as neti pots, squeeze bottles, or pulsatile irrigators, performing irrigation at least once daily for optimal benefit. 4
• Common side effects are minimal, limited primarily to fluid dripping from the nose. 1, 4

When Antibiotics Are NOT Indicated

• Do not prescribe antibiotics for simple sinus pressure or viral acute rhinosinusitis, as symptoms lasting less than 10 days are almost always viral and antibiotics provide no benefit. 2, 5
• Reserve antibiotics only for acute bacterial rhinosinusitis, defined as symptoms persisting beyond 10 days OR symptoms that worsen after initial improvement (double worsening). 2, 5
• When antibiotics are indicated, amoxicillin is first-line therapy for most adults. 2, 5

Role of Systemic Corticosteroids

• Avoid systemic corticosteroids as monotherapy—they are ineffective for acute sinusitis when used alone. 6
• Short-course oral corticosteroids (1-3 weeks) combined with antibiotics may provide modest short-term benefit in acute bacterial sinusitis, but the effect size is small (number needed to treat = 7) and should be reserved for severe cases. 2, 6
• The combination of oral corticosteroids plus antibiotics showed only marginal benefit over antibiotics alone in primary care settings, with high risk of bias in available studies. 6

Adjunctive Therapies to Consider

Decongestants

• Topical decongestants (xylometazoline) may temporarily reduce congestion but must be limited to 3-5 consecutive days maximum to prevent rebound congestion. 2, 7
• Oral decongestants can be used for symptomatic relief but do not address underlying inflammation. 7

Antihistamines

• Do not prescribe antihistamines for non-allergic sinus pressure—they may worsen congestion by drying the mucosa and have no role in non-allergic sinusitis. 2
• Consider antihistamines only if there is a clear allergic component to the patient's symptoms. 2

Critical Pitfalls to Avoid

• Never confuse saline spray with saline irrigation—irrigation is significantly more effective and is what the evidence supports. 1, 4
• Do not use topical decongestants beyond 3-5 days—this causes rhinitis medicamentosa (rebound congestion). 2
• Avoid prescribing antibiotics for symptoms lasting less than 10 days without worsening—this represents viral rhinosinusitis that will not respond to antibiotics. 2, 5
• Do not delay appropriate treatment in severe cases—patients with high fever (>38.3°C/101°F) and purulent discharge warrant immediate antibiotic therapy. 2, 5

When to Reassess or Refer

• If symptoms persist beyond 12 weeks despite appropriate medical therapy, the patient has chronic rhinosinusitis and requires specialist evaluation. 1
• Patients with recurrent acute rhinosinusitis (4+ episodes per year) should be evaluated for underlying factors such as allergic rhinitis, anatomic variation, or immunodeficiency. 2, 5
• Reassess patients at 7 days if they worsen or fail to improve with initial management to confirm diagnosis, exclude complications, and adjust therapy. 2, 5