What is the recommended treatment for a patient with chronic sinusitis lasting a few weeks, accompanied by facial pain?

Treatment of Sinusitis with Facial Pain Lasting a Few Weeks

For sinusitis lasting a few weeks with facial pain, start with intranasal corticosteroids (mometasone or fluticasone twice daily) plus saline irrigation, and reserve antibiotics only if symptoms persist beyond 10 days without improvement, severe symptoms are present for ≥3 consecutive days, or "double worsening" occurs after initial improvement. 1

Distinguish Viral from Bacterial Sinusitis First

Most cases of acute rhinosinusitis (98-99.5%) are viral and resolve spontaneously within 7-10 days without antibiotics. 1 The critical decision point is determining whether this represents:

• Persistent symptoms ≥10 days without improvement (most likely in your case given "few weeks" duration) 1
• Severe symptoms (fever ≥39°C with purulent discharge) for ≥3 consecutive days 1
• "Double sickening" - worsening after initial improvement from a viral URI 1

Only when one of these three criteria is met should you diagnose acute bacterial rhinosinusitis (ABRS) and consider antibiotics. 1

Cardinal Symptoms Required for Diagnosis

Acute rhinosinusitis requires purulent (not clear) nasal drainage accompanied by nasal obstruction, facial pain-pressure-fullness, or both. 1 Facial pain without purulent nasal drainage is not consistent with acute rhinosinusitis, even though many patients present with self-reported "sinus" problems. 1

First-Line Treatment Approach

If Bacterial Sinusitis is Confirmed:

Amoxicillin-clavulanate 875 mg/125 mg twice daily for 5-10 days is the preferred first-line antibiotic, providing 90-92% predicted clinical efficacy against major pathogens including β-lactamase-producing organisms. 1, 2

• For patients with recent antibiotic use within the past month, age >65 years, moderate-to-severe symptoms, or comorbid conditions, use high-dose amoxicillin-clavulanate (2 g/125 mg twice daily). 2
• Plain amoxicillin 500-875 mg twice daily remains acceptable for uncomplicated cases without recent antibiotic exposure. 1, 2

Watchful Waiting is Equally Appropriate:

For uncomplicated ABRS, watchful waiting without immediate antibiotics is an appropriate initial strategy when reliable follow-up can be assured, with antibiotics started only if no improvement occurs by 7 days or symptoms worsen at any time. 1, 2

Essential Adjunctive Therapies (For ALL Patients)

These provide symptomatic relief regardless of whether antibiotics are prescribed:

• Intranasal corticosteroids (mometasone, fluticasone, or budesonide twice daily) reduce mucosal inflammation and improve symptom resolution with strong evidence from multiple RCTs. 1, 2
• Saline nasal irrigation provides symptomatic relief and removes mucus. 1, 2
• Analgesics (acetaminophen or ibuprofen) for pain and fever. 1, 2
• Adequate hydration and warm facial packs. 2

The European guidelines show intranasal corticosteroids produce significant improvement in total symptom scores in acute post-viral rhinosinusitis, though the effect size is small. 1

Treatment Duration and Monitoring

• Standard duration is 5-10 days, with most guidelines recommending treatment until symptom-free for 7 days (typically 10-14 days total). 1, 2
• Recent evidence supports shorter 5-7 day courses with comparable efficacy and fewer adverse effects. 2

Reassess at 3-5 days: If no improvement or worsening symptoms, switch to second-line therapy immediately. 1, 2

Reassess at 7 days: If symptoms persist, reconfirm diagnosis and consider complications or alternative diagnoses. 2

Second-Line Options for Treatment Failure

If no improvement after 3-5 days of amoxicillin-clavulanate:

• Respiratory fluoroquinolones (levofloxacin 500 mg once daily or moxifloxacin 400 mg once daily for 10 days) provide 90-92% predicted clinical efficacy. 2
• Third-generation cephalosporins (cefpodoxime or cefdinir) offer superior activity against H. influenzae. 2

For Penicillin-Allergic Patients

• Non-severe allergy: Second- or third-generation cephalosporins (cefuroxime, cefpodoxime, or cefdinir) are safe and effective. 1, 2
• Severe Type I allergy: Respiratory fluoroquinolones (levofloxacin or moxifloxacin). 2

Critical Pitfalls to Avoid

• Do not prescribe antibiotics for symptoms <10 days unless severe features are present (fever ≥39°C with purulent discharge for ≥3 consecutive days). 1, 2
• Avoid azithromycin as first-line therapy due to resistance rates of 20-25% for both S. pneumoniae and H. influenzae. 2, 3
• Do not obtain imaging (X-ray or CT) for patients meeting diagnostic criteria unless a complication or alternative diagnosis is suspected. 1
• Reserve fluoroquinolones for treatment failures or documented severe β-lactam allergies to prevent resistance development. 2

When to Refer to a Specialist

Refer to otolaryngology or allergist-immunologist for: 2

• No improvement after 7 days of appropriate second-line antibiotic therapy
• Worsening symptoms at any time
• Suspected complications (orbital cellulitis, meningitis)
• Recurrent sinusitis (≥3 episodes per year)
• Need to clarify allergic or immunologic basis

Special Consideration: Chronic vs. Acute Sinusitis

If symptoms have truly persisted for "a few weeks" (>4 weeks), this may represent chronic rhinosinusitis rather than acute disease, which requires fundamentally different management. 2 Chronic sinusitis is defined as symptoms lasting >8 weeks and requires intranasal corticosteroids as primary therapy, with longer duration antibiotic therapy only for chronic infectious sinusitis. 2