What are the treatment and management options for sinusitis?

From the Guidelines

Sinusitis treatment begins with determining whether the infection is viral or bacterial, and the most recent and highest quality study recommends saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of chronic rhinosinusitis. For viral sinusitis, management focuses on symptom relief with:

• Saline nasal irrigation
• Intranasal corticosteroids like fluticasone (2 sprays per nostril daily) 1
• Oral decongestants such as pseudoephedrine (30-60mg every 4-6 hours)
• Analgesics like acetaminophen (650mg every 6 hours) or ibuprofen (400-600mg every 6-8 hours) Bacterial sinusitis, suspected when symptoms persist beyond 10 days or worsen after initial improvement, requires antibiotics. First-line treatment is amoxicillin-clavulanate (875/125mg twice daily for 5-7 days) or, for penicillin-allergic patients, doxycycline (100mg twice daily for 5-7 days). For patients with severe symptoms, recent antibiotic use, or in high-resistance areas, consider respiratory fluoroquinolones like levofloxacin (750mg daily for 5 days). Chronic sinusitis (symptoms lasting >12 weeks) often requires longer courses of antibiotics, extended use of intranasal steroids, and possibly surgical consultation. Patients should seek immediate medical attention if they develop high fever, severe headache, visual changes, or altered mental status, as these may indicate complications requiring urgent intervention.

Some key points to consider in the management of sinusitis include:

• The use of antibiotics should be based on the severity and duration of symptoms, as well as the presence of complications 1
• Surgical intervention may be necessary in cases of recurrent or persistent infectious sinusitis despite adequate medical management, or when anatomic defects exist that obstruct the sinus outflow tract 1
• The role of antibiotics in chronic sinusitis is controversial, and consideration should be given to systemic corticosteroids in cases of chronic non-infectious sinusitis 1

From the FDA Drug Label

DOSAGE & ADMINISTRATION SECTION Adults Infection *Recommended Dose/Duration of Therapy *DUE TO THE INDICATED ORGANISMS (See INDICATIONS AND USAGE.) ... Acute bacterial sinusitis500 mg QD × 3 days PEDIATRIC DOSAGE GUIDELINES FOR OTITIS MEDIA, ACUTE BACTERIAL SINUSITIS AND COMMUNITY-ACQUIRED PNEUMONIA ... ACUTE BACTERIAL SINUSITIS: (3-Day Regimen) * Dosing Calculated on 10 mg/kg/day Weight100 mg/5 mL200 mg/5 mLTotal mL per Treatment CourseTotal mg per Treatment Course KgLbs. Day 1–3Day 1–3

1. 2 Acute Maxillary Sinusitis Clarithromycin extended-release tablets (in adults) are indicated for the treatment of mild to moderate infections caused by susceptible isolates due to Haemophilus influenzae, Moraxella catarrhalis,or Streptococcus pneumoniae Table 1 Adult Dosage Guidelines Clarithromycin Extended-release Tablets Infection Dosage (every 24 hours) Duration (days) ... Acute maxillary sinusitis 1 gram 14

Sinusitis Treatment and Management:

• Azithromycin (PO): 500 mg QD × 3 days for adults, and 10 mg/kg once daily for 3 days for pediatric patients.
• Clarithromycin (PO): 1 gram every 24 hours for 14 days for adults with acute maxillary sinusitis. 2 and 3

From the Research

Treatment Options for Sinusitis

• Antibiotics such as azithromycin and amoxicillin/clavulanate are commonly used to treat acute sinusitis 4, 5, 6
• A 3-day course of azithromycin was found to be as effective as a 10-day course of amoxicillin/clavulanic acid in treating acute sinusitis 4
• Amoxicillin and clavulanate given every 12 hours was found to be as effective and safe as administration every 8 hours for the treatment of acute bacterial maxillary sinusitis 5

Management of Acute Bacterial Rhinosinusitis (ABRS)

• Clinicians should distinguish presumed ABRS from acute rhinosinusitis caused by viral upper respiratory infections and noninfectious conditions 7
• The management of ABRS should include an assessment of pain, with analgesic treatment based on the severity of pain 7
• Amoxicillin is recommended as first-line therapy for most adults with ABRS 7

Chronic Rhinosinusitis (CRS) and Recurrent Acute Rhinosinusitis

• Clinicians should distinguish CRS and recurrent acute rhinosinusitis from isolated episodes of ABRS and other causes of sinonasal symptoms 7
• Computed tomography of the paranasal sinuses is recommended for diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis 7
• Clinicians should educate/counsel patients with CRS or recurrent acute rhinosinusitis regarding control measures 7

Symptomatic Relief and Observation

• Symptomatic relief may be prescribed for managing viral rhinosinusitis and ABRS 7
• Observation without use of antibiotics is an option for selected adults with uncomplicated ABRS who have mild illness and assurance of follow-up 7