What is the recommended treatment for a patient with chronic maxillary sinusitis and possible allergies or asthma?

Treatment of Chronic Maxillary Sinusitis

For chronic maxillary sinusitis, initiate daily high-volume saline irrigation combined with intranasal corticosteroid sprays as first-line therapy, assess and treat underlying allergic rhinitis and asthma if present, and reserve antibiotics for documented bacterial infection requiring at least 3 weeks of therapy. 1

First-Line Medical Management

Begin with intranasal corticosteroids (mometasone furoate, fluticasone propionate, or beclomethasone dipropionate) combined with daily high-volume saline irrigation. 1, 2 This combination improves symptom scores and reduces polyp scores if nasal polyps are present. 1 Saline irrigation alone produces significant symptom improvement (standardized mean difference 1.42) compared to no treatment. 3

• Topical corticosteroids improve overall symptom scores (standardized mean difference -0.46) and polyp scores (standardized mean difference -0.73) in chronic sinusitis. 3
• If smoking, mandatory cessation is required before proceeding with any other interventions. 1

Address Underlying Comorbid Conditions

Allergic Rhinitis

Evaluate for allergic rhinitis in all patients with chronic sinusitis, as allergy augments bacterial sinusitis and is a major predisposing factor. 1, 2, 4

• Add antihistamines if allergic rhinitis is confirmed. 1, 2
• Consider allergy testing and immunotherapy for patients with documented allergic triggers. 1

Asthma

Recognize that medical or surgical management of chronic sinusitis results in objective and subjective improvement of asthma in patients with both conditions. 1

• Treat rhinitis or sinusitis aggressively in asthmatic patients, as therapy for the upper airway improves asthma control. 5
• Intranasal corticosteroids are particularly important in this population. 5

Gastroesophageal Reflux Disease

Evaluate for GERD, as medical treatment of reflux results in significant improvement in sinusitis symptoms. 1

Role of Antibiotics in Chronic Sinusitis

Reserve systemic antibiotics for chronic infectious sinusitis with evidence of active bacterial infection. 1 When bacterial infection is documented:

• Consider longer duration therapy (potentially 3 months) with attention to anaerobic pathogens. 1
• Amoxicillin/clavulanic acid, ciprofloxacin, clarithromycin, or trimethoprim/sulfamethoxazole are options for chronic bacterial sinusitis. 2
• Moraxella catarrhalis is a common pathogen in allergic children with chronic maxillary sinusitis, while anaerobic organisms are unusual. 6

Adjunctive Therapies

• Short-course systemic corticosteroids (1-3 weeks) may reduce polyp size in patients with nasal polyps, with effects lasting up to 3 months after treatment. 3
• Oral doxycycline for 3 weeks reduces polyp size compared to placebo. 3
• Leukotriene antagonists improve nasal symptoms in patients with nasal polyps. 3
• Macrolide antibiotics for 3 months may improve quality of life in patients WITHOUT polyps, with benefits seen at 24 weeks after therapy. 3
• Local nasal decongestants (oxymetazoline) may temporarily improve sinus aeration but should not be used long-term. 2

When to Refer to Otolaryngology

Refer to an otolaryngologist when first-line medical therapy fails after 8-12 weeks, quality of life is significantly affected, or sinusitis is recurrent (≥3 episodes per year). 1, 7

Additional referral indications include:

• Need to clarify allergic or immunologic basis for sinusitis. 7
• Suspected complications (orbital or intracranial involvement). 7
• Consideration for functional endoscopic sinus surgery. 1

Surgical Considerations

Consider functional endoscopic sinus surgery for medically resistant sinusitis, particularly with localized persistent disease within the ostiomeatal complex. 1

• Defer surgery until smoking cessation is achieved. 1
• Surgery should widen natural drainage openings while preserving ciliated epithelium. 2
• For nasal polyposis, more aggressive surgery involving removal of diseased polypous mucosa is required. 2
• Topical corticosteroids reduce polyp recurrence after surgery (relative risk 0.59). 3
• Continue medical treatment post-surgery to maintain results. 2

Critical Pitfalls to Avoid

• Do not treat chronic sinusitis with short courses of antibiotics appropriate for acute bacterial sinusitis—chronic infectious sinusitis requires minimum 3 weeks of therapy. 1, 7
• Do not ignore underlying allergic rhinitis, as untreated allergy perpetuates the inflammatory cycle. 1, 2, 4
• Do not proceed with surgery in active smokers, as outcomes are significantly worse. 1
• Do not use antibiotics as monotherapy without addressing mucosal inflammation with intranasal corticosteroids and saline irrigation. 1, 2