What is the recommended treatment for a patient with chronic sinusitis, characterized by persistent nasal congestion, facial pressure, and discharge, and potentially complicated by allergies?

Treatment of Chronic Sinusitis

Begin with daily high-volume saline irrigation combined with intranasal corticosteroids as first-line therapy for all patients with chronic sinusitis, while simultaneously evaluating for underlying allergic rhinitis, anatomic abnormalities, and immunodeficiency. 1

Initial Medical Management

First-Line Therapy

• Intranasal corticosteroids (fluticasone propionate 200 mcg daily or 100 mcg twice daily) should be initiated immediately to reduce mucosal inflammation and improve sinus drainage 1, 2, 3
• High-volume saline irrigation daily significantly improves symptom scores and should be performed regularly 1, 3
• Maximum effect from intranasal corticosteroids may take several days, though some improvement can occur within 12 hours 2

Distinguishing Infectious vs. Eosinophilic Chronic Sinusitis

This distinction is critical as it determines antibiotic necessity:

Chronic Infectious Sinusitis (neutrophilic inflammation):

• Consider prolonged antibiotic therapy (21-28 days) with high-dose amoxicillin-clavulanate (1.5-4 g/day), cefuroxime, or cefpodoxime 1, 4
• Add anaerobic coverage with clindamycin or metronidazole if there is poor response after 3-5 days 1, 4
• Avoid trimethoprim-sulfamethoxazole due to high resistance rates (50% for S. pneumoniae, 27% for H. influenzae) 4

Chronic Hyperplastic Eosinophilic Sinusitis (characterized by eosinophils and mononuclear cells with few neutrophils):

• Does NOT respond to antibiotics 1
• Often associated with nasal polyps, asthma, and aspirin sensitivity 5, 1
• Requires systemic corticosteroids such as oral prednisolone for 1-3 weeks 1, 3
• Leukotriene antagonists may improve nasal symptoms in patients with nasal polyps 3

Adjunctive Measures

• Adequate hydration, analgesics for facial pain, warm facial compresses, and sleeping with head elevated 1
• For patients with marked mucosal edema or nasal polyposis who fail initial treatment, consider short-term oral corticosteroids (typically 5 days) 4
• A 3-week course of oral doxycycline may reduce polyp size for up to 3 months after treatment 3

Evaluation of Underlying Conditions

Allergy Assessment

• Test for IgE sensitization to inhalant allergens in all patients with chronic or recurrent sinusitis 1
• Implement environmental control measures and consider allergen immunotherapy in selected patients 1
• If allergic rhinitis is confirmed, add antihistamines to the treatment regimen 6

Imaging for Anatomic Abnormalities

• Obtain coronal sinus CT with extra cuts through the ostiomeatal complex if symptoms persist despite 4 weeks of appropriate medical therapy 1
• Look for significant nasal septal deviation, middle turbinate deformity, or obstructing nasal polyps 1

When to Refer to Specialists

Refer to Allergist-Immunologist for:

• Evaluation and management of underlying allergic factors 1
• Assessment for unusual pathogens and immunodeficiency 1
• Chronic symptoms despite aggressive medical management 5, 1
• Recurrent sinusitis (3 or more episodes per year) 4

Refer to Otolaryngologist for:

• Structural abnormalities or obstructing nasal polyps 1
• Radiographic evidence of ostiomeatal obstruction despite aggressive medical management 1
• Consideration for functional endoscopic sinus surgery 5, 1

Surgical Intervention

• Maximize medical treatment before proceeding with surgery 5, 1
• Contemporary surgical therapy involves functional endoscopic sinus surgery aimed at widening natural drainage openings while preserving ciliated epithelium 5, 1, 6
• Most patients benefit from continued individualized medical therapy, including allergy management, after surgery 5, 1

Common Pitfalls to Avoid

• Do not use antibiotics for chronic hyperplastic eosinophilic sinusitis—they are ineffective and contribute to resistance 1
• Avoid antihistamines as primary therapy unless allergic rhinitis is documented, as they have no role in treating sinusitis alone 7
• Do not proceed to surgery without first maximizing medical therapy for at least 4 weeks 5, 1
• Recognize that more than 50% of patients with strong clinical history may have normal CT scans, so imaging should guide but not solely determine treatment 5