What intranasal corticosteroid regimen (type, dose, and duration) is recommended as adjunct therapy for acute or chronic sinusitis, and what are its contraindications?

Intranasal Corticosteroids for Sinus Infection

Intranasal corticosteroids should be used as adjunctive therapy in both acute and chronic sinusitis, with mometasone, fluticasone, or budesonide administered twice daily providing modest but clinically meaningful symptom relief. 1, 2

Recommended Regimen

Type and Dose

• Mometasone furoate, fluticasone propionate, or budesonide are the preferred agents due to negligible systemic bioavailability 1, 2
• Standard dosing: 2 sprays per nostril twice daily (total 200-400 mcg daily depending on formulation) 1, 2
• Triamcinolone acetonide is available over-the-counter but lacks specific evidence for acute bacterial rhinosinusitis 1

Duration

• Acute bacterial sinusitis: 15-21 days concurrent with antibiotic therapy 1
• Chronic rhinosinusitis: Minimum 8-12 weeks, continued long-term if beneficial 1, 2
• For chronic rhinosinusitis with nasal polyps, continue indefinitely after any oral corticosteroid course ends 2

Evidence for Efficacy

Acute Sinusitis

A Cochrane review of 4 RCTs demonstrated that intranasal steroids increased symptom improvement from 66% to 73% after 15-21 days (number needed to treat = 14) 1. The benefit is modest but clinically important when weighed against minimal adverse events. 1

When added to antibiotics in patients with recurrent acute or chronic sinusitis, fluticasone increased treatment success from 74% to 93% at 3 weeks 1. However, this benefit may not apply to sporadic acute bacterial sinusitis without a history of recurrent disease 1.

Chronic Rhinosinusitis

For chronic rhinosinusitis without nasal polyps, intranasal corticosteroids are the primary medical therapy, used for at least 8-12 weeks 1, 2. For chronic rhinosinusitis with nasal polyps, topical corticosteroid drops (not sprays) are recommended for 3 months, with continued use if beneficial 1.

Administration Technique

Patients must be instructed to direct sprays away from the nasal septum to minimize epistaxis, nasal irritation, and septal perforation 2. The nasal septum should be examined periodically for mucosal erosions 2. Proper technique is critical—failure to use correct administration reduces efficacy and increases side effects 2.

Contraindications and Precautions

• Recent nasal surgery or trauma (relative contraindication until healing occurs)
• Active nasal infection (treat infection first, then initiate corticosteroids)
• Nasal septal perforation (existing perforation is a contraindication)
• When used at recommended doses, intranasal corticosteroids are not associated with clinically significant systemic side effects 2

Common Pitfalls

• Using intranasal corticosteroids as monotherapy for confirmed bacterial sinusitis: Antibiotics remain the mainstay when bacterial infection is documented 1, 2
• Discontinuing too early: Benefits accumulate over days to weeks; patients may not notice improvement for 3-5 days 1, 2
• Confusing with topical decongestants: Unlike decongestants, intranasal corticosteroids do not cause rhinitis medicamentosa and can be used long-term 2
• Inadequate patient education on technique: Poor spray direction toward the septum increases bleeding risk 2

Integration with Other Therapies

Intranasal corticosteroids should always be combined with:

• Saline nasal irrigation (high-volume, hypertonic 3-5% solution preferred) for mechanical clearance 1, 2
• Antibiotics when bacterial infection is documented (amoxicillin-clavulanate 875/125 mg twice daily for 5-10 days as first-line) 1, 2
• Analgesics (acetaminophen or NSAIDs) for pain relief 1

For severe chronic rhinosinusitis with nasal polyps, a short course of oral corticosteroids (prednisone 40-60 mg daily for 5-7 days, then taper over 7-14 days) may be added, but intranasal corticosteroids must be continued long-term 2, 3.

When to Reassess

If symptoms do not improve after 3-4 weeks of appropriate intranasal corticosteroid therapy combined with other treatments, refer to an otolaryngologist or allergist-immunologist for further evaluation 2. Consider underlying allergic rhinitis, immunodeficiency, or anatomic abnormalities in patients with recurrent or refractory disease 1, 2.