How should I evaluate and manage a patient with frequent sinus infections, including work‑up for allergic rhinitis, chronic nasal obstruction, immunodeficiency, and appropriate acute and chronic treatment?

Evaluation and Management of Recurrent Sinus Infections

A patient with frequent sinus infections requires systematic evaluation for underlying causes including allergic rhinitis, anatomic abnormalities, and immunodeficiency, followed by targeted medical therapy and specialist referral when indicated.

Initial Classification and Diagnosis

First, classify the pattern of disease to guide your workup. Recurrent acute rhinosinusitis is defined as 4 or more episodes per year without symptoms between episodes, while chronic rhinosinusitis requires symptoms persisting ≥12 weeks 1, 2. This distinction is critical because recurrent acute disease suggests different organisms at different times, whereas chronic disease may have non-infectious inflammatory causes 1.

For diagnosis, you need both clinical criteria AND objective evidence 3. Clinical criteria include at least 2 of these 4 cardinal symptoms: facial pain/pressure, decreased smell, nasal drainage, and nasal obstruction 1, 3, 4. The objective evidence comes from either direct visualization (anterior rhinoscopy or nasal endoscopy showing purulent discharge or edema) or imaging 3.

Essential Diagnostic Workup

Imaging

Obtain a CT scan of the paranasal sinuses with coronal cuts through the ostiomeatal complex 1, 3. This is the gold standard for confirming chronic disease and identifying anatomic abnormalities 3. Critical timing: perform CT >4 weeks after any acute infection and after medical management to accurately assess chronic disease 3. The CT will reveal the extent and specific locations of disease, structural abnormalities like septal deviation compressing the middle turbinate, or accessory structures obstructing drainage 3, 5.

Allergy Testing

Test all patients with recurrent or chronic sinusitis for IgE sensitization to inhalant allergens 2, 3, 5. Allergic rhinitis is present in 40-84% of adults with chronic rhinosinusitis and causes edema that obstructs sinus drainage 5, 6. Skin testing is the preferred method 5. This is not optional—allergic inflammation is a major predisposing factor that must be identified and managed 3, 5.

Immunodeficiency Screening

Evaluate for immunodeficiency when patients have recurrent sinusitis associated with recurrent otitis media, bronchitis, bronchiectasis, or pneumonia 3, 5. The workup includes 3, 5:

• Quantitative serum immunoglobulins (IgG, IgA, IgM)
• Specific antibody responses to tetanus toxoid and pneumococcal polysaccharide vaccine

This matters because 10% of patients with refractory sinusitis have common variable immunodeficiency and 6% have IgA deficiency 5, 7. These patients require different management including possible immunoglobulin replacement therapy 7.

Nasal Endoscopy

Consider nasal endoscopy to visualize the ostiomeatal complex for hyperemic/edematous turbinates, purulent discharge from the middle meatus, nasal polyps, or structural lesions 1, 3. This provides direct visualization that CT cannot offer and allows for biopsy or culture if needed 1.

Treatment Approach

Medical Management

Start with intranasal corticosteroid sprays and nasal saline irrigation as first-line therapy 4. Intranasal corticosteroids reduce inflammation and improve sinus drainage 5, 4. Saline irrigation helps eliminate secretions 5.

For acute bacterial exacerbations, use amoxicillin-clavulanate at high dose (1.5-4g/day in divided doses) for 10-14 days 5. For penicillin-allergic patients, alternatives include cefuroxime, cefpodoxime, or cefdinir 5.

If you identify allergic rhinitis, add targeted allergy management—this is essential because patients benefit from continued individualized medical therapy including allergy management even after surgery 1.

For chronic hyperplastic eosinophilic sinusitis (often with nasal polyps), systemic corticosteroids may be necessary 1, 5.

When Medical Therapy Fails

Maximize medical treatment for underlying rhinitis before proceeding with surgical intervention 1. If symptoms persist after aggressive medical treatment, functional endoscopic sinus surgery should be considered 1, 8. Surgery is indicated for obstructive nasal polyps persisting despite oral corticosteroids or anatomic abnormalities obstructing sinus drainage 3, 5.

Mandatory Specialist Referrals

Refer to Allergist-Immunologist when:

• Condition persists several months or recurs 2-3 times/year despite primary care treatment 3
• Suspected immunodeficiency (especially with recurrent otitis, bronchitis, bronchiectasis, or pneumonia) 2, 3, 5
• Need for comprehensive allergy evaluation and immunologic workup 2, 3

Refer to Otolaryngologist when:

• Anatomic abnormalities obstruct drainage 3, 5
• Nasal polyps persist after appropriate medical therapy including oral corticosteroids 3, 5
• Consideration for surgical intervention 2
• Treatment failures despite optimal medical management 4

Common Pitfalls to Avoid

Do not rely on symptom-based diagnosis alone—more than 50% of patients with strong history of chronic sinusitis have normal CT scans 1. Always obtain objective evidence 3.

Do not perform CT during or immediately after acute infection—wait >4 weeks to avoid false positives from transient mucosal changes 3.

Do not skip allergy testing—it is a major modifiable risk factor present in the majority of patients 3, 5.

Do not use nasal vestibule or nasopharyngeal cultures—they are unreliable due to contamination 3. Only direct sinus aspiration or endoscopic culture reliably determines microbial etiology 3.