What is the recommended first‑line management for a patient with chronic sinusitis (symptoms ≥12 weeks: nasal congestion, facial pressure, purulent nasal discharge, hyposmia, and cough)?

First-Line Management of Chronic Rhinosinusitis

Begin with daily high-volume nasal saline irrigation combined with intranasal corticosteroid spray as first-line maintenance therapy for chronic rhinosinusitis. 1, 2

Confirming the Diagnosis

Before initiating treatment, confirm the diagnosis requires objective evidence through either:

• Nasal endoscopy showing mucopurulent discharge, edema, or mucosal obstruction in the middle meatus 3, 4
• CT imaging demonstrating mucosal thickening, sinus opacification, or inflammatory changes 5, 4

However, imaging is not required for initial medical management and should be reserved for cases where medical therapy fails, complications are suspected, or surgery is being considered. 3, 1

First-Line Medical Therapy

Intranasal Corticosteroids (Primary Maintenance)

• Fluticasone propionate, mometasone furoate, or beclometasone dipropionate should be used daily as the cornerstone of maintenance therapy 1, 6
• Intranasal corticosteroids improve overall symptom scores (SMD -0.46,95% CI -0.65 to -0.27) and are effective for long-term disease control 2
• These medications work locally in the nose with minimal systemic absorption, reducing the risk of systemic side effects 7
• Patients may notice improvement within the first day, but full effectiveness requires several days of consistent daily use 7

High-Volume Saline Irrigation (Primary Maintenance)

• Daily high-volume saline irrigation significantly improves symptom scores compared with no treatment (SMD 1.42,95% CI 1.01 to 1.84) 2
• This enhances mucociliary clearance and improves sinus drainage 1, 4
• Should be performed in conjunction with intranasal corticosteroids, not as monotherapy 1, 2

Addressing the Bacterial Component

Given the presence of purulent nasal discharge in this patient, consider whether bacterial superinfection is present:

When to Use Antibiotics

• Green thick discharge suggests mucopurulent inflammation and possible bacterial superinfection 3
• For chronic infectious sinusitis with neutrophilic inflammation, consider prolonged antibiotic therapy (21-28 days) with high-dose amoxicillin-clavulanate, cefuroxime, or cefpodoxime 1
• Add anaerobic coverage with clindamycin or metronidazole if necessary, as chronic infectious sinusitis may involve anaerobic bacteria, Bacteroides, Fusobacterium species, or S. aureus 3, 1

Important Caveat About Antibiotics

• Antibiotics are NOT effective for viral or post-viral rhinosinusitis 3
• The role of antibiotics in chronic rhinosinusitis is controversial, and they should be reserved for documented bacterial superinfection 5, 1
• A 10-14 day course is appropriate for acute bacterial exacerbations, but chronic infectious sinusitis may require up to 4 weeks of therapy 5, 3, 8

Distinguishing Disease Subtypes

Chronic Infectious Sinusitis (Neutrophilic)

• Characterized by neutrophil influx and purulent discharge 3
• Responds to prolonged antibiotics targeting respiratory pathogens and anaerobes 1
• This patient's purulent discharge suggests this subtype 3

Chronic Hyperplastic Eosinophilic Sinusitis

• Characterized by eosinophils and mononuclear cells with few neutrophils 1
• Does NOT respond to antibiotics 1
• Often associated with nasal polyps, asthma, and aspirin sensitivity 1
• Requires systemic corticosteroids (oral prednisolone for 1-3 weeks) rather than antibiotics 5, 1

Evaluating Underlying Causes

While initiating first-line therapy, simultaneously evaluate for:

• Allergic rhinitis: Test for IgE sensitization to inhalant allergens, as allergic rhinitis is found in 26% of patients with chronic sinusitis and may augment bacterial infection 5, 1
• Anatomic abnormalities: Significant nasal septal deviation, middle turbinate deformity, or obstructing nasal polyps 1
• Gastroesophageal reflux disease (GERD): Medical treatment of GERD results in significant improvement in sinusitis symptoms 5
• Immunodeficiency: Consider quantitative immunoglobulin measurement and functional antibody tests if recurrent infections are present 5

Adjunctive Symptomatic Measures

• Adequate hydration 1
• Analgesics for facial pain/pressure 1
• Warm facial compresses 1
• Sleep with head elevated 1
• Avoid prolonged use of topical decongestants (>3 days) as they cause rebound congestion; intranasal corticosteroids do not cause this rebound effect 7

When to Escalate or Refer

Indications for ENT Referral

• Symptoms persist despite 4 weeks of appropriate medical therapy 1
• Recurrent acute bacterial sinusitis (≥3-4 episodes per year) 3
• Suspected complications (orbital or intracranial involvement) 5
• Radiographic evidence of ostiomeatal obstruction despite aggressive medical management 1
• Presence of nasal polyps, osteitis, bony erosion, or fungal disease requiring comprehensive surgical intervention 5, 1

Indications for Allergy/Immunology Referral

• Need to clarify allergic or immunologic basis for sinusitis 5, 1
• Suspected immunodeficiency with recurrent infections 5
• Chronic symptoms despite aggressive medical management 1
• Concomitant conditions including asthma, aspirin sensitivity, or allergic fungal disease 5

Common Pitfalls to Avoid

• Do not obtain CT imaging initially unless complications are suspected or medical therapy has failed, as diagnosis can be confirmed clinically with endoscopy 3, 1
• Do not use antibiotics empirically without evidence of bacterial superinfection, as chronic hyperplastic eosinophilic sinusitis will not respond 1
• Do not use short courses of antibiotics (<10-14 days) for chronic infectious sinusitis, as longer duration (21-28 days) may be required 3, 1
• Do not proceed to surgery without maximizing medical therapy first, as approximately 70-80% of patients respond adequately to appropriate medical treatment 9
• Do not stop intranasal corticosteroids once symptoms improve; these are maintenance medications requiring daily use for sustained benefit 7, 2

Expected Timeline and Follow-Up

• Patients may notice improvement within the first day of intranasal corticosteroid use, but full effectiveness requires several days of consistent daily use 7
• If no improvement after 1 week of intranasal corticosteroids and saline irrigation, reassess for bacterial superinfection or alternative diagnosis 7
• If symptoms persist despite 4 weeks of appropriate medical therapy, obtain CT imaging and refer to otolaryngology 1
• Long-term maintenance with intranasal corticosteroids and saline irrigation is necessary, as chronic rhinosinusitis is generally controlled rather than cured 8