What is the most appropriate initial management for a patient with chronic sinusitis and foul‑smelling nasal discharge?

Management of Chronic Sinusitis with Foul-Smelling Nasal Discharge

Immediate Diagnostic Considerations

Foul-smelling nasal discharge in chronic sinusitis strongly suggests anaerobic bacterial infection, foreign body, dental source, or fungal infection—this requires urgent evaluation to exclude serious complications. 1

The presence of foul odor distinguishes this from typical chronic rhinosinusitis and mandates a different initial approach:

• Perform nasal endoscopy immediately to visualize purulent secretions, identify anatomic abnormalities, exclude foreign bodies, and assess for fungal debris or necrotic tissue. 2, 1
• Obtain sinus CT imaging to evaluate for complications including orbital involvement, intracranial extension, osteomyelitis, or dental pathology (particularly maxillary sinus disease from odontogenic source). 2, 1
• Consider direct sinus aspiration or endoscopic middle-meatus sampling for culture to identify causative organisms, especially in immunocompromised patients or when invasive fungal sinusitis is suspected. 2, 1

Initial Medical Management

First-Line Antibiotic Therapy

Amoxicillin-clavulanate 875 mg/125 mg twice daily for 3–4 weeks provides coverage against both aerobic and anaerobic bacteria commonly implicated in chronic rhinosinusitis with purulent discharge. 3, 1, 4

• The extended duration (3–4 weeks) is necessary for chronic infection, unlike the 5–10 day courses used for acute bacterial sinusitis. 2, 5
• Amoxicillin-clavulanate covers Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and importantly provides anaerobic coverage (including Peptostreptococcus, Prevotella, Fusobacterium) that may account for the foul odor. 3, 1, 4

For penicillin-allergic patients, use a respiratory fluoroquinolone (levofloxacin 500 mg once daily or moxifloxacin 400 mg once daily) for 3–4 weeks, which provides excellent gram-positive, gram-negative, and atypical coverage. 3, 1, 5

Essential Adjunctive Therapies

Intranasal corticosteroids (mometasone, fluticasone, or budesonide) twice daily are the cornerstone of chronic rhinosinusitis management and must be continued long-term to reduce mucosal inflammation. 2, 1, 6, 7, 8

• This recommendation is supported by strong evidence from multiple randomized controlled trials showing significant symptom improvement and reduced need for surgery. 2, 1, 6

High-volume saline irrigation (240 mL per nostril) 2–3 times daily mechanically removes purulent secretions, reduces bacterial load, and improves mucociliary clearance. 2, 1, 6, 7, 8

• Isotonic or hypertonic saline solutions are both effective; patient preference determines choice. 4, 6, 8

Monitoring and Reassessment

Reassess at 3–4 weeks after initiating therapy:

• If significant improvement occurs, continue intranasal corticosteroids and saline irrigation indefinitely as maintenance therapy. 6, 7, 8
• If partial response, extend antibiotic therapy for another 2–4 weeks (total 6–8 weeks) and consider adding oral corticosteroids (prednisone 20–30 mg daily for 5–7 days). 2, 1, 4
• If no improvement or worsening, proceed to urgent ENT referral for surgical evaluation. 1, 6, 7, 8

Red-Flag Situations Requiring Immediate ENT Referral

Refer urgently to otolaryngology if any of the following are present:

• Severe unilateral facial pain, periorbital swelling, visual changes, proptosis, or diplopia (suggesting orbital complications). 2, 1
• Severe headache, altered mental status, or cranial nerve deficits (suggesting intracranial extension). 2, 1
• Necrotic tissue, black eschar, or rapid progression in immunocompromised patients (suggesting invasive fungal sinusitis). 2, 1
• Persistent foul-smelling discharge despite 4–6 weeks of appropriate antibiotic therapy. 2, 1, 5
• Suspected odontogenic source requiring dental evaluation and possible tooth extraction. 1, 4

Special Considerations for Chronic Rhinosinusitis

Evaluate for underlying predisposing factors:

• Allergic rhinitis: Consider allergy testing and add antihistamines if positive. 2, 1, 4, 8
• Immunodeficiency: Check immunoglobulin levels, HIV status, and diabetes control in patients with recurrent or refractory disease. 1, 4, 8
• Anatomic abnormalities: Deviated septum, concha bullosa, or ostiomeatal complex obstruction may require surgical correction. 4, 6, 8
• Ciliary dysfunction: Consider primary ciliary dyskinesia or cystic fibrosis in young patients with chronic purulent rhinosinusitis. 4, 8
• Gastroesophageal reflux disease (GERD): Treat if present, as it may contribute to chronic sinonasal inflammation. 5

Role of Antifungal Therapy

Antifungal therapy (topical or systemic) is NOT recommended for routine chronic rhinosinusitis, even with foul-smelling discharge, unless invasive fungal sinusitis is documented. 5, 6

• Fungal cultures are frequently positive in chronic rhinosinusitis but represent colonization rather than infection in immunocompetent patients. 2, 5
• Invasive fungal sinusitis (mucormycosis, aspergillosis) requires urgent surgical debridement plus systemic antifungals and occurs primarily in immunocompromised hosts. 2, 1

Surgical Management

Functional endoscopic sinus surgery (FESS) is indicated when medical therapy fails after 8–12 weeks of optimal treatment. 2, 6, 7, 8

• Surgery aims to restore sinus ventilation and drainage, remove diseased mucosa, and improve access for topical medications. 2, 4, 6
• Post-operative medical therapy with intranasal corticosteroids and saline irrigation must be continued indefinitely to prevent recurrence. 4, 6, 8

Common Pitfalls to Avoid

• Do not use short-course antibiotics (5–10 days) for chronic rhinosinusitis; this is inadequate and promotes resistance. 2, 5
• Do not prescribe oral corticosteroids without concurrent antibiotics when bacterial infection is suspected, as this may worsen infection. 1
• Do not rely on imaging alone to diagnose chronic rhinosinusitis; clinical symptoms plus objective findings (endoscopy or CT) are both required. 6, 7, 8
• Do not use topical or systemic antifungals empirically; they have no role in non-invasive chronic rhinosinusitis. 5, 6
• Do not delay ENT referral in patients with alarm symptoms or failure of 8–12 weeks of optimal medical therapy. 1, 6, 7, 8