From the Guidelines
The treatment of refractory chronic sinusitis typically involves a combination of medical and surgical interventions.
Medical Management
Patients may be prescribed oral corticosteroids, such as prednisone 30-50 mg daily for 2-4 weeks, and/or antibiotics, including amoxicillin-clavulanate 875/125 mg twice daily for 3-6 weeks or levofloxacin 500 mg daily for 3-6 weeks 1.
- Topical nasal corticosteroids, such as fluticasone 200 mcg twice daily, and saline irrigations may be recommended for long-term management 1.
- In cases of chronic infectious sinusitis, a longer duration of antibiotic therapy might be required, with possible attention to anaerobic pathogens 1.
Surgical Management
In cases where medical therapy fails, functional endoscopic sinus surgery (FESS) or balloon sinuplasty may be considered to restore sinus drainage and ventilation 1.
- FESS has been shown to result in significant improvement in the majority of patients with refractory chronic sinusitis 1.
- The use of intravenous immunoglobulin (IVIG) is indicated only in patients with proved functional impairment of humoral immunity 1.
Adjunctive Therapy
Other adjunctive therapy, such as antihistamines, decongestants, mucolytics, and expectorants, might provide symptomatic benefit in selected cases 1.
- Aspirin desensitization may be beneficial for patients with aspirin-sensitive sinusitis and asthma 1.
From the Research
Treatment Options for Refractory Chronic Sinusitis
The treatment options for refractory chronic sinusitis include:
- Medical therapy, such as topical corticosteroid therapy and high volume saline irrigation, which continue to be the cornerstone of medical therapy 2
- Systemic corticosteroids and antibiotics, which may be used depending on the phenotype of chronic rhinosinusitis (CRS) and the presence of acute exacerbation 2
- Novel immunomodulatory therapies, such as anti-IL-4 receptor α antibodies and calcium channel blockers, which have shown promising early results in the management of CRS, but more research is needed before their routine use 2
- Functional endoscopic sinus surgery (FESS), which may be considered for patients with refractory CRS, and can be combined with an intra-oral approach for the treatment of sinusitis following maxillary sinus grafting 3
- Topical antibiotic therapy delivered by means of a large-particle nebulizer, which has been shown to be effective in improving symptoms and quality of life in patients with chronic rhinosinusitis refractory to medical and surgical therapy 4
- Maxillary sinus aspiration and irrigation with or without adenoidectomy, followed by culture-directed intravenous antibiotics and oral prophylaxis, which may be a reasonable alternative to endoscopic sinus surgery in children with chronic rhinosinusitis unresponsive to orally administered antimicrobial therapy 5
Surgical Interventions
Surgical interventions, such as FESS, may be necessary for patients with refractory CRS who do not respond to medical therapy. The use of a combined endoscopic and intra-oral approach has been proposed for the treatment of sinusitis following maxillary sinus grafting 3.
Novel Therapies
Novel therapies, such as anti-IL5, anti-IgE, and anti-IL4, are being investigated for the treatment of refractory CRS, but more research is needed to determine their efficacy and safety 2, 6.
Management Strategies
A practical management strategy for refractory CRS should be based on the individual patient's needs and may involve a combination of medical and surgical therapies. Assessing the degree of work productivity impairment can assist in treatment decision-making and may help predict treatment outcomes 2.