Treatment of Chronic Sinusitis

Initial Medical Management

The American Academy of Allergy, Asthma, and Immunology recommends initiating daily high-volume saline irrigation combined with intranasal corticosteroids as first-line therapy for chronic sinusitis, while simultaneously evaluating for underlying causes including allergic rhinitis, anatomic abnormalities, and immunodeficiency 1, 2
For chronic infectious sinusitis with neutrophilic inflammation, consider prolonged antibiotic therapy (21-28 days) with high-dose amoxicillin-clavulanate, cefuroxime, or cefpodoxime, and add anaerobic coverage with clindamycin or metronidazole if necessary 1, 3

The American Academy of Otolaryngology recommends adequate hydration, analgesics for facial pain, warm facial compresses, and sleeping with head elevated as adjunctive measures for chronic sinusitis 3

Chronic hyperplastic eosinophilic sinusitis is characterized by eosinophils and mononuclear cells with few neutrophils, and does not respond to antibiotics, often associated with nasal polyps, asthma, and aspirin sensitivity 1, 4
The American Academy of Allergy, Asthma, and Immunology recommends systemic corticosteroids, such as oral prednisolone for 1-3 weeks, for chronic hyperplastic eosinophilic sinusitis 1, 4

The American Academy of Allergy, Asthma, and Immunology recommends testing for IgE sensitization to inhalant allergens in all patients with chronic or recurrent sinusitis, and implementing environmental control measures and considering allergen immunotherapy in selected patients 1, 2
The American Academy of Otolaryngology recommends obtaining coronal sinus CT with extra cuts through the ostiomeatal complex if symptoms persist despite 4 weeks of appropriate medical therapy, to evaluate for anatomic abnormalities such as significant nasal septal deviation, middle turbinate deformity, or obstructing nasal polyps 1, 2, 5

The American Academy of Otolaryngology recommends referring to an otolaryngologist for structural abnormalities, obstructing nasal polyps, or radiographic evidence of ostiomeatal obstruction despite aggressive medical management 1, 2, 5
The American Academy of Allergy, Asthma, and Immunology recommends referring to an allergist-immunologist for evaluation and management of underlying allergic factors, assessment for unusual pathogens and immunodeficiency, and patients with chronic symptoms despite aggressive medical management 1, 2

The American Academy of Otolaryngology recommends that every effort should be made to maximize medical treatment before proceeding with surgery, and that contemporary surgical therapy involves functional endoscopic sinus surgery aimed at widening natural drainage openings while preserving ciliated epithelium 2, 5
The American Academy of Allergy, Asthma, and Immunology recommends that most patients benefit from continued individualized medical therapy, including allergy management, after surgery 2, 5

Computed tomography (CT) of the sinuses should be used to confirm chronic rhinosinusitis when needed, as it demonstrates mucosal thickening, sinus opacification, or other inflammatory changes that provide objective evidence of disease in adults with persistent sinonasal symptoms. 6

Antibiotics are not effective for viral or post‑viral rhinosinusitis and should be avoided in these contexts. 7
Antibiotic therapy is reserved for documented bacterial superinfection in chronic rhinosinusitis; empirical use without evidence of bacterial infection is not recommended. 7
Acute bacterial exacerbations of chronic rhinosinusitis merit a 10–14‑day course of appropriate antibiotics. 7
Chronic infectious (neutrophilic) sinusitis may require prolonged antibiotic courses of 21–28 days with high‑dose amoxicillin‑clavulanate, cefuroxime, or cefpodoxime, and anaerobic coverage (e.g., clindamycin or metronidazole) when anaerobes are suspected. 7

Chronic hyperplastic eosinophilic sinusitis (characterized by eosinophil‑predominant inflammation, nasal polyps, asthma, or aspirin sensitivity) does not respond to antibiotics; instead, it requires a short course of systemic corticosteroids (e.g., oral prednisolone for 1–3 weeks). 7

Allergic rhinitis is present in approximately 26 % of adults with chronic sinusitis and can exacerbate bacterial infection; testing for IgE sensitization to inhalant allergens is advised. 7
Gastro‑esophageal reflux disease (GERD) treatment has been shown to produce a significant improvement in sinusitis symptoms; clinicians should assess and manage GERD when present. 7
Immunodeficiency should be considered in patients with recurrent infections; quantitative immunoglobulin levels and functional antibody testing are recommended for evaluation. 7