Sinusitis Management Guidelines

Classification and Diagnosis

The American Academy of Allergy, Asthma, and Immunology recommends classifying sinusitis by duration to guide management: acute (<4 weeks), subacute (4-8 weeks), chronic (≥8 weeks), or recurrent (≥3 episodes/year) 1
Acute sinusitis presents with persistent upper respiratory symptoms, purulent rhinorrhea, postnasal drainage, anosmia, nasal congestion, facial pain, headache, fever, cough, and purulent discharge lasting less than 4 weeks 1
Chronic sinusitis requires symptoms persisting ≥8 weeks with abnormal CT or MRI findings; some patients present with vague or insidious symptoms 2

CT imaging is indicated for chronic sinusitis evaluation, treatment failures, or suspected complications 3, 4
Order coronal sinus CT with extra cuts through the ostiomeatal complex to clarify disease extent and location 1
Consider nasal-sinus biopsy in suspected neoplasia, fungal disease, granulomatous disease, or tracheal biopsy for ciliary evaluation 1

Continue treatment until 7 days after symptom resolution or for 10-14 days total 5
Nasal corticosteroids reduce mucosal inflammation and are beneficial in both acute and chronic sinusitis 4, 6
Decongestants (topical or systemic) may reduce tissue edema and facilitate drainage, though prospective evidence is limited 5

Switch to high-dose amoxicillin-clavulanate (90 mg/kg amoxicillin and 6.4 mg/kg clavulanate, maximum 2g every 12 hours) for 10-14 days 5, 4
Alternative antibiotics for resistant bacteria or penicillin allergy: cephalosporins, respiratory fluoroquinolones, or macrolides 3, 7, 5, 6

Recognize that chronic sinusitis (≥8 weeks) may be noninfectious and requires a different approach than acute bacterial sinusitis 1
Chronic hyperplastic eosinophilic rhinosinusitis does not respond to antibiotics; consider systemic corticosteroids 1, 3

Evaluate for IgE sensitization to inhalant allergens in suspected allergic rhinitis 3, 7
Refer to allergist-immunologist for chronic or recurrent sinusitis associated with otitis media, bronchitis, bronchiectasis, or pneumonia 3, 7, 2

Consult allergist-immunologist for recurrent sinusitis (≥3 episodes/year) requiring evaluation of inflammation, allergy, immunodeficiency, and anatomic abnormalities 3, 7, 5
Consult otolaryngology for structural abnormalities or nasal polyps 3, 7, 4