II. Management: General Measures

  1. Symptomatic relief
    1. Warm, moist compresses over sinuses
    2. Tylenol
  2. Nasal Saline spray (2% buffered saline) or Neti Pot
    1. Effective Decongestant
    2. Use pre-prepared solution or filtered, distilled or boiled water
      1. Non-sterilized tap water rinses have been associated with amebic Encephalitis
      2. Yoder (2012) Clin Infect Dis 55(9): e79-85 [PubMed]
    3. Also use as pretreatment prior to Intranasal Steroid
    4. Effective in recurrent Sinusitis when used daily
      1. Rabago (2002) J Fam Pract 51:1049-55 [PubMed]
      2. Papsin (2003) Can Fam Physician 49:168-73 [PubMed]
  3. Mucolytic
    1. Historically used, but evidence is lacking for benefit
    2. Overall low side-effect profile and reasonable to trial
    3. Guaifenesin (e.g. Mucinex) 600 to 1200 mg orally twice daily
  4. Topical Decongestants (Maximum of 3 days of use)
    1. Oxymetazoline (Afrin)
      1. Avoid afrin (Oxymetazoline) in children
      2. Risk of central alpha-2 Agonist activity (Clonidine-like CNS depression)
    2. Phenylephrine (Neo-Synephrine)
      1. If a nasal Decongestant is used in children, Neo-Synephrine (Phenylephrine) is preferred
  5. Systemic Decongestants (e.g Pseudoephedrine)
    1. Not recommended due to systemic adverse effects and adds little to symptomatic relief over other options
    2. Avoid in Hypertension and cardiovascular disease
    3. Limited course may be reasonable for refractory symptoms
    4. Diversion to Methamphetamine production only reinforces a policy to discourage pseudophedrine availability and use
    5. Consider 3 days of Afrin nasal spray for facial pain relief
  6. Intranasal Steroids (treat for 3-6 weeks minimum if indicated)
    1. Modest benefit even in Acute Sinusitis without underlying Allergic Rhinitis (NNT 15)
    2. Chronic Sinusitis
    3. Nasal Polyps
    4. Dolor (2001) JAMA 286:3097-105 [PubMed]
  7. Avoid Antihistamines
    1. Dry secretions
    2. Impede osteomeatal complex drainage
  8. Avoid Systemic Corticosteroids (inffective, adverse effects) in Acute Sinusitis
    1. Head (2016) Cochrane Database Syst Rev (4): CD011992 [PubMed]

III. Management: Antibiotics

  1. Precautions
    1. Premature antibiotic use (and Antibiotic Overuse) in Acute Sinusitis is common and unwarranted
    2. Up to 70% of Acute Sinusitis <14 days resolves without antibiotics
    3. Number Needed to Treat (NNT) for antibiotic in Acute Sinusitis benefit: 11-15
    4. Number needed to harm (NNH) for antibiotic in Acute Sinusitis adverse effects: 8
  2. Indicated only in acute Bacterial Sinusitis
    1. See Acute Sinusitis for Diagnosis
    2. See Sinusitis Prediction Rules
    3. Only 10% of Sinusitis cases overall are Bacterial
    4. Persistent Sinusitis symptoms >10 days (Bacterial in 60% of cases)
    5. Moderate to severe unilateral facial pain for at least 3-4 days
      1. May be associated with Maxillary Toothache
    6. Persistent Fever over 101 to 102 F
    7. Upper respiratory symptoms for 5 to 6 days that resolved and then recurred (double-Hump Sign)
    8. Delayed prescription may be considered (fill only for symptoms lasting >10-14 days)
  3. Protocol
    1. Antibiotic course
      1. Minimum course: 10 days (5-7 days may be sufficient)
        1. Falagas (2009) Br J Clin Pharmacol 67(2): 161-71 [PubMed]
      2. Consider longer course for persistent or recurrent symptoms suggestive of Bacterial Sinusitis: 14 days
    2. Change antibiotic if no improvement in 7 days
      1. Beta-Lactamase resistance in acute cases: <30%
      2. Beta-Lactamase resistance in chronic cases: 40-50%
  4. First-Line
    1. Indications to start on first-line agents
      1. Mild to moderate symptoms
      2. No Antibiotic Resistance risk factors
        1. No daycare exposure
        2. No recent antibiotic use in last 1-3 months
        3. Immunosuppression
        4. High local Antibiotic Resistance rates
      3. Consider starting with high dose Amoxicillin or second-line antibiotics if higher risk for Antibiotic Resistance
        1. Guidelines as of 2015, recommend Amoxicillin-clavulanate as a first-line agent
    2. Amoxicillin
      1. Adult: 1000 mg orally twice daily
        1. Consider Augmentin instead as first-line management in adults
      2. Child: 90 mg/kg/day divided bid to tid (high dose)
      3. Disadvantages: Misses Beta-Lactamase producers
        1. HaemophilusInfluenzae
        2. Moraxella catarrhalis
        3. Penicillin Resistant Pneumococcus (increasing)
    3. Amoxicillin-Clavulanate (Augmentin): Standard Low Dose
      1. Recommended as a first-line agent instead of Amoxicillin as of 2015 by IDSA for Acute Bacterial Rhinosinusitis
      2. Covers HaemophilusInfluenzae and Moraxella catarrhalis which Amoxicillin misses
      3. Child: 45 mg/kg/day divided every 12 hours
      4. Adult: Augmentin 875 mg orally twice daily (or 500 mg orally three times daily)
  5. Second-Line
    1. Indications to start on second-line agents (and to use high dose protocols, e.g. Augmentin high dose)
      1. High endemic rates of invasive Penicillin resistant Streptococcus Pneumoniae (>10% rate)
      2. Severe infection
      3. Daycare attendance
      4. Age <2 years or age over 65 years
      5. Recent antibiotics in last month
      6. Immunocompromised
    2. Amoxicillin-Clavulanate (Augmentin)
      1. Child: 90 mg/kg/day divided twice daily (high dose recommended for second line management)
      2. Adult
        1. Low Dose: Augmentin 875 mg orally twice daily (or 500 mg orally three times daily)
        2. High Dose: Augmentin XR 1000/62.5 mg TWO tabs (or 2000/125 mg ONE tab) orally twice daily
          1. Does not appear to benefit adults over standard dose in acute Bacterial Sinusitis
          2. Gregory (2021) JAMA Netw Open 4(3):e212713 +PMID: 33755168 [PubMed]
    3. Clindamycin
      1. Indicated in Penicillin Allergy (hives, Anaphylaxis)
      2. Child: 30-40 mg/kg/day orally divided 3-4 times daily
    4. Cefuroxime (Zinacef, Ceftin)
      1. Adult: 500 mg orally twice daily
      2. Child: 30 mg/kg/day orally divided twice daily
    5. Cefpodoxime (Vantin)
      1. Adult: 200 mg orally twice daily
      2. Child: 10 mg/kg/day orally once daily
    6. Cefdinir (Omnicef)
      1. Adult: 300 mg PO bid or 600 mg orally once daily
      2. Child: 14 mg/kg/day divided qd-bid
    7. Avoid Cefixime
      1. Poor Gram Positive Bacteria coverage
  6. Third Line
    1. Consider adding Metronidazole (Flagyl) to second-line agents
    2. Consider second-line agent for longer course (4 week)
    3. Consider CT Sinuses
    4. Consider Otolaryngology Consultation
    5. Fluoroquinolones (avoid under age 16 years, and those at higher risk of Tendinopathy, Neuropathy)
      1. Levofloxacin (Levaquin) 750 mg daily OR
      2. Moxifloxacin (Avelox) 400 mg daily
    6. Consider Parenteral management in severe cases of hospitalized patients
      1. Ceftriaxone 1-2 g IV every 24 hours OR
      2. Ampicillin-Sulbactam (Unasyn) 3 g IV every 6 hours OR
      3. Levofloxacin 750 mg IV every 24 hours

IV. Management: Penicillin or Cephalosporin Allergy

  1. Clindamycin (children with Penicillin Allergy)
    1. Dosing: 30-40 mg/kg/day divided three to four times daily
    2. Consider in combination with Rifampin if severe
    3. Poor efficacy against Gram Negative Bacteria
    4. Increasing resistance in Haemophilus and Moraxella
  2. Doxycycline (avoid under age 8 years old)
    1. Dosing: 100 mg orally twice daily for 5-7 days
  3. Fluoroquinolones (avoid under age 16 years old)
    1. See Third line agents above
  4. Agents that are no longer recommended due to high resistance rates
    1. Macrolide antibiotics (Erythromycin, Azithromycin, Clarithromycin)
    2. Trimethoprim-Sulfamethoxazole (Bactrim, Septra)

V. Management: Referral Indications to ENT

  1. See Also Sinus Surgery
  2. Sinusitis refractory to maximal medical management
    1. Recurrent Acute Sinusitis (>3-4 episodes per year)
    2. Persistent Chronic Sinusitis Symptoms
  3. Complicated Sinusitis
    1. Immunocompromised patient
    2. Toxic appearance or severe infection with high fever (e.g. >102 F or 39 C)
    3. Osteomeatal obstruction or sinus obstruction due to anatomic defects
    4. Fungal Sinusitis
    5. Nosocomial infection or other atypical Bacteria
    6. Suspected contiguous orbital or cerebral involvement
      1. See red flag symptoms in Acute Sinusitis
      2. Sphenoid and Frontal Sinusitis are higher risk
      3. Orbital Cellulitis or intraorbital abscess
      4. Subperiosteal abscess
      5. Cavernous Sinus Thrombosis
      6. Intracranial Abscess
      7. Frontal bone Osteomyelitis (Pott Puffy Tumor)

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