The main objective in treating sinusitis is to eradicate the infection, decrease the severity of the symptoms and prevent it from complicating. In acute viral sinusitis, management is based on supportive care i.e. manage the symptoms. This is accomplished through; decongestants, mucolytics and pain control. In acute bacterial sinusitis, there is an addition of antibiotic treatment when the symptoms persist. If all other treatment has failed, the last resort is a surgical incision and drainage of the sinus walls.
Acute viral sinusitis
Decongestants such a topical oxymetazoline are recommended to relieve the nasal congestion and obstruction. They should be used as a short course for 2-3 days as they may lead to rebound congestion, which is worsening of the original congestion. Decongestants work by initially reducing mucosal oedema by constricting the blood vessels in the nasal passage. Mucolytics reduce the viscosity of the mucus which makes it easier for it to drain. Pain control is accomplished using over the counter analgesics such as non-steroidal anti-inflammatories and acetaminophen. These help with pain and fever.
Acute bacterial sinusitis
This disease is usually self-limiting, however it may complicate to bacterial infection beyond the nasal cavity, if this becomes the case antibiotics are indicated. Antibiotics are most important in sinusitis that is severe or involves the frontal, ethmoid, or sphenoid sinuses, since this type is more prone to complications. Treatment is done on an emperic basis.
First line antibiotic treatment is Amoxicillin-clavulanate 500 mg/125mg taken orally, three times a day. If patients have a high risk factor for resistance then high dose Amoxicillin-clavulanate 2g/125mg taken orally twice a day is recommended. Patients with penicillin allergy should be given Doxycycline 100 mg orally twice a day.
Second line therapy is indicated if initial treatment does not work. Options for second-line empiric therapy include high-dose amoxicillin-clavulanate 2 g/125 mg extended-release tablets orally twice a day, or a respiratory fluoroquinolone such as levofloxacin 500 mg orally once a day or moxifloxacin 400 mg orally once a day. In patients with penicillin allergy, the following is recommended; doxycycline 100 mg orally twice a day or levofloxacin 500 mg orally once a day or moxifloxacin 400 mg orally once a day. The choice of second-line treatment will depend on the initial treatment given.
Indications for surgical treatment include; restoration of sinus disease, failure to respond to anti-biotic treatment, recurrent or persistent sinusitis and development of complications such as severe polyposis, bony erosion and extension of the disease beyond the nasal cavity. The mainstay surgical procedure is Functional endoscopic sinus surgery (FESS). Its main purpose is to restore physiologic sinus ventilation and drainage which can facilitate the gradual resolution of mucosal disease.