Chronic Sinusitis Treatment & Management

The American Academy of Otolaryngology-Head and Neck Surgery Foundation has updated its clinical practice guidelines for the treatment of adult sinusitis. ^[38] The recommendations to clinicians are as follows:

• Distinguish acute bacterial rhinosinusitis from acute rhinosinusitis caused by viral upper respiratory infections and noninfectious conditions
• Confirm the clinical diagnosis of CRS with objective documentation of sinonasal inflammation via anterior rhinoscopy, nasal endoscopy, or CT scan
• Offer either watchful waiting (without antibiotics) or initial antibiotic therapy for adults with uncomplicated acute bacterial rhinosinusitis
• If antibiotics are prescribed, the initial antibiotic therapy for adults with uncomplicated acute bacterial rhinosinusitis should be amoxicillin with or without clavulanate as first-line therapy for 5-10 days
• Reassess the patient to confirm the bacterial rhinosinusitis and exclude other causes of illness; assess for complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management
• Distinguish CRS and recurrent acute rhinosinusitis from isolated episodes of acute bacterial rhinosinusitis and other causes of sinonasal symptoms
• Assess patients with CRS or recurrent acute rhinosinusitis for multiple chronic conditions that would modify management (eg, asthma, cystic fibrosis, immunodeficiency, ciliary dyskinesia)
• Assess for nasal polyps in patients with CRS
• Recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptomatic relief of CRS
• Do not prescribe topical or systemic antifungal therapy in patients with CRS

Because chronic sinusitis has many risk factors and potential etiologies, apply a combined approach to control or modify these factors in the management of chronic sinusitis.

Viral upper respiratory tract infections

Reduce viral exposures by improved personal hygiene. The roles of zinc and vitamin C in the prevention of viral upper respiratory tract infection are controversial. On June 16, 2009, the US Food and Drug Administration (FDA) issued a public health advisory and notified consumers and health care providers to discontinue the use of intranasal zinc products. ^[39] The intranasal zinc products (Zicam Nasal Gel/Nasal Swab; Matrixx Initiatives) are herbal cold remedies that claim to reduce the duration and severity of cold symptoms and are sold without a prescription. The FDA received more than 130 reports of anosmia (ie, an inability to detect odors) associated with intranasal zinc. Many of the reports described the loss of smell with the first dose.

Environmental and allergic factors

Environmental factors and/or allergic factors may predispose some individuals to chronic sinusitis. Reduce exposure to dust, molds, cigarette smoke, and other environmental chemical irritants. For patients with confounding nasal allergy, other antiallergy therapies, including either oral or topical antihistamines, cromolyn, topical steroids, and immunotherapy, may reduce recurrences and symptoms of allergic rhinitis.

Smoking cessation likely plays a large role in the success of both medical and surgical treatments because tobacco products act as an irritant to normal nasal mucosa and cilia function.

Gastroesophageal reflux disease

Patients with adult chronic sinusitis may benefit from control of gastroesophageal reflux disease (GERD), which has increasingly been implicated in causing or exacerbating respiratory ailments such as asthma and chronic sinusitis. The exact relationships and mechanisms are presently a matter of speculation.

Immunodeficiency

Appropriate control of various congenital and acquired immunodeficiency states is necessary to cure chronic sinusitis.

Asthma

Especially for patients with co-existing asthma, leukotriene inhibitors may play a role. ^[40]

Cystic fibrosis 

Guidelines fortreatment of  cystuc fibrosis induced sinusistis are not available. Treatment with intranasal dornase alfa, topical tobramycin and coiistin, and targeting the genetic defect, are promising. ^[40]

Symptoms may be relieved with topical decongestants, topical steroids, antibiotics, nasal saline, topical cromolyn, or mucolytics.

Steam inhalation and nasal saline irrigation may help by moistening dry secretions, reducing mucosal edema, and reducing mucous viscosity. A recent review concluded that low-volume (5 mL) nebulized saline spray was not more beneficial than intranasal steroids. Larger volume (150 mL) was marginally more efficacious than placebo. ^[41]

Initial oral steroid therapy followed by topical steroid therapy was found to be more effective than topical steroid therapy alone in decreasing polyp size and improving olfaction in patients with CRS with at least moderate nasal polyposis. ^[42] The severity of all symptoms was lessened. ^[43]

There was mo increased risk of acquiring COVID 19 infection in individuals with CRS treated with oral coritcosteroids compared with those who were not treated. ^[44]

In June 2019, the FDA approved dupilumab for the treatment of inadequately controlled severe chronic rhinosinusitis with nasal polyps (CRSwNP) in adults. Dupilumab is a humanized monoclonal antibody that inhibits interleukin-4 (IL-4) and IL-13 signaling by specifically binding to the IL-4R-alpha subunit shared by the IL-4 and IL-13 receptor complexes. Blocking the IL-4R-alpha subunit inhibits IL-4 and IL-13 cytokine-induced responses, including the release of proinflammatory cytokines, chemokines, and IgE. Approval was supported by phase 3 clinical trials (eg, SINUS-24, SINUS-52) demonstrating significant improvement nasal congestion/obstruction, nasal polyps score, sinus opacification, and improvement in smell when added to standard-of-care mometasone furoate nasal spray compared with placebo plus mometasone. ^{[45, 46, 47]}

In individuals with CRSwNP, the major intervention is to relieve the obstruction to sinus drainage by reducing or eliminating the polyp. This is achieved primarily with glucocorticosteroids, both systemically and intranasally. Antileukotriene agents can be adjunctive to the effect of the steroids, especially in patients with asthma or an allergy to aspirin. ^[48]  Biologics for CRSwNP modulate the type 2 inflammatory pathway. ^[49]  The efficacy and safety of biologicals  (dupilumab, omalizumab, mepolizumab, and reslizumab-) for CRS with nasal polyps compared with the standard of care was evaluated by Agache et al. ^[50]  Dupilumab and omalizumab reduce the need for surgery and oral corticosteroid use and improve smell and quality of life, and patients experienced fewer treatment-related adverse events. There was low certainty for mepolizumab or reslizumab in achieving these goals. A systematic review by Chong et al ^[51]  found that omalizumab probably improves disease-specific health-related quality of life compared with placebo. There was no evidence regarding the effect of omalizumab on disease severity.

Catalano et al evaluated balloon dilation for the treatment of chronic frontal sinusitis in 20 patients with advanced sinus disease in whom medical therapy had failed and who therefore required operative intervention. Preoperative and postoperative CT scans were compared. There were no significant complications from balloon dilation, and there was significant improvement in patients with certain subsets of CRS. ^[52]

To see complete information on Balloon Sinuplasty, please go to the main article by clicking here.

An adequate antibiotic trial in CRS usually consists of a minimum of 3 to 4 weeks of treatment, preferably culture directed. Oral antibiotic regimens are generally used to treat chronic sinusitis, since this condition is primarily treated in an outpatient setting. For resistant cases, there may be a role for intravenous antibiotic therapy.

Initial choice of the appropriate antimicrobial(s) is usually empiric. Sinus cultures generally are not obtained for community-acquired infections unless empiric therapy fails to elicit a response. The agent(s) chosen should be effective against the most likely bacterial etiologies, including both aerobic and anaerobic pathogens. The likelihood of involvement by beta-lactamase–producing organisms should be considered. If methicillin-resistant Staphylococcus aureus (MRSA) is a possible pathogen, coverage for this should be included. History of drug allergies (if any) and cost of therapy should be taken into account as well. In addition, if the patient has received antibiotics during the preceding 3 months, a different class of antibiotics should be used.

Therapeutic regimens include the combination of a penicillin (eg, amoxicillin) plus a beta-lactamase inhibitor (eg, clavulanic acid), a combination of metronidazole plus a macrolide or a second- or third-generation cephalosporin, and the newer quinolones (eg, moxifloxacin). All of these agents (or similar ones) are available in oral and parenteral forms. Other effective antimicrobials are available only in parenteral form (eg, cefoxitin, cefotetan). If aerobic gram-negative organisms (eg, Pseudomonas aeruginosa) are involved, parenteral therapy with an aminoglycoside, a fourth-generation cephalosporin (cefepime or ceftazidime), or oral or parenteral treatment with a fluoroquinolone (only in postpubertal patients) is added. Parenteral therapy with a carbapenem (ie, imipenem, meropenem) is more expensive but provides coverage for most potential pathogens, both anaerobes and aerobes.

Agents that provide coverage for MRSA should be administered. Some options include tetracyclines, trimethoprim-sulfamethoxazole or linezolid, which are added to other regimens that cover anaerobes. Parenteral antimicrobials effective against MRSA include vancomycin, linezolid, and daptomycin. Biologics have shown promise in the treatment of refractory sinusitis. ^[53]

Ferguson et al performed a prospective observational study of 125 adults with classic symptoms of CRS who underwent nasal endoscopy and sinus CT. Severe symptoms occurred more often in younger patients with normal CT scans of the sinus than in those with positive CT findings. Improvement in response to antibiotics was similar for patients with positive CT findings and those with normal CT scans. The authors concluded that most symptoms considered to be typical for CRS proved to be nonspecific, and they suggest that objective evidence of mucopurulence assessed by endoscopy or CT should be obtained if a prolonged course of antibiotics is being considered. ^[54] Overall, there is little concrete evidence that systemic antibiotic therapy offers much improvement in the quality of life among adults with chronic sinusitis without polyps. ^[55]

It is useful to tailor therapy to the clinical type of CRS. ^[56] CRS without nasal polyps is treated with prednisone 20-40 mg daily tapered over 10 days plus an intranasal steroid. Antibiotic therapy is often required for up to 6 weeks or longer and should not be discontinued until the patient is asymptomatic. Discontinuation of antimicrobial therapy prior to complete resolution increases the likelihood of relapse.

Nebulized antibiotics and antifungal agents be used in refractory cases, especially in patients who have undergone sinus surgery and as a means to avoid prolonged therapy with intravenous antibiotics. Further studies need to be done to establish their role in treating CRS. ^{[57, 58]}

There is a high rate of S aureus colonization of the sinus mucosa in CRS with nasal polyps. Three weeks of doxycycline therapy has been demonstrated to reduce polyp size, possibly because of the anti-inflammatory properties of the tetracyclines, as well as their anti-staphylococcal effects. ^[59]

Failure to relieve the polyposis obstruction with medical therapy is an indication for a surgical approach.

A 2015 study indicates that there is little difference in clinical outcomes between 3 weeks versus 6 weeks of antibiotic therapy for CRS. ^[60] This conclusion is contrary to the experience of many practitioners. At minimum, 3 weeks of antibiotic therapy could be used as a benchmark to reevaluate whether the patient has adequately responded. If not, a surgical approach may be considered.

The role of nebulized antibiotics and antifungal agents in treating refractory cases, especially in patients who have undergone sinus surgery, is very limited and generally should be avoided. ^[57] Fungal CRP is primarily treated with appropriate surgery. ^[38]

Difficult-to-treat chronic sinusitis is associated with nasal polyps, asthma, and aspirin-exacerbated respiratory disease. ^[61]

In summary, daily saline irrigation with topical cortical steroid therapy is to be considered prime therapy for chronic sinusitis. In patients with nasal polyposis, systemic corticosteroids (3 weeks), doxycycline (3 weeks), and/or a leukotriene antagonist should be considered. Omalizumab (anti-IgE antibody) is a biologic that may help patients with severe CR with polyps. Omalizumab made patients' symptom better and shrank their polyps in small-size randomised controlled trials. ^{[62, 63, 64]}  In patients without nasal polyps, 3 months of a macrolide antibiotic may be useful. ^[65]

Probiotic therapies may offer clinical benefit in CRS. ^[66]  Further investigation is warranted for evaluation of long-term outcomes and pathogenic deterrence.

Functional Endoscopic Sinus Surgery

Surgical care is used as an adjunct to medical treatment in some cases. Surgical care is usually reserved for cases that are refractory to medical treatment and for patients with anatomic obstruction. Preoperative CT findings prior to sinus surgery may be poor predictors of surgical outcomes. ^[67]

The goal in surgical treatment is to reestablish sinus ventilation and to correct mucosal opposition in order to restore the mucociliary clearance system. Surgery strives to restore the functional integrity of the inflamed mucosal lining.

Recent advances in endoscopic technology and a better understanding of the importance of the ostiomeatal complex in the pathophysiology of sinusitis have led to the establishment of functional endoscopic sinus surgery (FESS) as the surgical procedure of choice for the treatment of chronic sinusitis. ^[68]

FESS facilitates the removal of disease in key areas, restores adequate aeration and drainage of the sinuses by establishing patency of the ostiomeatal complex, debulks severe polyposis, and causes less damage to normal nasal functioning. FESS is successful in restoring sinus health, with complete or at least moderate relief of symptoms in 80% to 90% of patients. Supportive medical treatment is instituted preoperatively and postoperatively. In children, surgical management is not as well established and should be reserved for complicated cases.

Occupational exposure may affect FESS outcomes. Symptoms may persist with work-related exposure to inhaled agents, and revision surgery may be required. ^[69]

In patients who have undergone endoscopic sinus surgery, total and direct healthcare costs, antibiotic usage, and the total number of imaging studies performed decreased after surgery for at least 3 years. However, the use of oral corticosteroids did not change. ^[70]

For more information, see the Medscape Reference article Functional Endoscopic Sinus Surgery.

Balloon Sinuplasty

Balloon sinuplasty is an option in the treatment of sinusitis that has failed to respond to appropriate medical therapy. Evidence is best for limited disease in patients with chronic rhinosinusitis without nasal polyposis affecting the frontal, sphenoid, and maxillary sinuses. Because it can be performed in an office setting, it can be a viable therapeutic alternative in patients with comorbidities who are unable to tolerate general anesthesia. ^[71]

Management of Chronic Maxillary Sinusitis

Three main surgical options are available for chronic maxillary sinusitis:

• Endoscopic uncinectomy with or without maxillary antrostomy

• Caldwell-Luc procedure

• Inferior antrostomy (naso-antral window)

Management of Fungal Sinusitis

The preferred treatment for chronic fungal sinusitis is surgical debridement. Mycetomas or fungus balls are best treated by means of surgical removal. Allergic fungal sinusitis, which usually manifests as nasal polyps and allergic sinusitis, is treated by means of systemic steroids and surgical removal of polyps and mucinous secretions. Prolonged postoperative tapering doses of prednisone and anterior nasal glucocorticoid steroids are indicated to suppress the symptoms of fungal CRS. ^[72]

Some literature has suggested that topical antifungals may have a role in the treatment of CRS ^[73] ; however, this treatment remains controversial, and other studies have not supported this approach. A recent assessment that included 6 studies (N = 380) showed no statistically significant benefit of topical or systemic antifungals over placebo for the treatment of CRS. ^[74] Head et al concluded uncertainty regarding whether topical or systemic antifungals affect patient outcomes in adults with chronic rhinosinusitis compared with placebo or no treatment. ^[75]

Garlic has an active ingredient (allyl thiosulfinate) that provides a short-term decongestant effect. Eating foods highly seasoned with garlic has been considered therapeutic. Chewing horseradish root is another home remedy reported by some patients as effective for clearing the sinuses, but no scientific data support this belief.

The most common complication of chronic sinusitis is superimposed acute sinusitis. In children, the presence of pus in the nasopharynx may cause adenoiditis, and a high percentage of such patients develop secondary serous or purulent otitis media. Dacryocystitis and laryngitis may also occur as complications of chronic sinusitis in children.

Patients should be urgently referred to an otolaryngologist when they manifest any of these signs and/or symptoms: double or reduced vision, proptosis, rapidly developing periorbital edema, ophthalmoplegia, focal neurologic signs, high fever, severe headache, meningeal irritation, or significant or recurrent nose bleeding. ^[28]

Orbital complications include preseptal cellulitis, subperiosteal abscess, orbital cellulitis, orbital abscess, and cavernous sinus thrombosis. Intracranial complications include meningitis, epidural abscess, subdural abscess, and brain abscess. ^[28]

Other complications include osteomyelitis and mucocele formation.

Some studies have suggested a higher incidence of complications associated with fungal sinusitis. ^{[76, 77]} Untreated chronic sinusitis can lead to life-threatening complications, as in patients with cystic fibrosis. ^[78]

Individuals with medically resistant CRS exhibit a higher rate of asthma development. Those who have undergone endoscopic surgery early in their course appear to have a decreased risk of asthma. ^[79]

Persistent or recurrent episodes of sinusitis despite appropriate medical therapy necessitate referral to an otolaryngologist. Examination, including nasal endoscopy and CT scanning, is mandatory to exclude surgically amenable conditions.

A consult with an otolaryngologist should be considered when one of the following occurs:

• The disease is refractory to maximal medical therapy.

• The disease has progressed beyond the paranasal sinuses.

• The disease is unilateral (patient should be evaluated for potential neoplasm).

• Patients have coexisting morbidities that are exacerbated by the sinus disease.

• Urgent referral when a complication is suspected (see above)

Seek consultation with an ophthalmologist at the earliest suggestion of orbital involvement. Seek consultation with a dentist when an odontogenic infection is present or suspected.

Continued outpatient medical treatment with nasal decongestants and topical steroids is important even after surgical treatment.

Nasal douching may improve symptoms, particularly following surgical treatment. Steam inhalation may have a role to liquefy and soften crusts while moisturizing dry inflamed mucosa.

Nasal cavity irrigation using buffered normal saline may have a role in decreasing mucosal edema. Irrigation should be performed at least twice daily.

Patients with presumed allergic rhinitis in conjunction with chronic sinusitis may benefit from an evaluation by an otolaryngologist trained in otolaryngic allergy or an allergist/immunologist. In most instances, prick/puncture tests are performed to clarify the role of allergies.