Sinusitis: Drug Therapy

Therapeutic targets

  • Elimination of the pathogens
  • Avoidance of complications

Therapy recommendations

Sinusitis

Acute bacterial sinusitis should be treated with antibiotics only in the presence of fever above 38.3°C, severe symptoms (alternatively, a secretion detection on imaging), increase in symptoms during the course of the disease, impending complications, and in immunosuppressed patients. The following therapy is indicated for acute bacterial sinusitis:

  • In the presence of the above indications, amoxicillin (broad-spectrum antibiotic from the group of aminopenicillins; belongs to the group of active substances β-lactam antibiotics) is the drug of first choice.
  • Note: Therapy with a topical glucocorticoid (mometasone nasal spray) is clearly superior to previous therapies.
  • If necessary, also use of expectorants (mucolytic drugs) such as acetylcysteine (ACC), bromhexine and ambroxol.
  • See also under “Further therapy“.

In chronic bacterial sinusitis (duration 2-3 months), the following therapy is indicated:

  • Vasocontrictory (decongestant) nasal drops; these relieve without shortening the disease.
  • Adjuvant topical glucocorticoid therapy (mometasone for topical application) in combination with antibiosis/antibiotics if necessary (as an alternative to surgical therapy)
  • Antibiosis (antibiotics) indicated only in cases of severe symptoms, fever, impending complications, or immunocompromised individuals; review antibiotic therapy after 3 to 4 days to determine if therapy is responding
  • Agent of choice for acute exacerbation (marked worsening of symptoms/disease flare-ups) is aminopenicillin plus a beta-lactamase inhibitor
  • See also under “Further therapy.”

Rhinosinusitis

Antibiotic therapy may be recommended for acute rhinosinusitis (ARS) or acute exacerbation of recurrent ARS and severe or very severe pain plus markedly elevated levels of inflammation and/or worsening of symptoms during the course of the disease and/or fever >38.5 °C (strong consensus, 7/7) [consensus decision of the S2k guideline]. In ARS and recurrent ARS:

  • Local applications with physiological saline solution.
  • Inhalation of hot vapors (38-42 °C) are recommended.
  • For symptomatic therapy
    • Analgesics, if necessary
    • Decongestants, if necessary
  • Antibiotic therapy – as a rule, not!

Indications for antibiotic therapy in acute rhinosinusitis (ARS; simultaneous inflammation of the nasal mucosa (rhinitis) and the mucosa of the paranasal sinuses) are:

  • Impending complications (severe headache, swelling, lethargy).
  • Severe discomfort and/or intensification of symptoms during the course of the disease and/or fever > 38.5 °C.
  • Severe or very severe pain and elevated levels of inflammation (CRP).
  • Detection of Moraxella catarrhalis, pneumococci or hemophilus influenzae in the nasal swab.
  • Secretion detection (secretion level or total shadowing) by computed tomography (CT).

Note: Drug Safety Communication: because of the risk of serious complications, antibiotics from the fluoroquinolone group should no longer be used to treat sinusitis, bronchitis, and uncomplicated urinary tract infections. The following therapy is indicated for chronic rhinosinusitis (CRS) [S2k guideline].

  • Mild form:
    • Nasal lavage, topical steroids (see above).
    • If no improvement within 3 months: CT + cultures, long-term antibiotics if necessary; nasal lavage if necessary, topical steroids (considered first-line therapy for CRS; should be used to treat CRSsNP/without nasal polyps and especially CRScNP/with nasal polyps); long-term antibiotics if necessary.
  • Moderate to severe form:
    • Cultures, long-term antibiotics if necessary; nasal lavage if necessary, topical steroids (considered first-line therapy for CRS; should be used to treat CRSsNP and especially CRScNP); long-term antibiotics if necessary.
    • CT, adenotomy/sinus lavage if necessary.
    • Possibly endoscopic sinus surgery

In chronic rhinosinusitis (CRS), the following therapy is indicated (modified according to):

  • Saline (NaCl)/sea water nasal spray or nasal lavage with 250 ml of isotonic or slightly hypertonic (or buffered) NaCl solution (saline)-for mobilization of secretions and crusts (evidence class IA)
  • Glucocorticoid-containing nasal drops/nasal sprays (intranasal steroids, INS) – to reduce nasal obstruction, swelling, adenoid vegetations, polyposis nasi, sleep apnea (evidence class IA); dosage: daily.
  • Allergen exposure prophylaxis, if necessary antihistamines/INS/specific immunotherapy (SIT) or also hyposensitization – if allergic component.
  • Mucolytics (eg, N-acetylcysteine; in cystic fibrosis: dornase alfa); hypertonic NaCl solution (3-6%)).
  • Alpha-sympathomimetics (max. 5 days) – in acute exacerbation of CRS with nasal obstruction.
  • Note: Oral antibiotics or antifungals have no place in the therapy of general pediatric CRS (EPOS-12 guideline).
  • See also under “Other therapy.”

Further notes

  • Symptoms of laryngopharyngeal reflux and chronic rhinosinusitis can be significantly relieved by daily treatment with a proton pump inhibitor (PPI) for eight weeks: Reflux symptoms (RSI/reflux symptom index and RFS/(reflux finding score)) could be alleviated significantly more in the verum group than in the placebo group (p < 0.001).

Consensus decision of the AWMF guideline:

  • In CRSsNP (without (sine) nasal polyps), prolonged use of clarithromycin should be considered if standard therapy fails. In individual cases, erythromycin may be used to improve the findings or roxithromycin may be used for passagerelimited improvement in quality of life. Azithromycin should not be used (strong consensus, 7/7). Note: Use of low-dose macrolides (= half dose) for 6 months only in chronic sinusitis without polyps.
  • In CRScNP (with (cum) nasal polyps), prolonged therapy with doxycycline may be aerobic in case of recurrent polyposis (strong consensus, 7/7).
  • The use of erythromycin, azithromycin, and roxithromycin cannot be recommended in CRScNP (strong consensus, 7/7).
  • Topical use of antibiotics in patients with CRS should not be done (strong consensus, 7/7).

Additional notes on CRScNP

  • Dupilumab (monoclonal antibody; dosing 30 mg s.c., every 2 weeks) can inhibit the growth of polyps and keep the airways open in patients with chronic rhinosinusitis.Mode of action: Binding to the receptors of interleukins 4 and 13: blocking two cytokines of TH2 inflammation involved in allergic reactions.

Note regarding fluoroquinolones:

  • FDA warning: fluoroquinolones administered systemically (orally or by injection) can cause serious side effects with potentially permanent damage to the musculoskeletal system and the peripheral and central nervous system, among others!
  • Drug Safety Communication: because of the risk of serious complications, antibiotics from the group of fluoroquinolones should no longer be used for the treatment of sinusitis, bronchitis and uncomplicated urinary tract infections.

Legend: with age-related restrictions.

Phytotherapeutics

Use of phytotherapeutics in acute and recurrent rhinosinusitis:

Supplements (dietary supplements; vital substances)

Suitable supplements for natural defense should contain the following vital substances:

Note: The listed vital substances are not a substitute for any drug therapy. Food supplements are intended to supplement the general diet in the particular life situation.