Medical Management of Chronic sinusitis

We see a lot of patients with  chronic sinusitis who have often not had a full course of medical management before being referred to our department.  Many patients will come right with adequate treatment and will avoid a surgical option.

SymptomsCommon symptoms include facial pain / pressure / fullness; nasal obstruction / blockage; purulent nasal or post nasal discharge; hyposmia or anosmia; fever (acute sinusitis only); dental pain.

Physical SignsOften minimal. Mucosal swelling/inflammation; postnasal drip; facial tenderness and
swelling. Post nasal mucous alone is not typical of sinusitis.
Look for nasal polyps, deviated nasal septum or enlarged turbinates.
Examination ideally done after decongestion (Otrivine spray or Co-phenylcaine Forte
Spray in multidose container).

Differential DiagnosisAllergic rhinitis: atypical facial pain; headaches (migraine or tension).
Gastro-oesophageal reflux: TMJ pain; dental pain.

 Chronic sinusitis (continuous symptoms > 3 months)
Management

•  Supportive treatment 
•  - increase fluids, analgesia (paracetamol, NSAIDS) steam inhalations, decongestants i.e. otrivine / drixine nasal sprays or oral pseudoephedrine (maximum 5 days only), and most importantly nasal saline irrigation (Sinus Rinse or Narium commercial preparations are OTC products or use saline irrigation using syringe or straw inhalation). see video here
•  First line antibiotic 4 weeks
• First line antibiotics – amoxycillin, cotrimoxazole, doxycyline.
•  Topical nasal steroid 3 months.

 If no improvement second line antibiotic for further 1 month plus oral steroid minimum 2 weeks – Prednisone 20mg/day for 1 week then Prednisone 10mg/day for further week.

RadiologyPlain x-rays not indicated.
CT Scan indicated for recurrent or chronic sinusitis if no response to medical management as above.

See Healthpoint for full management options and referral criteria