Sinusitis Treatment
Acute Sinusitis—Antibiotics, or Watch and Wait?
A recent article in JAMA suggests that among 133 adults with uncomplicated rhinosinusitis, treatment with amoxicillin resulted in no significant difference in symptoms compared with placebo. “There is now a considerable body of evidence from clinical trials conducted in the primary care setting that antibiotics provide little if any benefit for patients with clinically diagnosed acute rhinosinusitis. Yet, antibiotic treatment for upper respiratory tract infections is often both expected by patients and prescribed by physicians,” the researchers write.
Take a minute to read the abstract. How do you currently treat acute sinusitis in adults? Will this study change your treatment patterns?
I typically wait until about 3 weeks of acute sinusitis symptoms before starting an antibiotic regimen, which is usually Amoxicillin, Augmentin, or Biaxin (depending on recent antibiotic use and allergies.) I always recommend nasal rinses for all patients who can tolerate doing them as long as they are able to have air transfer through both nostrils. I discourage OTC nasal sprays other than nasal saline, such as Afrin, because it can be only used for 3 days prior to rebound congestion symptoms, and feel patients will be tempted to use it longer. A syrup or capsule OTC medication for nasal congestion is recommended, such as Mucinex. I occasionally prescribe an antibiotic at two weeks of symptoms if symptoms are unilateral and/or if the patient has a comorbidity such as asthma where symptoms are worsening, and I’d they will be traveling on an airplane, due to altitude worsening symptoms.
I like to avoid antibiotics in the absence of fever in my immunocompetent patients with sinus symptoms, but it is a hard sell and it is much quicker to just give them all an antibiotic. I relent if the symptoms last more than a week. Dr. Schreiber and others have published important work on that many “sinus headaches” are in fact really a migraine and respond to triptan therapy. When I think it is infectious, I like to use a Neti pot or NS sprays and often a nasal steroid.