What is the proper role of oral antibiotics in the treatment of patients with chronic sinusitis?

Abstract

Chronic rhinosinusitis is a common illness for which systemic antibiotics are frequently prescribed, although high-level evidence for this practice is largely lacking. We review the available literature addressing the proper role of oral antibiotics in the treatment of chronic rhinosinusitis. Chronic rhinosinusitis is an incompletely understood disease process for which the role of antibiotics remains difficult to define despite its historical prominence. There is no high-level evidence to support the use of oral antibiotics in chronic rhinosinusitis. Placebo-controlled studies of macrolide antibiotics indicate either no effect or limited degrees of improvement. Recent literature has identified that sinusitis refractory to medical therapy may represent an odontogenic source, and this should be addressed by dental surgery rather than by additional antibiotics. Oral antibiotics can be prescribed most confidently for the management of chronic rhinosinusitis when purulent exacerbations of disease are detected endoscopically and antibiotic choices are directed by culture. Long-term macrolide antibiotic therapy, acting through immunomodulatory pathways, may be of benefit in chronic rhinosinusitis patients with low immmunoglobulin E levels. Odontogenic sources of sinusitis are best detected by a computed tomography scan and treated through dental surgery. There is no high-level experimental evidence to support the use of oral antibiotics in the management of chronic rhinosinusitis. The challenge continues to be the inability to perform double-blinded studies, as both patients and physicians are generally unwilling to participate in chronic sinusitis treatment studies with a placebo arm, given the deep-seated belief of oral antibiotic efficacy in treatment.