Sinusitis: irrigation, time, and when antibiotics are actually needed

Acute rhinosinusitis is usually viral and resolves in one to two weeks without treatment. The evidence for antibiotics in uncomplicated acute sinusitis is weak — pooled analyses find a small benefit at the cost of side effects and resistance, and most guidelines recommend watchful waiting or delayed prescribing rather than immediate antibiotics.

Saline irrigation has randomised evidence in chronic rhinosinusitis for symptom reduction, and it is the intervention with the best risk-benefit ratio on this page. It also helps acute symptoms.

Pelargonium sidoides has trials in acute bronchitis rather than sinusitis specifically, and the evidence for sinusitis is thin.

Adjunct measures with a plausible basis: steam inhalation (which reduces the sensation of congestion, though trials show minimal objective effect), warm compresses, adequate hydration, elevating the head while sleeping, and avoiding the topical decongestant trap — decongestant sprays used beyond 3-5 days cause rebound congestion, which is the single most common self-inflicted cause of a chronically blocked nose.

When antibiotics are actually indicated. Severe symptoms with high fever and facial pain for more than 3-4 days, symptoms that worsen after initial improvement (double worsening), or symptoms persisting beyond 10 days without improvement. This is a clinical judgement, and the double-worsening pattern is the most specific.

Chronic sinusitis is a different disease. It often involves polyps, allergy, or a structural problem, and the treatment is a prolonged course of a nasal steroid, irrigation, and sometimes surgery or biologics. A person with chronic sinusitis needs an ENT assessment, not another herb.

The red flags are the important part, because the dangerous complication is orbital or intracranial spread. Swelling around the eye, visual change, severe headache, or a stiff neck with sinus symptoms is an emergency.