Management of Rhinosinusitis
For acute bacterial rhinosinusitis (ABRS), start with watchful waiting for all patients regardless of severity, and if antibiotics become necessary, use amoxicillin with or without clavulanate as first-line therapy. 1
Acute Bacterial Rhinosinusitis (ABRS)
Initial Management Strategy
The 2025 AAO-HNSF guidelines represent a significant shift from previous recommendations by extending watchful waiting (without antibiotics) to all patients with uncomplicated ABRS regardless of severity, not just those with mild illness 1. This approach recognizes that most acute rhinosinusitis begins as a viral infection, with less than 2% progressing to bacterial infection 2.
When to Consider Antibiotics
Antibiotics should only be considered when:
- Purulent nasal drainage persists for at least 10 days beyond onset of upper respiratory symptoms, OR
- Symptoms worsen within 10 days after initial improvement 3
First-Line Antibiotic Choice
When antibiotics are indicated, use amoxicillin with or without clavulanate 1. This represents a change from the 2015 guideline which recommended amoxicillin alone. The addition of clavulanate provides broader coverage against beta-lactamase producing organisms.
Common Pitfall
Do not prescribe antibiotics reflexively for acute rhinosinusitis. The vast majority are viral and will resolve without antibiotics, while inappropriate antibiotic use contributes to resistance and unnecessary side effects 4.
Chronic Rhinosinusitis (CRS)
Core Medical Management
Intranasal corticosteroids are the cornerstone of CRS treatment and should be used long-term 5. Nasal saline irrigation is also strongly recommended, though the superiority of irrigation versus sprays remains uncertain 5.
Antibiotic Use in CRS
Do not prescribe antibiotics for CRS unless significant purulent nasal discharge is present on examination 3. This is a strong recommendation because:
- CRS is primarily an inflammatory condition, not an infectious one 6
- The role of bacteria in perpetuating CRS inflammation is unclear 3
- Evidence for antibiotic efficacy in CRS is limited and variable 3
The exception is macrolide antibiotics, which may be considered for their anti-inflammatory properties rather than antimicrobial effects, though optimal dosing and duration remain undefined 3, 4.
Oral Corticosteroids
Short-term oral corticosteroids are strongly recommended for CRS exacerbations 5. However, appropriate medical management reduces the need for repeated courses of systemic steroids 7.
Biologics for CRS with Nasal Polyps (CRSwNP)
The 2025 guidelines include new recommendations on biologics:
- Recommend against biologics when patients do not have nasal polyps 1
- Educate patients about biologics when polyps are present 1
- Dupilumab is recommended for severe CRSwNP when consensus criteria are met 5
- Omalizumab may be considered with concomitant poorly controlled asthma 5
- Mepolizumab and reslizumab are options particularly with uncontrolled asthma 5
Special Populations
Management must be modified for patients with:
- Asthma
- Cystic fibrosis
- Immunocompromised state
- Ciliary dyskinesia
- Aspirin-exacerbated respiratory disease (AERD) 1
For AERD specifically, aspirin desensitization followed by aspirin ≥300 mg daily may be considered 5.
Medications to Avoid
- Antifungal agents: Offer no benefit and potential harm 5
- Antileukotrienes: Inferior to intranasal corticosteroids with unlikely added benefit 5
- Oral antihistamines and decongestants: Unlikely that benefits outweigh potential harm 5
- Empiric antibiotics for CRS: Strongly discouraged for subacute or chronic use 1, 3
Surgical Considerations
Surgery is recognized as beneficial for CRSwNP, though evidence-based criteria for when maximum medical therapy has failed remain lacking 5. The decision should involve shared decision-making based on symptom burden, quality of life impact, and response to appropriate medical management.
Quality Improvement Opportunity
Previous utilization of antibiotics and oral corticosteroids predicts future use of these medications 7. Breaking this cycle through appropriate medical management with intranasal corticosteroids and saline irrigation reduces systemic medication dependence and improves disease control.