Latest Updates in ENT Clinical Practice Guidelines
The most current ENT guidelines emphasize evidence-based diagnosis and judicious antibiotic use, with the 2025 Adult Sinusitis guideline representing the most recent comprehensive update 1.
Acute Bacterial Rhinosinusitis (ABRS)
Diagnosis
Diagnose ABRS when patients present with purulent nasal drainage plus nasal obstruction and/or facial pain-pressure-fullness in one of three patterns 2, 1:
- Persistent illness: Symptoms lasting ≥10 days without improvement
- Worsening course: Symptoms worsen or new symptoms appear within 10 days after initial improvement (double worsening)
- Severe onset: Fever ≥39°C (102.2°F) with purulent nasal discharge for ≥3 consecutive days
Critical update: Imaging is NOT recommended for uncomplicated ABRS diagnosis—it does not distinguish bacterial from viral infection and adds unnecessary cost and radiation 3.
Treatment Approach
Watchful waiting (without antibiotics) is now recommended as an initial management strategy for ALL patients with uncomplicated ABRS, regardless of severity 1. This represents a major shift from the 2015 guideline that limited this approach to "mild" illness only.
If antibiotics are prescribed, amoxicillin with or without clavulanate is first-line therapy for 5-10 days 2, 1. This differs from the 2007 guideline that recommended amoxicillin alone 4.
Reassess at 7 days: If the patient worsens or fails to improve, confirm ABRS diagnosis, exclude complications, and either initiate antibiotics (if initially observed) or change antibiotic therapy 2.
Symptomatic Management
Recommend analgesics based on pain severity, topical intranasal steroids, and/or nasal saline irrigation for symptom relief 2.
Pediatric Considerations (Ages 1-18)
The 2013 AAP guideline defines three diagnostic presentations 3:
- Persistent: Nasal discharge or daytime cough lasting >10 days without improvement
- Worsening: New or worsening symptoms after initial improvement
- Severe onset: Fever ≥39°C with purulent discharge for ≥3 consecutive days
Treat immediately with antibiotics for severe onset or worsening course. For persistent illness, either prescribe antibiotics OR observe for 3 additional days 3.
Amoxicillin with or without clavulanate remains first-line 3.
Complications Requiring Immediate Action
Hospitalize and obtain contrast-enhanced CT if any of the following are present 3:
- Proptosis
- Impaired visual acuity
- Impaired/painful extraocular movements
- Altered mental status
- Severe headache
- Pott's puffy tumor (frontal bone osteomyelitis)
Start IV vancomycin immediately to cover methicillin-resistant S. pneumoniae, then tailor to culture results 3. Obtain multidisciplinary consultation (otolaryngology, ophthalmology, infectious disease, neurosurgery as indicated).
Chronic Rhinosinusitis (CRS)
Diagnosis
CRS is defined as symptoms persisting >12 weeks 2, 1. The 2025 guideline strongly recommends objective confirmation with anterior rhinoscopy, nasal endoscopy, or CT scan 2, 1.
Distinguish CRS from recurrent ARS (≥4 episodes annually without persistent symptoms between episodes) 2.
Assessment of Modifying Factors
Evaluate for chronic conditions that modify management 2, 1:
- Asthma
- Cystic fibrosis
- Immunocompromised state
- Ciliary dyskinesia
- Aspirin-exacerbated respiratory disease (AERD) [new in 2025 guideline] 1
Consider testing for allergy and immune function 2.
Treatment
Recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief 2, 1.
Do NOT prescribe topical or systemic antifungal therapy—it is ineffective 2.
Antibiotics in CRS
The 2025 surgical guideline strongly recommends AGAINST prescribing antibacterial therapy if significant purulent nasal discharge is absent on examination 5. CRS is primarily inflammatory, not infectious.
Do NOT prescribe antibiotics empirically solely to satisfy third-party requirements for surgery or imaging [new recommendation] 1.
Macrolide antibiotics (≥3 weeks) have mixed evidence for anti-inflammatory effects in CRS without polyps, but routine use is not recommended 5.
CRS with Nasal Polyps
Confirm presence or absence of polyps in all CRS patients 2.
New 2025 recommendations regarding biologics 1:
- Recommend against biologics when patients do NOT have polyps
- Educate patients about biologics when polyps ARE present
Special consideration: Eosinophilic otitis media associated with CRS with polyps, NSAID hypersensitivity, and asthma may respond to biologic therapy 6.
Otitis Media with Effusion (OME)
The 2016 guideline provides comprehensive management recommendations 7:
Diagnosis
Document middle ear effusion with pneumatic otoscopy (strong recommendation). Obtain tympanometry if diagnosis is uncertain after pneumatic otoscopy 7.
Management
Manage children not at risk with watchful waiting for 3 months from effusion onset or diagnosis 7.
Strong recommendations AGAINST 7:
- Intranasal or systemic steroids
- Systemic antibiotics
- Antihistamines or decongestants
At-Risk Children
Determine if child is at increased risk for speech, language, or learning problems due to baseline sensory, physical, cognitive, or behavioral factors 7.
Evaluate at-risk children at diagnosis and at 12-18 months of age 7.
Obtain age-appropriate hearing test if OME persists ≥3 months OR for any duration in at-risk children 7.
Surgical Intervention
For children <4 years: Recommend tympanostomy tubes; do NOT perform adenoidectomy unless distinct indication exists 7.
For children ≥4 years: Recommend tympanostomy tubes, adenoidectomy, or both 7.
Key Pitfalls to Avoid
Do NOT obtain imaging for uncomplicated ABRS—it does not aid diagnosis and exposes patients to unnecessary radiation 3.
Do NOT prescribe antibiotics indiscriminately for CRS—it is an inflammatory condition, not primarily infectious 5.
Do NOT use antifungals for CRS—multiple studies show no benefit 2.
Do NOT assume all purulent discharge requires antibiotics—viral URI commonly produces colored secretions 2, 1.
Do NOT miss complications—maintain high suspicion for orbital or intracranial involvement with severe headache, visual changes, or altered mental status 3.
Quality Improvement Opportunities
The 2025 guidelines emphasize patient education, shared decision-making, and avoiding ineffective care 1. Watchful waiting reduces antibiotic overuse while maintaining safety, and objective confirmation of CRS prevents misdiagnosis and inappropriate treatment 2, 1.