What is the treatment for rhinosinusitis?

Treatment of Rhinosinusitis

The first-line treatment for rhinosinusitis should be intranasal corticosteroids and nasal saline irrigation, with antibiotics reserved only for specific cases of bacterial infection that meet strict diagnostic criteria. 1

Classification and Diagnosis

Rhinosinusitis is classified based on duration:

• Acute rhinosinusitis (ARS): symptoms lasting less than 4 weeks
  • Viral rhinosinusitis (VRS): most common, self-limiting
  • Post-viral rhinosinusitis: symptoms worsening after 5 days or persisting beyond 10 days
  • Acute bacterial rhinosinusitis (ABRS): small percentage (0.5-2%) of cases
• Chronic rhinosinusitis (CRS): symptoms lasting more than 12 weeks
  • With nasal polyps (CRSwNP)
  • Without nasal polyps (CRSsNP)

Diagnostic Criteria for Bacterial Rhinosinusitis

Antibiotics should be reserved for patients with:

• Symptoms persisting for more than 10 days without improvement
• Severe symptoms (fever >39°C, purulent nasal discharge, facial pain) for at least 3 consecutive days
• "Double sickening" pattern (worsening symptoms after initial improvement) 1

Treatment Algorithm

1. Acute Viral Rhinosinusitis (Common Cold)

• First-line: Symptomatic treatment only 1
  • Analgesics/antipyretics for pain and fever
  • Nasal saline irrigation
  • Short-term decongestants (≤3-5 days to avoid rebound congestion)
  • Intranasal corticosteroids may provide modest benefit

2. Post-viral Rhinosinusitis

• First-line:
  • Intranasal corticosteroids 1
  • Nasal saline irrigation 1
• Not recommended: Systemic corticosteroids (benefit does not outweigh potential harm) 1

3. Acute Bacterial Rhinosinusitis

• First-line options (choose one):
  • Watchful waiting with symptomatic treatment for uncomplicated cases 1
  • Amoxicillin with or without clavulanate for 5-10 days if antibiotics are deemed necessary 1
• Adjunctive therapy:
  • Intranasal corticosteroids
  • Nasal saline irrigation

4. Chronic Rhinosinusitis Without Nasal Polyps

• First-line:
  • Intranasal corticosteroids 1
  • Nasal saline irrigation 1
• Second-line (if no improvement after 3 months):
  • Consider long-term macrolide therapy based on culture results 1
  • Consider CT imaging 1
• Third-line (if still no improvement):
  • Referral to otolaryngologist for evaluation for sinus surgery 1

5. Chronic Rhinosinusitis With Nasal Polyps

• First-line:
  • Intranasal corticosteroid drops/sprays 1
• Second-line (if no improvement after 3 months):
  • Short course of oral corticosteroids (1 month) 1
• Third-line (if still no improvement):
  • Referral to otolaryngologist for evaluation for sinus surgery 1

Specific Medications

Intranasal Corticosteroids

• Mechanism: Reduce inflammation in nasal passages
• Examples: Fluticasone propionate
• Benefits: May provide relief starting from first day of use, with full effectiveness after several days 2
• Side effects: Minor - occasional nasal irritation, sneezing, or minor nosebleeds 2

Nasal Saline Irrigation

• Mechanism: Mechanical cleansing, improved mucociliary clearance
• Benefits: Low risk, improves symptoms, may reduce need for other medications 1
• Evidence: High aggregate quality of evidence supports effectiveness 3

Decongestants

• Mechanism: Reduce nasal congestion through vasoconstriction
• Caution: Topical decongestants (e.g., oxymetazoline) should not be used for more than 3-5 days due to risk of rebound congestion (rhinitis medicamentosa) 1, 4

Antibiotics

• Indications: Only for confirmed or strongly suspected bacterial infection
• First choice: Amoxicillin with or without clavulanate 1
• Duration: 5-10 days for acute bacterial rhinosinusitis 1
• Caution: Overuse contributes to antibiotic resistance; 60% of presumed bacterial cases resolve spontaneously 1

Important Considerations

When to Refer to a Specialist

• Failure to respond to appropriate medical therapy
• Recurrent episodes of acute rhinosinusitis
• Complications (orbital, intracranial)
• Suspected fungal sinusitis or immunodeficiency
• Presence of nasal polyps or anatomical abnormalities 1

Common Pitfalls to Avoid

1. Overuse of antibiotics: Most cases of rhinosinusitis are viral and self-limiting 1
2. Prolonged use of topical decongestants: Can lead to rebound congestion 1
3. Inadequate duration of intranasal corticosteroid therapy: Full benefits may take several days to develop 2
4. Assuming colored nasal discharge indicates bacterial infection: Discoloration relates to neutrophils, not necessarily bacteria 1
5. Failure to address underlying conditions: Allergies, immunodeficiency, or anatomical issues may require specific management 1

By following this evidence-based approach to rhinosinusitis management, clinicians can improve patient outcomes while reducing unnecessary antibiotic use and healthcare costs.