How to manage rhinosinusitis that is unresponsive to antibiotic treatment and intranasal corticosteroid and is accompanied by a dry cough?

Management of Rhinosinusitis Unresponsive to Initial Treatment with Dry Cough

For rhinosinusitis that has not responded to antibiotics and intranasal corticosteroids and is accompanied by a dry cough, the recommended approach is to add a short course of oral corticosteroids (5-7 days) along with saline nasal irrigation and consider referral to an otolaryngologist for evaluation. 1

Assessment of Treatment Failure

When initial treatment with antibiotics and intranasal corticosteroids fails to resolve rhinosinusitis symptoms with accompanying dry cough, consider:

1. Disease severity assessment:

   • Use visual analog scale (VAS) to categorize severity (0-3: mild, >3-7: moderate, >7-10: severe) 1
   • Evaluate for specific symptoms: nasal obstruction, rhinorrhea, facial pain/pressure, and loss of smell

2. Potential causes of treatment failure:

   • Inadequate duration of initial therapy (intranasal corticosteroids should be used for at least 3 months) 1
   • Incorrect diagnosis (consider Upper Airway Cough Syndrome) 1
   • Medication non-adherence
   • Bacterial resistance (if antibiotics were prescribed)
   • Underlying conditions (allergies, anatomical abnormalities)

Stepped Treatment Approach

Step 1: Optimize Current Therapy

• Ensure proper technique for intranasal corticosteroid administration
• Continue intranasal corticosteroids at adequate dosing 1
• Add saline nasal irrigation (Grade A/Ib evidence) 1, 2
  • Improves mucous clearance
  • Enhances ciliary activity
  • Disrupts and removes antigens, biofilms, and inflammatory mediators 2

Step 2: Add Short-Term Oral Corticosteroids

• Add a short course (5-7 days) of oral corticosteroids for patients with moderate to severe symptoms 1
• This is particularly effective for rhinosinusitis with nasal polyps 1
• Single administration of parenteral corticosteroids is discouraged 1

Step 3: Consider Additional Therapies

• For dry cough component:

  • First-generation antihistamine/decongestant combinations may be effective for Upper Airway Cough Syndrome 1, 2
  • Consider ipratropium bromide nasal spray for rhinorrhea-predominant symptoms 2
  • Limit topical decongestants to 5-7 days maximum to prevent rhinitis medicamentosa 2

• For persistent symptoms:

  • Consider long-term macrolide therapy (if not already tried) for CRS without nasal polyps 1
  • Leukotriene receptor antagonists may be considered as an additional treatment option 2

When to Refer

Referral to an otolaryngologist is indicated when:

• Symptoms persist despite appropriate medical therapy for 3 months 1
• Presence of unilateral symptoms or bloody discharge 2
• Suspicion of anatomical abnormalities requiring surgical intervention
• Recurrent episodes of sinusitis 1

Imaging Considerations

• CT scan should be considered for patients with persistent symptoms despite appropriate medical therapy 1
• CT helps evaluate for anatomical abnormalities and extent of disease
• CT findings guide potential surgical intervention

Important Caveats

1. Avoid prolonged antibiotic use without clear evidence of bacterial infection, as most rhinosinusitis cases are self-limited and antibiotics have more adverse effects than benefits (NNT=18, NNH=8) 1

2. Beware of rhinitis medicamentosa from overuse of topical decongestants (>5-7 days), which can worsen symptoms 1, 2

3. Monitor for corticosteroid side effects, especially with oral formulations:

   • Short-term: increased appetite, mood changes, insomnia
   • Long-term: osteoporosis, adrenal suppression, cataracts

4. Consider comorbidities that may contribute to treatment failure:

   • Allergic rhinitis
   • Gastroesophageal reflux disease
   • Immunodeficiency
   • Cystic fibrosis 1, 2

The evidence strongly supports that intranasal corticosteroids remain the cornerstone of treatment for chronic rhinosinusitis, with the addition of saline irrigation and short-course oral corticosteroids for those who fail initial therapy 3. Judicious use of antibiotics is recommended, as the evidence supporting their routine use in chronic rhinosinusitis is lacking 4.