What are the guidelines for managing rhinosinusitis?

Guidelines for Managing Rhinosinusitis

The management of rhinosinusitis should follow evidence-based guidelines that prioritize saline nasal irrigation and topical intranasal corticosteroids as first-line therapies for both acute and chronic rhinosinusitis, with antibiotics reserved only for specific cases of bacterial infection. 1

Classification of Rhinosinusitis

• Rhinosinusitis is defined as symptomatic inflammation of the paranasal sinuses and nasal cavity 1
• Classification by duration:
  • Acute rhinosinusitis (ARS): less than 4 weeks 1
  • Subacute rhinosinusitis: 4-12 weeks 1
  • Chronic rhinosinusitis (CRS): more than 12 weeks, with or without acute exacerbations 1
• Acute rhinosinusitis may be further classified as:
  • Viral rhinosinusitis (VRS) - most common 1
  • Acute bacterial rhinosinusitis (ABRS) 1

Diagnosis

Acute Rhinosinusitis

• Clinicians should distinguish presumed ABRS from ARS caused by viral upper respiratory infections and noninfectious conditions (strong recommendation) 1
• ABRS should be diagnosed when symptoms or signs of acute rhinosinusitis persist without improvement for ≥10 days beyond the onset of upper respiratory symptoms, or when symptoms worsen within 10 days after initial improvement 1
• Radiographic imaging is not recommended for uncomplicated cases of ARS (recommendation against) 1

Chronic Rhinosinusitis

• Clinical diagnosis of CRS must be confirmed with objective documentation of sinonasal inflammation using anterior rhinoscopy, nasal endoscopy, or computed tomography (strong recommendation) 1
• Clinicians should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms 1
• Clinicians should confirm the presence or absence of nasal polyps in patients with CRS 1
• Patients with CRS should be assessed for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia 1

Management of Acute Rhinosinusitis

Viral Rhinosinusitis (VRS)

• Symptomatic relief is the primary approach 1
• Options include:
  • Analgesics for pain management 1
  • Saline nasal irrigation 1
  • Intranasal corticosteroids 1

Acute Bacterial Rhinosinusitis (ABRS)

• Initial management options:
  • Watchful waiting (without antibiotics) for uncomplicated ABRS regardless of severity (recommendation) 1
  • If antibiotics are prescribed, amoxicillin with or without clavulanate is recommended as first-line therapy for 5-10 days 1
  • For penicillin-allergic patients, doxycycline or a respiratory fluoroquinolone is recommended 1
• Reassessment is necessary if the patient worsens or fails to improve within 7 days after diagnosis 1
• If treatment fails, clinicians should:
  • Confirm ABRS diagnosis
  • Exclude other causes of illness
  • Detect complications
  • Consider prescribing an alternate antibiotic 1

Management of Chronic Rhinosinusitis (CRS)

First-line Therapy

• Clinicians should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS (recommendation) 1, 2
• Saline irrigation helps with:
  • Moisturizing the nasal cavity
  • Removing crusts
  • Improving mucociliary clearance 3, 2
• Intranasal corticosteroids reduce inflammation and improve mucociliary clearance 4, 5

Additional Therapies for CRS

• Short courses of systemic corticosteroids may be beneficial, particularly for CRS with nasal polyps 1, 5
• Antibiotics should be reserved for acute exacerbations with evidence of bacterial infection 6, 5
• Antifungal therapy (topical or systemic) is not recommended for patients with CRS (recommendation against) 1

CRS with Nasal Polyps

• Treatment approach differs based on severity:
  • Mild to moderate cases: Topical intranasal corticosteroids for initial 3 months 1
  • Severe cases: Short course (1 month) of oral corticosteroids may be added 1
• If no improvement after initial therapy, CT imaging is recommended and surgical evaluation should be considered 1

Special Considerations

• Testing for allergy and immune function may be obtained in evaluating patients with CRS or recurrent ARS 1
• Off-label nasal steroid irrigations may provide better distribution to the paranasal sinuses than standard nasal sprays for patients with refractory CRS 7
• Emerging biologic therapies (monoclonal antibodies) show promise for CRS with nasal polyps 6

Common Pitfalls to Avoid

• Overuse of antibiotics for viral rhinosinusitis or mild ABRS 1
• Relying on mucus color to determine need for antibiotics (color relates to neutrophils, not bacteria) 1
• Failure to confirm CRS diagnosis with objective evidence of inflammation 1
• Not assessing for underlying conditions that may modify CRS management 1
• Using antifungal agents for routine CRS treatment 1

By following these evidence-based guidelines, clinicians can effectively manage both acute and chronic rhinosinusitis while minimizing unnecessary antibiotic use and optimizing patient outcomes.