What is the treatment for atrophic rhinosinusitis?

Treatment of Atrophic Rhinosinusitis

The mainstay of treatment for atrophic rhinosinusitis includes continuous nasal hygiene with saline or sodium bicarbonate irrigations, periodic crust debridement, and antibiotics for purulent secretions or acute infections. 1

First-Line Management

• Regular nasal lavage with saline or sodium bicarbonate solution is recommended as the foundation of treatment to moisturize the nasal cavity and remove crusts (2-3 times daily) 1, 2
• Periodic debridement of crusts when necessary to prevent obstruction and secondary infection 1
• Intranasal saline irrigation is particularly effective for symptom relief and should be considered an essential component of therapy 1, 3
• For patients with purulent secretions, adding antibiotics such as mupirocin to the lavage solution is recommended 1

Antibiotic Therapy

• For acute infectious exacerbations, systemic antibiotics should be targeted against common pathogens including Klebsiella ozaenae, Staphylococcus aureus, Proteus mirabilis, and E. coli 1
• When prescribing antibiotics for secondary bacterial infections, amoxicillin-clavulanate is preferred over amoxicillin alone based on rhinosinusitis treatment guidelines 4
• The duration of antibiotic therapy for adults with uncomplicated acute bacterial rhinosinusitis should be 5-7 days, while children may require 10-14 days 4

Adjunctive Therapies

• Intranasal corticosteroids are recommended as an adjunct to antibiotics in cases with inflammatory components, particularly in patients with a history of allergic rhinitis 4, 3
• Topical corticosteroids should be used cautiously as they may potentially worsen dryness in some patients 2
• Neither topical nor oral decongestants and/or antihistamines are recommended as adjunctive treatment in patients with rhinosinusitis 4

Types and Clinical Considerations

• Primary (idiopathic) atrophic rhinitis is more prevalent in developing countries with warm climates and affects predominantly young and middle-aged adults, especially females 1, 5
• Secondary atrophic rhinitis develops from other conditions such as chronic granulomatous disorders, chronic sinusitis, excessive nasal turbinate surgery, trauma, and radiation 1, 6
• Clinical presentation includes nasal dryness, paradoxical nasal congestion despite enlarged nasal cavities, crusting, foul odor (fetor), and possible epistaxis 1, 7

Treatment Challenges and Special Considerations

• No controlled trials with adequate follow-up exist evaluating therapies for atrophic rhinitis, making evidence-based recommendations challenging 7
• Patients who fail to respond to initial empiric antimicrobial therapy after 3-5 days or worsen after 48-72 hours should be considered for alternative management strategies 4
• Referral to specialists (otolaryngologist, infectious disease specialist, or allergist) is indicated for patients who are seriously ill, immunocompromised, continue to deteriorate despite extended courses of antimicrobial therapy, or have recurrent episodes 4
• Surgical options may be considered for refractory cases, with the aim to decrease the size of the nasal cavities, promote regeneration of normal mucosa, increase lubrication, and improve vascularity 7, 8

Prevention Strategies

• Hygiene, well-balanced diet, smoking cessation, and early detection and treatment of nasal pathology can help prevent progression of atrophic rhinitis 5
• Avoiding excessive turbinate surgery is important as it has been implicated as a potential cause of secondary atrophic rhinitis 6