What is the initial management and treatment for rhinosinusitis?

Initial Management and Treatment for Rhinosinusitis

For acute rhinosinusitis, start with symptomatic relief using saline nasal irrigation and intranasal corticosteroids, reserving antibiotics only for confirmed bacterial cases after 10 days of symptoms or worsening after initial improvement—and even then, watchful waiting remains an appropriate first-line strategy. 1, 2

Distinguishing Viral from Bacterial Rhinosinusitis

The critical first step is determining whether you're dealing with viral acute rhinosinusitis (ARS) or acute bacterial rhinosinusitis (ABRS), as this fundamentally changes management 2:

• Diagnose ABRS when: symptoms persist ≥10 days without improvement OR symptoms worsen within 10 days after initial improvement (the "double sickening" pattern) 1, 2, 3
• Most cases are viral: The majority of acute rhinosinusitis resolves spontaneously without antibiotics 1
• Common pitfall: Do NOT use mucus color (yellow or green) to determine need for antibiotics—color reflects neutrophils, not bacteria 2

First-Line Symptomatic Treatment (All Acute Rhinosinusitis)

Regardless of suspected etiology, initiate these measures immediately 1, 2:

Saline Nasal Irrigation

• Use regularly 2-3 times daily to remove mucus and moisturize nasal passages 1, 2
• This is supported by Grade A evidence from multiple systematic reviews 1

Intranasal Corticosteroids

• Provide modest symptom relief after 15 days of use 1
• Number needed to treat is approximately 14 (meaning 14 patients must use them for 1 additional patient to benefit) 1
• Side effects include headache, nasal itching, and epistaxis 1

Analgesics

• Acetaminophen or ibuprofen for pain and fever relief 1

Decongestants (Optional)

• Nasal spray formulations: limit to 3 days maximum to avoid rebound congestion 1
• Oral decongestants may be used without this time restriction 1

What NOT to Use

• Avoid routine antihistamines and oral corticosteroids in acute rhinosinusitis—they have side effects without proven symptom relief 1

Management of Confirmed Acute Bacterial Rhinosinusitis

When ABRS is diagnosed (symptoms ≥10 days or worsening pattern), you have two evidence-based options 1, 2:

Option 1: Watchful Waiting (Preferred Initial Strategy)

• This is appropriate for ALL patients with uncomplicated ABRS, regardless of severity 1, 2
• Provide a prescription but instruct the patient to fill it ONLY if:
  • No improvement after 7 days from diagnosis, OR
  • Symptoms worsen at any time 1
• Rationale: Most patients improve spontaneously; antibiotics provide only modest benefit (NNT = 10-15) 1
• Critical requirement: Ensure reliable follow-up is possible 1, 2

Option 2: Immediate Antibiotic Therapy

If prescribing antibiotics immediately or after failed watchful waiting:

• First-line: Amoxicillin with or without clavulanate for 5-10 days 1, 2
• For penicillin allergy: Doxycycline or respiratory fluoroquinolone (e.g., levofloxacin) 2
• Shorter courses (5-7 days) have fewer side effects and may be equally effective 1

For treatment failures or high-resistance areas:

• High-dose amoxicillin-clavulanate, cefuroxime, cefpodoxime, cefprozil, or cefdinir 1
• Consider quinolones or macrolides as alternatives 1

Management of Chronic Rhinosinusitis (CRS)

CRS is defined as symptoms lasting >12 weeks and MUST be confirmed with objective evidence (nasal endoscopy, anterior rhinoscopy, or CT scan) 1, 2, 4:

First-Line Treatment for CRS

• Saline nasal irrigation (2-3 times daily) 2, 4
• Topical intranasal corticosteroids (continuous use) 2, 4
• These should be used together as initial therapy 2

Additional Medical Options

• Short courses of systemic corticosteroids may benefit patients, particularly those with nasal polyps 2, 5
• Antibiotics: Reserve for acute exacerbations with evidence of bacterial infection—routine use in CRS lacks strong evidence 6, 5, 4
• Long-term macrolide therapy may be considered in select cases 1

What NOT to Use in CRS

• Do NOT use topical or systemic antifungal therapy—this is explicitly recommended against 1, 2

When to Escalate Care

• Confirm presence or absence of nasal polyps—this modifies management 1, 2
• Assess for modifying conditions: asthma, cystic fibrosis, immunodeficiency, ciliary dyskinesia, allergic rhinitis 1, 2
• Consider allergy testing in recurrent or refractory cases 1, 2
• Refer to otolaryngology if medical management fails or for consideration of endoscopic sinus surgery 4, 3

Common Pitfalls to Avoid

• Overprescribing antibiotics: Most ARS is viral and self-limited; antibiotics increase adverse events and resistance 1, 6
• Using mucus color as an indication for antibiotics: This is unreliable 2
• Failing to obtain objective evidence for CRS diagnosis: Clinical symptoms alone are insufficient 2, 4
• Not assessing for underlying conditions that modify CRS management (asthma, immunodeficiency, structural abnormalities) 1
• Prolonged nasal decongestant spray use: Causes rebound congestion after 3 days 1