What is the next best step for a patient with persistent nasal congestion, sinus pressure, green nasal drainage, and loss of smell despite treatment with Augmentin (amoxicillin/clavulanate), nasal steroid, and loratadine?

Next Best Step for Persistent Rhinosinusitis Despite Initial Treatment

This patient meets criteria for difficult-to-treat chronic rhinosinusitis (CRS) and requires CT imaging of the sinuses to guide further management, along with optimization of intranasal corticosteroid therapy and consideration of specialist referral. 1

Diagnostic Classification

This patient has chronic rhinosinusitis based on symptoms persisting ≥12 weeks (nasal congestion, purulent drainage, loss of smell, sinus pressure) despite treatment. 1 The failure to respond to appropriate medical therapy (antibiotics, nasal steroid, antihistamine) classifies this as difficult-to-treat rhinosinusitis—defined as persistent symptoms despite adequate intranasal corticosteroid treatment and up to two short courses of antibiotics or systemic corticosteroids. 1

Immediate Management Steps

1. Obtain CT Imaging of Paranasal Sinuses

• CT without contrast is the imaging modality of choice for evaluating chronic rhinosinusitis that has failed initial medical management. 1
• Multiplanar CT provides excellent anatomic bony detail and soft-tissue imaging to assess extent of disease, identify anatomic variants, and evaluate for complications. 1
• CT findings will guide decisions regarding continued medical therapy versus surgical intervention. 1
• MRI and plain radiographs have no role in CRS evaluation. 1

2. Optimize Intranasal Corticosteroid Therapy

• Intranasal corticosteroids remain the most effective monotherapy for nasal congestion and should be continued or optimized. 2
• Verify proper administration technique: patient should use opposite hand for each nostril (right hand for left nostril), aim spray laterally away from septum, keep head upright, and shake bottle before use. 1
• Poor technique is a common cause of treatment failure and increases risk of epistaxis. 1
• Consider switching to a different intranasal corticosteroid formulation if adherence or tolerability is an issue. 2

3. Discontinue Loratadine

• Antihistamines have no role in treating infectious rhinosinusitis in non-atopic patients and may worsen congestion by drying nasal mucosa. 1
• Loratadine should only be continued if there is clear evidence of significant allergic component (sneezing, watery rhinorrhea, itchy eyes). 1

4. Add Nasal Saline Irrigation

• Buffered hypertonic saline (3-5%) irrigation provides symptomatic relief, improves quality of life, and may decrease medication requirements. 1
• Saline irrigation has minimal risk of adverse effects and superior anti-inflammatory effects compared to isotonic solutions. 1
• This should be performed twice daily as adjunctive therapy. 1

Specialist Referral Indications

Refer to otolaryngology (ENT) if: 1

• Symptoms remain uncontrolled despite optimized intranasal corticosteroid therapy 1
• CT demonstrates significant disease requiring surgical consideration 1
• Patient has recurrent episodes requiring multiple antibiotic courses 1
• Any warning signs develop (see below) 1

Warning Signs Requiring Urgent Referral

Immediate ENT or emergency evaluation needed for: 1

• Periorbital edema or erythema 1
• Diplopia or ophthalmoplegia 1
• Reduced visual acuity 1
• Severe frontal headache or frontal swelling 1
• Neurological signs or reduced consciousness 1

Role of Additional Antibiotics

• Do not prescribe additional antibiotics at this time. The patient has already completed a course of amoxicillin-clavulanate (Augmentin), which is the preferred agent for acute bacterial rhinosinusitis. 1
• Repeated antibiotic courses without objective evidence of acute bacterial infection increase resistance and adverse effects without proven benefit. 1
• Culture-directed topical antibiotics may be considered later if CT shows evidence of chronic infection and cultures are obtained, but this is not first-line therapy. 1

Avoid Common Pitfalls

• Do not add oral decongestants (pseudoephedrine) as first-line therapy—these have cardiovascular side effects and limited evidence in CRS. 1
• Do not use topical decongestants (oxymetazoline) beyond 3-5 days due to risk of rhinitis medicamentosa. 1
• Do not order plain sinus radiographs—they are inaccurate and have been supplanted by CT when imaging is necessary. 1
• Do not assume this is allergic rhinitis requiring continued antihistamine therapy without specific allergic symptoms (itching, sneezing, watery discharge). 1, 3