What is the recommended management for rhinosinusitis?

Management of Rhinosinusitis

Acute Rhinosinusitis (ARS)

For uncomplicated acute bacterial rhinosinusitis (ABRS), watchful waiting without antibiotics is the preferred initial approach, reserving antibiotics only for patients with symptoms persisting ≥10 days, worsening symptoms within 10 days after initial improvement, or severe unilateral facial pain. 1, 2

Diagnosis of ABRS

• Distinguish ABRS from viral upper respiratory infections by identifying symptoms that persist without improvement for ≥10 days beyond onset of upper respiratory symptoms, or symptoms that worsen within 10 days after initial improvement (strong recommendation). 1, 2

• Do not rely on purulent nasal discharge color alone to diagnose bacterial infection—mucus color reflects neutrophils, not bacteria. 2

• Reserve sinus radiography for complicated cases only, not for routine diagnosis. 3

Treatment Approach for ABRS

Symptomatic management is first-line for most patients:

• Intranasal corticosteroids provide effective symptom relief for nasal congestion and inflammation. 2, 4, 5

• Saline nasal irrigation helps clear secretions and reduce symptoms. 2, 4

• Analgesics for pain management as needed. 2, 5

If antibiotics are prescribed (for patients meeting ABRS criteria):

• Amoxicillin with or without clavulanate is first-line therapy for 5-10 days. 1, 2

• For penicillin-allergic patients, use doxycycline or a respiratory fluoroquinolone. 2

• Reassess patients who worsen or fail to improve within 7 days to confirm ABRS diagnosis, exclude complications, and consider alternative diagnoses. 1

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Chronic Rhinosinusitis (CRS)

Intranasal corticosteroids combined with saline nasal irrigation form the foundation of CRS management, with antibiotics reserved only for acute exacerbations showing purulent discharge on examination. 1, 2

Diagnosis of CRS

• Confirm CRS diagnosis with objective documentation of sinonasal inflammation using anterior rhinoscopy, nasal endoscopy, or computed tomography (strong recommendation). 1, 2

• CRS is defined as symptoms persisting >12 weeks. 2, 6

• Distinguish CRS from recurrent ARS (multiple discrete episodes with complete resolution between episodes). 1

• Determine presence or absence of nasal polyps, as this modifies treatment approach. 1

Medical Management of CRS

First-line therapy:

• Intranasal corticosteroids are the most effective single agent for controlling symptoms. 1, 2, 7

• Saline nasal irrigation as monotherapy or adjunctive treatment. 1, 2, 7

For moderate-to-severe symptoms or CRS with nasal polyps:

• Short courses of systemic corticosteroids provide additional benefit, particularly in CRS with polyps. 2, 4, 5

• Long-term macrolide therapy (≥3 weeks) may be considered for anti-inflammatory effects in select patients. 1

Antibiotics in CRS:

• Do not prescribe antibiotics if significant or persistent purulent nasal discharge is absent on examination (strong recommendation). 1

• Reserve antibiotics for acute exacerbations with documented purulent discharge. 2, 4

• Antifungal therapy (topical or systemic) is not recommended for CRS. 2

Assessment for Modifying Conditions

• Evaluate for asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia, as these conditions modify CRS management. 1, 2

• Consider testing for allergy and immune function in patients with CRS or recurrent ARS. 1, 2

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Surgical Management of CRS

Offer sinus surgery when anticipated benefits exceed nonsurgical management alone, particularly for patients with nasal polyps, polyps with bony erosion, eosinophilic mucin, or fungal balls. 1

Candidacy Assessment

• Verify CRS diagnosis meets established diagnostic criteria before considering surgery. 1

• Assess candidacy based on symptoms, disease characteristics, quality of life, and prior medical or surgical therapy. 1

• Do not require a predefined, one-size-fits-all regimen or duration of medical therapy as a prerequisite to surgery. 1

• Identify patients most likely to benefit from surgery: those with CRS with polyps, polyps with bony erosion, eosinophilic mucin, or fungal balls are least likely to benefit from continued medical therapy alone. 1

Preoperative Planning

• Obtain CT scan with fine-cut protocol for surgical planning in surgical candidates. 1

• Do not plan surgical extent solely based on arbitrary criteria for mucosal thickening or sinus opacification on CT. 1

• Counsel patients about realistic expectations, including potential for chronicity or relapse and likelihood of long-term medical management post-surgery. 1

Surgical Technique

• For disease involving polyps, osteitis, bony erosion, or fungal disease, perform surgery that includes full exposure of sinus cavity and removal of diseased tissue, not just balloon or manual ostial dilation. 1

Postoperative Management

• Follow up between 3-12 months after surgery to assess outcomes through history (symptom relief, quality of life, complications) and nasal endoscopy. 1

• Educate patients preoperatively about anticipated postoperative care including pain control, debridement, medical management, activity restrictions, and potential for recurrent disease. 1

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Common Pitfalls to Avoid

• Failing to confirm CRS diagnosis with objective evidence of inflammation leads to misdiagnosis and inappropriate treatment. 2

• Not assessing for underlying conditions (asthma, cystic fibrosis, immunodeficiency) that modify CRS management. 2

• Prescribing antibiotics for CRS without documented purulent discharge on examination. 1

• Using topical decongestants beyond 3-5 days risks rhinitis medicamentosa. 7, 8

• Relying on mucus color alone to determine need for antibiotics. 2