What is the most appropriate next step for a patient with persistent postnasal drainage, nasal congestion, headache, facial pressure, occasional cough, and decreased sense of smell, despite previous antibiotic therapy and current use of loratadine and a nasal spray?

Management of Persistent Chronic Rhinosinusitis Despite Multiple Antibiotic Courses

This patient requires a CT scan of the sinuses and referral to an otolaryngologist, while simultaneously initiating intranasal corticosteroids and saline irrigation as definitive medical therapy—antibiotics should be discontinued immediately as they have failed twice and chronic rhinosinusitis is primarily an inflammatory, not infectious, condition. 1

Why This Patient Has Chronic Rhinosinusitis, Not Acute Bacterial Infection

This patient meets diagnostic criteria for chronic rhinosinusitis based on symptoms persisting beyond 8 weeks, including nasal congestion, postnasal drainage, facial pressure, decreased sense of smell, and cough 2. The failure of two separate antibiotic courses strongly indicates this is not a bacterial infection requiring antimicrobial therapy 1.

• Stop prescribing antibiotics: The American Academy of Otolaryngology states antibiotics should NOT be prescribed unless significant or persistent purulent nasal discharge is present on examination, as chronic sinusitis is primarily inflammatory rather than infectious 1
• The patient's mild inflammation of nasal turbinates without purulent discharge confirms this is not acute bacterial rhinosinusitis 2

Immediate Medical Management (Start Today)

First-Line Therapy: Intranasal Corticosteroids

Initiate fluticasone propionate nasal spray 200 mcg daily (two 50-mcg sprays in each nostril once daily) as the most effective first-line treatment for chronic rhinosinusitis 1, 3:

• Intranasal corticosteroids provide superior symptom relief by reducing inflammation and nasal congestion 1
• Maximum effect may take several days, but some improvement can occur within 12 hours 3
• After 4-7 days of response, may reduce to 100 mcg daily (one spray per nostril once daily) for maintenance 3
• Proper technique is critical: Look down by bending neck toward floor, use right hand for left nostril and left hand for right nostril, aim toward outer wall, do not sniff hard after application 1

Concurrent Saline Irrigation

Prescribe high-volume saline irrigation twice daily (morning and evening) using a squeeze bottle or neti pot 1, 4:

• Saline irrigation is highly effective as adjunctive therapy, improving mucous clearance, enhancing ciliary activity, and removing inflammatory mediators 1
• Use irrigation rather than spray—irrigation is more effective in expelling secretions 1
• Normal saline (isotonic) is better tolerated than hypertonic saline with fewer side effects 4

Discontinue Ineffective Medications

• Stop loratadine: Second-generation antihistamines like loratadine have been shown ineffective for chronic rhinosinusitis and post-viral rhinitis 2
• The European Position Paper on Rhinosinusitis found no additive effect of antihistamines over standard treatment in acute bacterial rhinosinusitis 2
• Discontinue the patient's current nasal spray (likely a topical decongestant based on lack of efficacy): If used for more than 3-5 days, topical decongestants cause rebound congestion (rhinitis medicamentosa) 1

Diagnostic Workup Required

CT Scan of Sinuses

Order coronal sinus CT with extra cuts through the ostiomeatal complex to clarify extent of disease and specific locations of obstruction 2:

• CT imaging is essential when symptoms persist despite medical therapy to provide objective documentation of inflammation 4
• Chronic rhinosinusitis requires abnormal findings on CT or MRI for definitive diagnosis 2
• CT will guide decisions about surgical intervention if medical management fails 2

Otolaryngology Referral

Refer to ENT specialist now rather than waiting for treatment failure, given 2, 1:

• Recurrent symptoms despite two courses of antibiotics indicate refractory disease 1
• Decreased sense of smell is a cardinal symptom suggesting possible nasal polyps, which require endoscopic evaluation 4
• The patient requires nasal endoscopy to evaluate for nasal polyps, purulent discharge, or anatomical abnormalities 4
• Radiographic evidence of ostiomeatal obstruction despite aggressive medical management benefits from surgical evaluation 2

Short-Term Adjunctive Therapy to Consider

Oral Corticosteroids (Optional Based on Severity)

If symptoms are severe and significantly impacting quality of life, consider prednisone 30-60 mg daily for 7-14 days while awaiting ENT evaluation 2:

• Short courses of systemic corticosteroids show significant reduction in facial pain and nasal obstruction at days 3-7 compared to placebo 2, 5
• Particularly beneficial if nasal polyps are suspected based on decreased sense of smell 4
• However, benefits are short-term only (no data beyond 30 days), and this should not delay definitive management 6

What NOT to Do (Common Pitfalls)

• Do not prescribe another antibiotic: Two failed courses indicate this is not bacterial infection 1
• Do not continue loratadine: It is ineffective for chronic rhinosinusitis 2
• Do not use topical decongestants beyond 3-5 days: Risk of rebound congestion 1
• Do not discontinue intranasal corticosteroids when symptoms improve: Continue as maintenance therapy 1
• Do not use saline spray instead of irrigation: Irrigation is more effective 1

Follow-Up Timeline

• Reassess symptoms after 4 weeks of intranasal corticosteroids and saline irrigation 4
• If improvement occurs, continue intranasal corticosteroids as maintenance therapy 4
• If minimal or no improvement after 4 weeks, the CT scan and ENT evaluation will guide next steps including possible functional endoscopic sinus surgery 2
• Every effort should be made to maximize medical treatment before proceeding with surgical intervention 2