What is the best course of treatment for a 29-year-old patient with persistent nasal pain, difficulty breathing, and headaches, who has been diagnosed with chronic allergic rhinitis unresponsive to nasal corticosteroids (e.g. mometasone) and antihistamines (e.g. loratadine, fexofenadine), and is concerned about chronic sinusitis?

Management of Chronic Rhinosinusitis with Ethmoiditis Unresponsive to Initial Medical Therapy

This patient requires CT imaging of the sinuses and ENT referral for surgical evaluation, as they have objective evidence of ethmoiditis with chronic rhinosinusitis unresponsive to adequate medical therapy (nasal corticosteroids and antihistamines), meeting criteria for surgical candidacy. 1

Diagnostic Confirmation

This patient meets established diagnostic criteria for chronic rhinosinusitis (CRS):

• Duration >12 weeks with persistent bilateral nasal pain, difficulty breathing, and headaches 1
• Cardinal symptoms present: nasal obstruction, facial pain/pressure, and mucopurulent drainage 1
• Objective findings on examination: bilateral turbinate enlargement and ethmoiditis 1

The presence of ethmoiditis on examination is particularly significant, as this represents objective inflammation of the paranasal sinuses and confirms the diagnosis beyond symptom assessment alone 1.

Why Current Medical Therapy Has Failed

The patient has already trialed:

• Nasal corticosteroids (mometasone or similar)
• Oral antihistamines (loratadine, fexofenadine)
• Duration of several weeks to months

This represents adequate medical therapy failure for CRS without nasal polyps 1. The 2025 surgical management guidelines explicitly state that surgeons should not require a "one-size-fits-all regimen or duration of medical therapy as a prerequisite to sinus surgery" 1. The patient has tried first-line therapies without improvement, and the presence of ethmoiditis with severe symptoms (including vomiting episodes) indicates more aggressive intervention is warranted.

Immediate Next Steps

1. CT Imaging of Sinuses

CT scanning is strongly recommended before surgical referral to:

• Confirm extent of sinus disease 1
• Evaluate ethmoid involvement specifically 1
• Rule out anatomic abnormalities or complications 1
• Guide surgical planning if indicated 1

2. Consider Short-Term Interventions While Awaiting ENT Evaluation

Oral corticosteroids (e.g., prednisone 20-40 mg daily for 5-7 days) may provide temporary symptom relief, particularly given the severe recent episode with vomiting 1, 2. This is appropriate for moderate-to-severe symptoms while awaiting definitive management.

Saline irrigation (not just sprays) should be initiated if not already tried, as this has level Ib evidence for benefit in CRS 1.

Avoid antibiotics unless there is significant purulent discharge on examination, which was not documented here 1, 3. The American Academy of Otolaryngology guidelines specifically state antibiotics should not be prescribed for CRS without significant purulent nasal discharge 1. The role of antibiotics in chronic sinusitis is controversial and should be reserved for acute bacterial exacerbations only 3.

ENT Referral and Surgical Candidacy

This patient meets clear criteria for surgical evaluation 1:

• Symptoms significantly impacting quality of life (affecting work concentration, severe episodes with vomiting)
• Objective evidence of disease (ethmoiditis on examination)
• Failed appropriate medical therapy (nasal corticosteroids and antihistamines)
• Duration >12 weeks

The 2025 guidelines state surgeons should "offer sinus surgery to an adult with CRS when the anticipated benefits exceed that of nonsurgical management alone" 1. This patient clearly fits these criteria.

Functional endoscopic sinus surgery (FESS) targeting the ethmoid cells and ostiomeatal complex is the standard surgical approach 4. The surgery aims to restore sinus drainage and ventilation while preserving normal mucosa 4.

Additional Workup to Consider

Before or concurrent with ENT referral, consider:

Allergy testing (skin testing or specific IgE) to identify specific allergen triggers 1, 5. While the patient has been diagnosed with "chronic allergic rhinitis," specific allergen identification may guide avoidance strategies and determine if allergen immunotherapy is appropriate 1.

Rule out underlying conditions if surgery fails or disease is particularly severe 3, 6:

• Immunodeficiency screening (quantitative immunoglobulins: IgG, IgA, IgM) 3, 6
• Consider aspirin-exacerbated respiratory disease if there is history of asthma or aspirin sensitivity 1, 6
• Cystic fibrosis screening if other suggestive features present 6

Common Pitfalls to Avoid

Do not continue indefinite medical therapy without objective improvement 1. This patient has already failed appropriate medical management and continuing the same approach will only delay definitive treatment.

Do not prescribe antibiotics without purulent discharge 1, 3. Chronic sinusitis is not primarily a bacterial infection requiring antibiotic therapy 3.

Do not use topical decongestants (oxymetazoline) beyond 3-5 days, as this can cause rhinitis medicamentosa 3.

Do not delay CT imaging before ENT referral, as this is essential for surgical planning 1.

Patient Counseling

The patient should understand 1:

• CRS is a chronic condition that may require long-term management even after surgery
• Surgery aims to improve symptoms and quality of life, not necessarily "cure" the condition
• Postoperative medical therapy (nasal corticosteroids, saline irrigation) will likely be needed long-term
• Success rates for FESS are generally good, with most patients experiencing significant symptom improvement 4