What are the guidelines for managing sinusitis?

Management of Sinusitis in Adults

For acute bacterial rhinosinusitis (ABRS), watchful waiting without antibiotics is appropriate initial management for all patients with uncomplicated disease, regardless of severity; if antibiotics are prescribed, use amoxicillin with or without clavulanate for 5-10 days. 1

Diagnostic Classification

Acute Rhinosinusitis (ARS)

• Duration: Less than 4 weeks 1
• Distinguish bacterial from viral: ABRS is diagnosed when symptoms persist without improvement for ≥10 days beyond onset of upper respiratory symptoms, OR when symptoms worsen within 10 days after initial improvement (the "double worsening" pattern) 2
• Critical distinction: Most acute sinusitis is viral and self-limited, lasting 7-10 days; bacterial infection becomes more likely beyond 7-10 days 3, 4
• Strong recommendation: Clinicians must distinguish presumed ABRS from viral upper respiratory infections and noninfectious conditions 1

Chronic Rhinosinusitis (CRS)

• Duration: More than 12 weeks with or without acute exacerbations 1
• Strong recommendation: Confirm clinical diagnosis with objective documentation of sinonasal inflammation using anterior rhinoscopy, nasal endoscopy, or computed tomography 1
• Common pitfall: Failure to confirm CRS with objective evidence leads to misdiagnosis and inappropriate treatment 2

Management of Acute Bacterial Rhinosinusitis

Initial Treatment Decision

• Watchful waiting (without antibiotics) is now extended to ALL patients with uncomplicated ABRS regardless of severity, not just those with mild disease 1
• This represents a major update from prior guidelines that restricted watchful waiting to mild cases only 1

Antibiotic Therapy (If Prescribed)

• First-line: Amoxicillin with or without clavulanate for 5-10 days 1
• Note the guideline changed from amoxicillin alone to amoxicillin with or without clavulanate 1
• Penicillin allergy: Doxycycline or respiratory fluoroquinolone (e.g., levofloxacin) 2, 3

Reassessment Protocol

• Mandatory reassessment at 7 days: If patient worsens or fails to improve with initial management, reassess to confirm ABRS, exclude other causes, and detect complications 1
• Failure to respond after 72 hours should prompt either switching antibiotics or reevaluation 1

Symptomatic Management for Viral or Bacterial ARS

• Saline nasal irrigation to cleanse passages and improve mucociliary clearance 2, 3
• Intranasal corticosteroids to reduce inflammation 2, 3
• Analgesics for pain or fever 2, 3
• Decongestants may provide relief but evidence is limited; avoid topical decongestants beyond 3-5 days to prevent rhinitis medicamentosa 3

Management of Chronic Rhinosinusitis

First-Line Medical Therapy

• Saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief 1
• This is the cornerstone of CRS management 2
• For patients with recurrent disease, continue nasal washing and topical corticosteroids for extended periods or permanently 5

Additional Medical Options

• Short courses of systemic corticosteroids may be beneficial, particularly for CRS with nasal polyps 2
• Antibiotics should be reserved for acute exacerbations with evidence of bacterial infection 2
• Recommendation against: Do NOT use topical or systemic antifungal therapy for CRS 1, 2

Assess for Nasal Polyps

• Confirm presence or absence of nasal polyps as this modifies management 1
• Polyps are a key modifying factor in CRS treatment decisions 1

Assessment for Modifying Conditions

Mandatory Screening for CRS or Recurrent ARS

Assess for multiple chronic conditions that modify management: 1

• Asthma (newly added as modifying condition; sinusitis can trigger asthma and vice versa) 1, 6, 7
• Cystic fibrosis 1
• Immunocompromised state 1
• Ciliary dyskinesia 1

Optional Testing

• Testing for allergy and immune function may be obtained when evaluating CRS or recurrent ARS 2
• Consider referral for nasal endoscopy in recurrent or chronic cases to confirm diagnosis and exclude other causes 3

Critical Pitfalls to Avoid

• Do NOT rely on mucus color to determine need for antibiotics; color relates to neutrophils, not bacteria 2
• Overuse of antibiotics for presumed bacterial sinusitis when symptoms are actually viral 3
• Prolonged topical decongestants (>3-5 days) cause rhinitis medicamentosa 3
• Failure to distinguish between viral, bacterial, and chronic sinusitis leads to inappropriate treatment 3
• Not assessing for underlying conditions that modify CRS management 2
• Failure to confirm CRS diagnosis with objective evidence of inflammation 2

Imaging Considerations

• Uncomplicated sinusitis does NOT require imaging 8
• Plain radiography has limited role; air-fluid levels and complete opacification are specific but only seen in 60% of cases 8
• CT imaging is reserved for difficult cases or to define anatomy prior to sinus surgery 8
• MRI is only used to differentiate soft-tissue structures in suspected fungal infection or neoplasm 8