What are the current treatment guidelines for chronic sinusitis?

Treatment Guidelines for Chronic Rhinosinusitis in Adults

The most current evidence-based approach to chronic rhinosinusitis (CRS) begins with confirming the diagnosis through objective documentation of sinonasal inflammation via nasal endoscopy, anterior rhinoscopy, or CT imaging, followed by first-line therapy with daily high-volume saline irrigation and intranasal corticosteroids, with antibiotics reserved only for patients demonstrating significant purulent discharge. 1, 2

Diagnostic Confirmation Required Before Treatment

Before initiating any therapy, you must verify the diagnosis meets established criteria 1:

• At least 2 of 4 cardinal symptoms present for ≥12 consecutive weeks: facial pain/pressure, hyposmia/anosmia, nasal drainage, and nasal obstruction 3
• Objective evidence of sinonasal inflammation documented by nasal endoscopy, anterior rhinoscopy, or CT scan 1, 2
• Assess for nasal polyps in every patient, as their presence fundamentally changes treatment approach and prognosis 1, 2

Identify Disease-Modifying Comorbidities

Evaluate for conditions that alter management strategy 1, 2:

• Asthma (present in many CRS patients; treating CRS may improve asthma control) 1, 2
• Aspirin-exacerbated respiratory disease (AERD) (requires consideration of aspirin desensitization) 1
• Cystic fibrosis, immunodeficiency, or ciliary dyskinesia (require specialized management) 1, 2

First-Line Medical Therapy (Grade A Evidence)

Saline Nasal Irrigation

• Use high-volume saline irrigation daily as it improves symptom scores with a standardized mean difference of 1.42 (95% CI, 1.01 to 1.84) compared to no treatment 2, 4
• This enhances mucociliary clearance and improves sinus drainage 3, 5

Intranasal Corticosteroids

• Prescribe intranasal corticosteroids for all patients unless contraindicated 2, 4
• Evidence shows improvement in overall symptom scores (SMD, -0.46 [95% CI, -0.65 to -0.27]) 2, 4
• Corticosteroid drops and nasal irrigation are more effective than spray formulations for reducing polyp size and improving symptoms 6
• Mometasone furoate or budesonide are appropriate options 6, 5

Management Based on Nasal Polyp Status

For CRS WITH Nasal Polyps (CRSwNP)

Short-course oral corticosteroids:

• Consider oral prednisolone 25-60 mg daily for 7-14 days for moderate to severe disease 6
• Alternative: prednisolone 1 mg/kg daily for 2 days, then taper until day 10 6
• Important caveat: Benefit is transient—symptom improvement significant at 2-4 weeks but disappears by 10-12 weeks 6
• Polyp reduction persists slightly longer but also diminishes over time 6, 4

Transition immediately to topical intranasal corticosteroids for sustained control after oral steroid course 6

Additional options:

• Leukotriene antagonists improve nasal symptoms compared with placebo in patients with nasal polyps (P < .01) 4
• Doxycycline 3-week course reduces polyp size for up to 3 months (P < .001) 4
• Biologic therapy should be considered for patients with CRSwNP, particularly those with comorbid asthma or AERD 1

For CRS WITHOUT Nasal Polyps (CRSsNP)

• Topical intranasal corticosteroids as first-line therapy 2, 6
• Saline nasal irrigation 2
• Macrolide antibiotic for 3 months may be considered, as it was associated with improved quality of life at 24 weeks compared with placebo (SMD, -0.43 [95% CI, -0.82 to -0.05]) 4

What NOT to Do (Critical Safety Points)

Antibiotics

Do NOT prescribe antibacterial therapy unless significant or persistent purulent nasal discharge (anterior, posterior, or both) is present on examination 1. The strongest 2025 guideline evidence emphasizes that:

• CRS is primarily an inflammatory condition, not an infectious problem 1
• Antibiotics have limited efficacy and high potential for side effects in CRS 1
• The role of bacteria in perpetuating CRS inflammation is uncertain 1
• Exception: Antibiotics may be appropriate for superimposed acute bacterial infection with purulent discharge 3, 5

Other Therapies to Avoid

• Do NOT prescribe topical or systemic antifungal therapy (Grade A recommendation against use based on lack of efficacy, significant cost, and adverse effects) 2
• Do NOT use antihistamines unless the patient has documented allergic rhinitis as a comorbid condition 2
• Do NOT require a predefined, one-size-fits-all regimen of medical therapy as a prerequisite to surgery 1

When to Consider Surgical Referral

Refer for surgical evaluation when 1, 2:

• Symptoms persist after 3 months of appropriate medical therapy 2
• CT imaging shows extensive disease 2
• Patient has specific CRS subtypes that benefit most from surgery and are least likely to benefit from continued medical therapy alone 1:
  • CRS with nasal polyps showing bony erosion 1, 2
  • Eosinophilic mucin 1, 2
  • Fungal balls (surgery is first-line treatment to remove fungal debris and open affected sinus) 1

Before surgery, obtain fine-cut CT scan if not already available for surgical planning 1

Preoperative and Postoperative Management

Preoperative

• Oral prednisolone 30-60 mg daily for 5-10 days reduces blood loss, improves surgical field quality, and decreases operation time 6
• Topical mometasone 200 μg twice daily for 4 weeks provides similar benefits 6

Postoperative

• Continue topical intranasal steroids postoperatively 6
• Postoperative oral steroids show no significant benefit 6
• Topical corticosteroids reduce polyp recurrence after surgery (relative risk, 0.59 [95% CI, 0.45 to 0.79]) 4

Patient Counseling Requirements

Before any surgical intervention, counsel patients to establish realistic expectations 1:

• Potential for chronicity or relapse 1
• Likelihood of long-term medical management even after surgery 1
• Anticipated postoperative care including pain control, debridement, medical management, activity restrictions, return to work, and potential for revision surgery 1

Follow-Up Monitoring

Reassess patients between 3 and 12 months after initiating therapy or after surgery, documenting 2:

• Symptom relief and quality of life changes
• Nasal endoscopy findings
• Adherence to therapy
• Complications or adverse effects

Common Pitfalls to Avoid

• Overuse of antibiotics for presumed bacterial sinusitis when inflammation is the primary problem 1, 7
• Prolonged use of topical decongestants (>3-5 days) leading to rhinitis medicamentosa 7
• Using spray formulations when drops or irrigation would be more effective for polyp disease 6
• Failing to assess for asthma as a comorbid condition that may improve with CRS treatment 1, 2
• Not transitioning to long-term topical therapy after short-course oral steroids, leading to symptom recurrence 6