What is the recommended treatment approach for a patient with Rhinosinusitis?

Treatment of Rhinosinusitis

Initial Management: Symptomatic Treatment First

For most patients with acute rhinosinusitis, start with symptomatic treatment using saline nasal irrigation, intranasal corticosteroids, and analgesics—antibiotics are reserved only for those meeting specific criteria for acute bacterial rhinosinusitis (ABRS). 1, 2

The majority of acute rhinosinusitis cases are viral and resolve spontaneously within 10-14 days. 1, 3 Even in bacterial cases, the benefit of antibiotics is modest, with most patients improving without them. 1

First-Line Symptomatic Therapy (All Patients)

• Saline nasal irrigation: Relieves congestion and facilitates mucus clearance with no serious adverse effects. 1, 2
• Intranasal corticosteroids: Provide modest but clinically meaningful benefit, increasing symptom resolution from 66% to 73% at 15-21 days (number needed to treat = 14). 2
• Analgesics/antipyretics: Use acetaminophen or ibuprofen for pain relief and fever control. 1, 2
• Oral decongestants: May provide additional relief but use cautiously in patients with hypertension, cardiac arrhythmia, cerebrovascular disease, glaucoma, or hyperthyroidism. 1, 2
• Topical nasal decongestants: Limit to 3-5 days maximum to avoid rebound congestion (rhinitis medicamentosa). 1, 2

When to Consider Antibiotics: Diagnostic Criteria for ABRS

Only prescribe antibiotics when patients meet one of these three specific criteria: 1, 4, 2

1. Persistent symptoms ≥10 days without improvement: Nasal discharge, nasal obstruction, facial pain/pressure, or reduced sense of smell lasting at least 10 days with no sign of clinical improvement. 1, 4

2. Severe symptoms for ≥3 consecutive days: High fever ≥39°C (102.2°F) with purulent nasal discharge AND facial pain/pressure. 1, 4

3. "Double sickening" pattern: Initial improvement from a viral cold followed by new fever or substantial worsening of nasal discharge or symptoms within the first 10 days. 1, 4

Critical Pitfall to Avoid

Do not prescribe antibiotics based on colored nasal discharge alone. 4, 2 Purulent discharge reflects neutrophil presence from inflammation, not bacterial infection, and occurs in both viral and bacterial rhinosinusitis. 4 Fewer than 1 in 15 patients with colored mucus actually have bacterial infection. 4

Antibiotic Selection When Indicated

First-Line Antibiotics

Amoxicillin-clavulanate is the preferred first-line antibiotic (changed from amoxicillin alone in prior guidelines due to increasing resistance). 1, 2

• Dosing: Amoxicillin 875 mg with clavulanate 125 mg twice daily for 5-7 days, or high-dose amoxicillin-clavulanate (2000 mg/125 mg) twice daily for patients with recent antibiotic use or moderate disease. 2, 5

Alternative Antibiotics (Penicillin Allergy)

• Doxycycline or trimethoprim-sulfamethoxazole for mild disease with beta-lactam allergy. 1, 5
• Respiratory fluoroquinolones (levofloxacin, moxifloxacin) for moderate disease with beta-lactam hypersensitivity. 2, 5

Second-Line Antibiotics

Consider if no response within 72 hours, recent antibiotic use (past 6 weeks), or moderate disease: 5

• High-dose amoxicillin-clavulanate
• Respiratory fluoroquinolones (levofloxacin, moxifloxacin)
• Cephalosporins (cefuroxime, cefpodoxime, cefprozil, cefdinir) 2, 5

Target pathogens: Streptococcus pneumoniae and Haemophilus influenzae are the most common bacterial causes. 1

Watchful Waiting Strategy

For patients meeting ABRS criteria but with mild-to-moderate symptoms, offer watchful waiting for an additional 3 days before starting antibiotics. 1, 4 This approach is now extended to all patients with uncomplicated ABRS regardless of severity (updated from prior guidelines that limited this to "mild" illness only). 1

During watchful waiting, continue symptomatic treatment and educate patients about worsening signs requiring immediate reevaluation. 1, 4

Chronic Rhinosinusitis (CRS) Management

For symptoms lasting >12 weeks with objective evidence of sinonasal inflammation, diagnose as chronic rhinosinusitis. 1

CRS Treatment Approach

• Saline nasal irrigation and intranasal corticosteroids are the cornerstones of CRS management. 1, 6
• Assess for modifying conditions: Asthma, cystic fibrosis, immunocompromised state, ciliary dyskinesia, and confirm presence or absence of nasal polyps. 1
• Systemic corticosteroids (oral prednisolone) may be used for acute exacerbations. 6
• Prolonged antibiotic courses (3-6 weeks) with amoxicillin-clavulanate, ciprofloxacin, clarithromycin, or trimethoprim-sulfamethoxazole may be considered for underlying bacterial infection. 6
• Do not use topical or systemic antifungal agents for routine CRS treatment. 1

When to Refer to Otolaryngology

Refer if symptoms persist after 21-28 days of appropriate antibiotic treatment, if there are suspected complications, or if maximal medical therapy fails. 1, 2, 3

Warning Signs Requiring Immediate Evaluation

Do not ignore these signs of potential complications: 4, 2

• Periorbital edema or erythema
• Diplopia or vision changes
• Severe headache or altered mental status
• Focal neurologic deficits
• Signs of meningitis

These indicate possible orbital, intracranial, or bony involvement requiring urgent imaging and specialist consultation. 3

Common Clinical Pitfalls

• Prescribing antibiotics for symptoms <7 days: Patients are unlikely to have bacterial infection. 1, 4
• Using imaging routinely: Sinus radiography and CT are not recommended for uncomplicated rhinosinusitis due to high false-positive rates in viral cases. 1
• Ignoring antibiotic resistance risk factors: Consider recent antibiotic use, daycare contact, or local resistance patterns when selecting antibiotics. 1
• Failing to educate patients: Explain the rationale for symptomatic treatment versus antibiotics and provide clear instructions on when to return for worsening symptoms. 1, 4