What is the best approach to manage a patient with recurrent allergic rhinosinusitis?

Management of Recurrent Allergic Rhinosinusitis

Assess all patients with recurrent allergic rhinosinusitis for modifying factors including asthma, immunodeficiency, and allergic triggers, then initiate treatment with intranasal corticosteroids, saline irrigation, and address underlying allergies through testing and immunotherapy. 1

Initial Diagnostic Evaluation

Confirm the Diagnosis

• Document inflammation through nasal endoscopy or CT imaging showing mucosal edema, purulent drainage in the middle meatus, or radiographic evidence of sinus disease 1
• Distinguish recurrent acute rhinosinusitis (2-4 isolated episodes per year with complete symptom resolution between episodes) from chronic rhinosinusitis (symptoms ≥12 weeks) 1

Identify Modifying Factors

Clinicians must systematically assess for chronic conditions that alter management: 1

• Asthma: Present in a significant proportion of patients; treating rhinosinusitis may improve asthma control and vice versa 1
• Immunodeficiency: 10% have common variable immunodeficiency and 6% have selective IgA deficiency in refractory cases 1, 2
• Cystic fibrosis: Consider in younger patients with persistent disease 1
• Ciliary dyskinesia: Suspect with history of chronic otitis media and bronchiectasis 1

Allergy and Immune Testing

Obtain allergy testing in all patients with recurrent disease, as 60-84% have significant allergic sensitivities, predominantly to perennial allergens (house dust mites, pet dander, cockroaches, fungi). 1, 3

• Skin prick testing is the preferred method for detecting IgE-mediated sensitization 1, 4
• Test for both perennial and seasonal allergens, with emphasis on perennial triggers given their predominance 4, 3

For patients with recurrent infections despite aggressive therapy, obtain immunologic workup: 1, 2

• Quantitative immunoglobulins (IgG, IgA, IgM) 1, 2
• Pre- and post-immunization antibody titers to tetanus toxoid and pneumococcal polysaccharide vaccines (measure 4-6 weeks after immunization) 1, 2
• Consider HIV testing, as 30-68% of HIV-infected patients develop chronic rhinosinusitis 2

Imaging

• Obtain coronal CT of sinuses when symptoms persist despite optimal medical treatment or to identify structural abnormalities before considering surgery 1, 4
• CT helps localize obstructions in the ostiomeatal complex and assess disease extent 4

Confirm Presence or Absence of Nasal Polyps

Examine for nasal polyps through anterior rhinoscopy or nasal endoscopy, as their presence modifies treatment strategy. 1

• Polyps indicate need for topical or systemic corticosteroid therapy 1
• Polyps warrant evaluation for conditions like aspirin-exacerbated respiratory disease, allergic fungal rhinosinusitis, or cystic fibrosis 1

Medical Management

First-Line Therapy

Intranasal Corticosteroids (Mandatory) 4, 5

• Fluticasone propionate 200 mcg daily (2 sprays per nostril once daily) for adults 6
• Alternative: 100 mcg twice daily (1 spray per nostril twice daily) 6
• For children ≥4 years: start with 100 mcg daily (1 spray per nostril); increase to 200 mcg daily only if inadequate response 6
• Maximum benefit may take several days; continue regularly for optimal effect 6

Saline Nasal Irrigation (Mandatory) 4, 5

• Helps eliminate secretions and reduce inflammation 4, 5
• Use regularly as adjunctive therapy 5

Antibiotic Therapy for Acute Bacterial Exacerbations

When bacterial infection is suspected (persistent symptoms ≥10 days, worsening after initial improvement, or severe onset): 4, 5

• First-line: Amoxicillin-clavulanate high-dose (1.5-4 g/day in divided doses) for 10-14 days 4, 5
• Penicillin allergy: Cefuroxime, cefpodoxime, or cefdinir 4
• For chronic disease requiring antibiotics, extend treatment to 4 weeks or more 7

Allergy Management

For patients with confirmed allergies: 4

• Environmental control measures targeting identified allergens 5
• Antihistamines for symptomatic relief 4
• Allergen immunotherapy: Strongly consider as it addresses underlying pathophysiology and may prevent recurrence 4, 8

Additional Adjunctive Measures

• Adequate hydration 5
• Analgesics for facial pain 5
• Warm compresses over sinuses 5
• Sleep with head elevated 5

Specialty Referral Indications

Refer to Allergist-Immunologist

• Recurrent or chronic rhinosinusitis for comprehensive allergy evaluation 4, 5
• Suspected or confirmed immunodeficiency requiring immunoglobulin replacement therapy 4, 2
• Initiation of allergen immunotherapy 4, 5

Refer to Otolaryngologist

• Nasal polyps unresponsive to medical therapy 4, 5
• Structural abnormalities (significant septal deviation compressing middle turbinate, concha bullosa obstructing ostiomeatal complex) 4
• Failure to respond to maximal medical therapy after 4-7 weeks 4
• Suspected allergic fungal rhinosinusitis (requires surgical debridement) 9, 8

Surgical Considerations

Functional endoscopic sinus surgery is indicated for: 4, 5

• Obstructive nasal polyps persisting despite corticosteroid therapy 4
• Anatomic abnormalities blocking sinus drainage pathways 4
• Recurrent acute rhinosinusitis despite optimal medical management 4
• Allergic fungal rhinosinusitis (surgery is mainstay, followed by long-term medical management) 9, 8

Long-Term Management Strategy

After initial control is achieved: 1, 4

• Continue intranasal corticosteroids indefinitely to prevent recurrence 4
• Maintain saline irrigation 4
• Monitor for disease recurrence with regular follow-up 9, 8
• For allergic fungal rhinosinusitis, follow total serum IgE levels as prognostic marker for recurrence 8
• Coordinate care between otolaryngology and allergy/immunology for optimal outcomes 8

Common Pitfalls to Avoid

• Do not rely on plain radiography—it has no role in chronic rhinosinusitis evaluation; use CT when imaging is needed 1
• Do not delay allergy testing until after surgery; identify and treat allergies before considering surgical intervention, as many patients respond to medical management when allergies are addressed 1
• Do not use antifungal agents (oral or topical) for allergic fungal rhinosinusitis—they have no proven benefit 9
• Do not overlook immunodeficiency in patients with recurrent purulent infections or concurrent bronchiectasis/pneumonia 1, 2