What is the recommended treatment approach for a patient with Rhinosinusitis, considering potential allergies and treatment failures?

Treatment Approach for Rhinosinusitis

For acute rhinosinusitis, start with intranasal corticosteroids (fluticasone 200 mcg daily) plus nasal saline irrigation, reserving antibiotics only for confirmed bacterial infection meeting specific criteria: persistent symptoms ≥10 days without improvement, severe symptoms (fever >39°C with purulent discharge and facial pain for ≥3 consecutive days), or "double sickening" pattern. 1

Distinguishing Viral from Bacterial Rhinosinusitis

The critical first step is determining whether antibiotics are indicated, as fewer than 1 in 15 patients develop true bacterial sinusitis during or after a common cold 1:

Criteria for Acute Bacterial Rhinosinusitis (ABRS)

Prescribe antibiotics ONLY when one of these three patterns is present 1:

• Persistent symptoms: Nasal discharge or daytime cough lasting ≥10 days without improvement 1
• Severe symptoms: High fever (≥39°C) for ≥3 consecutive days with thick, colored nasal discharge and facial pain/pressure 1
• "Double sickening": Initial improvement from viral cold followed by new fever (≥38°C) or substantial worsening of nasal discharge or cough 1

Critical Pitfall to Avoid

Purulent or colored nasal discharge alone does NOT indicate bacterial infection and should never be used as the sole criterion for prescribing antibiotics 1. The yellow-green color reflects neutrophil presence from inflammatory cells that accumulate during both viral AND bacterial infections 1. Purulent discharge increases specificity for bacterial infection only when combined with other cardinal symptoms (nasal obstruction or facial pain/pressure) and appropriate timing criteria 1.

First-Line Treatment for Acute Rhinosinusitis (Viral or <10 Days)

Primary Therapy

• Intranasal corticosteroids: Fluticasone propionate 200 mcg daily (two 50-mcg sprays per nostril once daily) 2. Symptom improvement begins within 12 hours, with maximum effect in several days 2. Direct sprays away from the nasal septum to prevent mucosal erosions and potential septal perforations 3

• Nasal saline irrigation: Use as sole or adjunctive treatment for chronic rhinorrhea and to maintain mucosal health 4, 3, 5

Adjunctive Symptomatic Treatment

• Analgesics: For facial pain/pressure 6
• Short-term decongestants: Topical oxymetazoline for maximum 3 days only to avoid rhinitis medicamentosa 3, 7. Oral decongestants may be used with similar precautions 4
• Intranasal antihistamine (azelastine): If allergic component suspected, can be added to intranasal corticosteroid for greater efficacy 3

What NOT to Use

• Oral antihistamines: Not effective for nonallergic rhinitis and provide no additional benefit when added to intranasal corticosteroids 4, 3
• Antibiotics: Ineffective for viral rhinosinusitis, expose patients to unnecessary adverse effects (RR 1.28,95% CI 1.06-1.54), and contribute to antimicrobial resistance that persists up to 12 months 1

Treatment for Confirmed Acute Bacterial Rhinosinusitis

When ABRS criteria are met 1, 7, 6:

Antibiotic Selection

First-line: Amoxicillin 500 mg three times daily for 10-14 days 7

Second-line (use if moderate disease, recent antibiotic use within 6 weeks, or no response within 72 hours): 7

• Amoxicillin-clavulanate potassium (best coverage for H. influenzae and S. pneumoniae) 7
• Fluoroquinolones (levofloxacin or moxifloxacin) 7

Beta-lactam allergy: 7

• Mild disease: Trimethoprim/sulfamethoxazole or doxycycline 7
• Moderate disease: Fluoroquinolone 7

Concurrent Symptomatic Treatment

Continue intranasal corticosteroids and nasal saline irrigation alongside antibiotics 6

Treatment for Chronic Rhinosinusitis (Symptoms ≥12 Weeks)

Diagnostic Requirements

Diagnosis requires ≥2 of 4 cardinal symptoms (nasal obstruction, nasal discharge, facial pain, loss of smell) for ≥12 weeks PLUS objective evidence on nasal endoscopy (nasal polyps, mucopurulent discharge, or mucosal edema in middle meatus) or CT scan (mucosal changes in ostiomeatal complex or sinuses) 1

Treatment Algorithm by Severity

Mild CRS (VAS 0-3): 4

• Nasal saline irrigation 4, 5
• Intranasal corticosteroids: Fluticasone 200 mcg daily 4, 5
• If no improvement after 1 month, escalate to moderate treatment 4

Moderate CRS (VAS >3-7): 4

• Topical corticosteroid drops for 3 months 4
• Nasal lavage 4
• Long-term macrolide therapy (consider if no improvement) 4
• If beneficial, continue and review every 6 months 4
• If no improvement after 3 months, add short course of oral corticosteroids and consider CT scan to evaluate as surgical candidate 4

Severe CRS (VAS >7-10): 4

• Short course of oral corticosteroids PLUS topical corticosteroid for 1 month 4
• If beneficial, switch to topical corticosteroid drops only and review after 3 months 4
• If no improvement, perform CT and evaluate as surgical candidate 4

Special Considerations for CRS

• Antibiotics: Role is controversial in chronic disease; may be useful for acute exacerbations only 4, 8. Long-term macrolides (clarithromycin, roxithromycin) may reduce inflammation in select patients 4, 8
• Treat underlying conditions: Address gastroesophageal reflux disease, allergic rhinitis, asthma 4
• Avoid: Routine oral antihistamines (not effective for nonallergic rhinitis) 4, prolonged topical decongestants (>10 days causes rhinitis medicamentosa) 3, 7

Management of Treatment Failures and Allergic Component

When Initial Treatment Fails

Reassess if: 1

• Symptoms worsen after initial improvement
• New fever ≥39°C with purulent discharge and facial pain for ≥3 consecutive days
• Symptoms persist beyond 28 days without improvement

For Recurrent or Allergic Rhinosinusitis

Add intranasal antihistamine (azelastine) to intranasal corticosteroid for moderate to severe recurrent allergic rhinitis, as this combination provides greater symptom reduction than either agent alone 3

Do NOT add: 3

• Oral antihistamines to intranasal corticosteroids (no additional benefit in multiple high-quality trials) 3
• Leukotriene receptor antagonists to intranasal corticosteroids (no additional benefit, less effective than intranasal corticosteroids alone) 3

Consider Allergen Immunotherapy

Immunotherapy is the only treatment that modifies the natural history of allergic rhinitis, with benefits persisting years after discontinuation 3. It may prevent development of new allergen sensitizations and reduce risk of future asthma development 3. Consider for patients with demonstrable specific IgE antibodies to clinically relevant allergens 3

Referral Criteria

Refer to Allergist/Immunologist when: 4

• Prolonged manifestations of rhinitis not responding to standard therapy 4
• Complications: otitis media, sinusitis, nasal polyposis 4
• Comorbid conditions: asthma, chronic sinusitis 4
• Required systemic corticosteroids for rhinitis treatment 4
• Symptoms or medication side effects interfere with function (sleep disturbance, impaired school/work performance) 4
• Rhinitis medicamentosa diagnosed 4
• Immunotherapy is a treatment consideration 4

Refer to Otolaryngologist when: 5, 6

• Failure of maximal medical therapy with CT evidence of sinus disease 6
• Suspected complications: orbital involvement, intracranial involvement, bony involvement 6
• Endoscopic sinus surgery consideration for chronic rhinosinusitis refractory to medical management 5

Warning Signs Requiring Immediate Evaluation

Do not ignore: Periorbital edema, diplopia, severe headache, or altered mental status—these may indicate serious complications requiring immediate evaluation 1, 6