What is the best course of treatment for a middle-aged adult with a history of allergies or respiratory issues, presenting with polypoidal mucosal thickening in the left main maxillary sinus and minimal mucosal thickening in the right maxillary sinus, possibly indicating chronic sinusitis?

Management of Polypoidal Mucosal Thickening in Maxillary Sinuses

Initial Medical Management is the Appropriate First-Line Approach

For a middle-aged adult with polypoidal mucosal thickening in the left maxillary sinus and minimal thickening in the right maxillary sinus, particularly with a history of allergies, initiate medical therapy with intranasal corticosteroids as the primary treatment, combined with nasal saline irrigation, before considering any surgical intervention. 1, 2

Understanding the Clinical Significance

Radiologic Findings Do Not Always Correlate with Symptoms

• Mucosal thickening ≥2 mm in the maxillary sinuses occurs in 17.7% of completely asymptomatic individuals without any sinonasal symptoms 1
• The presence of a patent ostiomeatal complex (OMC) is more clinically important than the degree of mucosal thickening itself 2
• If the patient has minimal or no symptoms and the OMC is patent, no specific treatment may be needed at all 2
• Radiologic evidence of sinonasal inflammation can persist even after resolution of an upper respiratory tract infection, and even nose blowing can cause up to 0.5 mm of mucosal thickening 1

When to Be Concerned

The following findings would indicate more aggressive intervention is needed:

• Air-fluid levels within the sinuses 1, 2
• Complete opacification of the sinus 2
• Bone erosion or destruction 2
• Symptoms lasting more than 4 weeks including facial pain/pressure, nasal congestion, purulent discharge, or decreased sense of smell 2

Stepwise Treatment Algorithm

Step 1: Assess Symptom Severity and Duration

Determine if the patient meets criteria for chronic rhinosinusitis (CRS):

• At least 2 of 4 cardinal symptoms (nasal obstruction, nasal discharge, facial pain/pressure, loss of smell) present for ≥12 weeks 3
• Objective evidence of inflammation on imaging (which is present in this case with polypoidal thickening) 3

Step 2: Initiate Medical Therapy

Primary treatment regimen:

• Intranasal corticosteroids (e.g., fluticasone propionate 2 sprays per nostril once daily) are the treatment of choice for polypoidal mucosal changes 4, 5, 6
• Nasal saline irrigation daily 2, 3
• This combination significantly decreases polyp size, nasal congestion, and rhinorrhea while increasing nasal airflow 5

Duration and expectations:

• It may take several days to reach maximum effect with intranasal corticosteroids 4
• Continue treatment as long as exposed to allergens that trigger symptoms 4
• For patients age 12 or older, if daily use extends beyond 6 months, check with a physician 4

Step 3: Consider Systemic Corticosteroids for Severe Cases

If polypoidal changes are extensive and causing significant symptoms:

• Short courses of oral corticosteroids may be needed to reduce polyp size initially, followed by maintenance with topical steroids 5, 6
• A combined short-term steroid therapy (oral plus topical) is highly effective in chronic polypoid rhinosinusitis, reducing mucosal inflammation particularly in the maxillary sinuses (40% reduction) and significantly reducing symptoms in 80% of patients 7
• This approach can reduce the extent of disease and facilitate any future surgical procedures if needed 7

Step 4: Address Underlying Allergic Component

Given the history of allergies:

• Consider adding an intranasal antihistamine (e.g., azelastine) if allergic symptoms persist 3
• Allergy testing should be performed if symptoms are consistent with allergic rhinitis and have not responded adequately to initial therapy 8
• Oral antihistamines may help concurrent allergic symptoms in atopic patients, though they are not primary treatment for sinusitis itself 1

Step 5: Determine Need for Antibiotics

Antibiotics should NOT be prescribed based on imaging findings alone 2, 3

Only prescribe antibiotics if the patient meets criteria for acute bacterial rhinosinusitis:

• Persistent symptoms ≥10 days without improvement 3
• Severe symptoms (fever >39°C, purulent discharge, facial pain) for ≥3 consecutive days 3
• "Double sickening" pattern (worsening after initial improvement) 3

Important caveat: Mucosal thickening alone, even if present on imaging, does not indicate bacterial infection requiring antibiotics 1, 3

When to Consider Surgical Intervention

Surgery is reserved for specific circumstances:

• Medical therapy failure after appropriate duration (typically several months of optimal medical management) 1, 5
• Polyps causing severe obstruction or recurrent sinusitis 5
• Complete opacification or other concerning radiologic findings 2

Key consideration from recent guidelines:

• The 2025 American Academy of Otolaryngology guidelines emphasize that patients with lesser radiologic evidence of sinus disease who have medically refractory symptoms can still experience significant improvement in quality of life from endoscopic sinus surgery 1
• However, comprehensive ESS may lead to improved outcomes and lower revision rates, particularly for patients with nasal polyps 1

Critical Pitfalls to Avoid

• Do not prescribe antibiotics based solely on imaging findings of mucosal thickening 2, 3
• Do not assume all mucosal thickening represents active infection—it may be incidental, post-viral, or related to allergies 1, 2
• Do not rush to surgery without an adequate trial of medical therapy—topical steroids are highly effective for polypoidal changes 5, 6, 7
• Do not ignore the allergic component—uncontrolled allergies will perpetuate sinus inflammation regardless of other treatments 8, 5, 6
• Do not use antihistamines as primary treatment for sinusitis, though they may help if concurrent allergic symptoms are present 1

Monitoring and Follow-Up

Reassess the patient if:

• Symptoms persist beyond 12 weeks despite appropriate medical therapy 1
• Symptoms worsen after initial improvement 3
• New fever ≥39°C develops with purulent discharge and facial pain for ≥3 consecutive days 3
• Quality of life remains significantly impaired despite medical management 1

Consider ENT referral for:

• Medically refractory symptoms after 3-6 months of optimal medical therapy 1
• Concerning radiologic findings (complete opacification, bone erosion) 2
• Need for endoscopic evaluation to assess OMC patency and rule out other pathology 1