Guidelines for Managing Rhinosinusitis

Classification and Diagnosis

The American Academy of Otolaryngology-Head and Neck Surgery defines rhinosinusitis as symptomatic inflammation of the paranasal sinuses and nasal cavity 3
Acute rhinosinusitis (ARS) is classified as less than 4 weeks, subacute rhinosinusitis as 4-12 weeks, and chronic rhinosinusitis (CRS) as more than 12 weeks, with or without acute exacerbations 3
Clinicians should distinguish presumed acute bacterial rhinosinusitis (ABRS) from ARS caused by viral upper respiratory infections and noninfectious conditions (strong recommendation) 1
ABRS should be diagnosed when symptoms or signs of acute rhinosinusitis persist without improvement for ≥10 days beyond the onset of upper respiratory symptoms, or when symptoms worsen within 10 days after initial improvement 2
Clinical diagnosis of CRS must be confirmed with objective documentation of sinonasal inflammation using anterior rhinoscopy, nasal endoscopy, or computed tomography (strong recommendation) 1

The American Academy of Otolaryngology-Head and Neck Surgery recommends watchful waiting (without antibiotics) for uncomplicated ABRS regardless of severity (recommendation) 1
If antibiotics are prescribed, amoxicillin with or without clavulanate is recommended as first-line therapy for 5-10 days 1
For penicillin-allergic patients, doxycycline or a respiratory fluoroquinolone is recommended 2
Symptomatic relief is the primary approach for viral rhinosinusitis (VRS), with options including analgesics for pain management, saline nasal irrigation, and intranasal corticosteroids 2, 4, 5

The American Academy of Otolaryngology-Head and Neck Surgery recommends saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS (recommendation) 1
Short courses of systemic corticosteroids may be beneficial, particularly for CRS with nasal polyps 6
Antibiotics should be reserved for acute exacerbations with evidence of bacterial infection 2
Antifungal therapy (topical or systemic) is not recommended for patients with CRS (recommendation against) 2

Testing for allergy and immune function may be obtained in evaluating patients with CRS or recurrent ARS 2
The American Academy of Otolaryngology-Head and Neck Surgery recommends against relying on mucus color to determine need for antibiotics (color relates to neutrophils, not bacteria) 5
Failure to confirm CRS diagnosis with objective evidence of inflammation is a common pitfall to avoid 1
Not assessing for underlying conditions that may modify CRS management is a common pitfall to avoid 1