Management of Persistent Chronic Rhinosinusitis

Diagnosis and Initial Management

The American Academy of Otolaryngology states that antibiotics should NOT be prescribed unless significant or persistent purulent nasal discharge is present on examination, as chronic sinusitis is primarily inflammatory rather than infectious 1
The patient meets diagnostic criteria for chronic rhinosinusitis based on symptoms persisting beyond 8 weeks, including nasal congestion, postnasal drainage, facial pressure, decreased sense of smell, and cough 2, 3
The European Position Paper on Rhinosinusitis found no additive effect of antihistamines over standard treatment in acute bacterial rhinosinusitis 4

The American Academy of Otolaryngology recommends initiating fluticasone propionate nasal spray 200 mcg daily as the most effective first-line treatment for chronic rhinosinusitis 1
Intranasal corticosteroids provide superior symptom relief by reducing inflammation and nasal congestion 1
Saline irrigation is highly effective as adjunctive therapy, improving mucous clearance, enhancing ciliary activity, and removing inflammatory mediators 1, 5
Normal saline is better tolerated than hypertonic saline with fewer side effects 5

CT imaging is essential when symptoms persist despite medical therapy to provide objective documentation of inflammation 5
Chronic rhinosinusitis requires abnormal findings on CT or MRI for definitive diagnosis 2, 3
The patient requires nasal endoscopy to evaluate for nasal polyps, purulent discharge, or anatomical abnormalities 5

Refer to ENT specialist now rather than waiting for treatment failure, given recurrent symptoms despite two courses of antibiotics 2, 3, 1
Reassess symptoms after 4 weeks of intranasal corticosteroids and saline irrigation 5
If minimal or no improvement after 4 weeks, the CT scan and ENT evaluation will guide next steps including possible functional endoscopic sinus surgery 2, 3