Management of Chronic Rhinosinusitis

First‑Line Medical Therapy

The American Academy of Otolaryngology–Head and Neck Surgery (AAO‑HNS) recommends that initial therapy consist of high‑volume saline nasal irrigation combined with intranasal corticosteroids, which together form the cornerstone of medical management. 1
Intranasal corticosteroids (e.g., mometasone, fluticasone, beclomethasone) reduce mucosal inflammation and improve patient‑reported symptoms. 1
Using saline irrigation and intranasal steroids together provides greater symptom relief than either modality alone. 1

AAO‑HNS advises the following technique for each spray: shake the bottle well, tilt the head forward looking down, use the opposite hand for the opposite nostril, aim the applicator toward the lateral nasal wall (not the septum), and avoid forceful inhalation after administration. 1

Approximately 4 % of patients with chronic rhinosinusitis have concurrent nasal polyps. 1
Large polyps are readily visible with a nasal speculum, whereas small polyps require endoscopic examination for detection. 1
The Rhinology guideline rates both topical intranasal corticosteroids (Level Ib, Grade A) and short courses of oral corticosteroids (Level Ib, Grade A) as recommended treatments for nasal polyps. 2
Long‑term antibiotic therapy (> 12 weeks) has Level Ib evidence for preventing late polyp recurrence. 2

AAO‑HNS (2025) states that FESS should be offered when the expected benefits clearly outweigh those achievable with medical therapy alone, when expected outcomes are well defined, and when the patient understands long‑term management expectations. 3
Pre‑operative planning must include a fine‑cut computed tomography (CT) scan of the sinuses to guide surgical approach. 3
The extent of surgery should not be determined solely by minimal mucosal thickening observed on CT. 3
In cases with polyps, osteitis, bony erosion, or fungal disease, the operation must achieve complete sinus cavity exposure and removal of diseased tissue; simple balloon ostial dilation is insufficient. 3

The Rhinology guideline (2007) reports that functional endoscopic sinus surgery is superior to minimal conventional procedures (e.g., limited polypectomy and antral irrigation) for achieving disease control. 2
In patients who have not undergone prior sinus surgery, extended sinus surgery does not provide better outcomes than limited, targeted procedures. 2

AAO‑HNS recommends routine postoperative visits between 3 and 12 months after FESS, with assessment through history (symptom relief, quality of life, complications, medication adherence) and nasal endoscopy. 3

Major complications after sinus surgery occur in less than 1 % of cases (Rhinology guideline). 2
Approximately 10 % of patients require revision sinus surgery within three years of the initial procedure (Rhinology guideline). 2
The Rhinology guideline notes that, for the majority of chronic rhinosinusitis patients, appropriately applied medical therapy is as effective as surgical intervention, and surgery should be reserved for those who fail to achieve satisfactory control with medical management. 2

The American Academy of Otolaryngology-Head and Neck Surgery recommends intranasal corticosteroids and saline nasal irrigation as first-line therapy for chronic sinusitis, with consideration for antibiotics in cases of infectious etiology, and surgical intervention for medically refractory cases 4
Saline nasal irrigation helps clear mucus, reduce inflammation, and improve medication delivery to the sinonasal mucosa, and can be used in conjunction with intranasal corticosteroids for enhanced effectiveness 4

The use of antibiotics in chronic sinusitis is controversial, with limited evidence supporting their routine use, but a minimum 3-week course of antibiotics effective against common pathogens may be beneficial for chronic infectious sinusitis 5
For chronic infectious sinusitis, antibiotics such as those effective against H. influenzae, anaerobes, and S. pneumoniae may be beneficial, and if no improvement is seen within 3-5 days of antibiotic therapy, consider alternative antibiotics 5, 6
Systemic corticosteroids may be beneficial for patients with chronic non-infectious sinusitis, particularly those with nasal polyps, and can reduce polyp size for up to 3 months after treatment 6

Consider endoscopic sinus surgery for patients with documented chronic sinus infection refractory to medical therapy, anatomic obstruction amenable to surgical correction, localized persistent disease within the ostiomeatal complex, or nasal polyps that don't respond to medical therapy 5, 6, 7

Evaluate for and treat underlying conditions that may contribute to chronic sinusitis, such as allergic rhinitis, immunodeficiency, gastroesophageal reflux disease (GERD), and aspirin sensitivity, and consider specialist consultation when sinusitis is refractory to usual antibiotic treatment, recurrent, or significantly affects quality of life 7, 8
The American Academy of Allergy, Asthma, and Immunology recommends considering allergen testing and appropriate management for patients with allergic rhinitis, and immunoglobulin measurements and functional antibody tests for patients with immunodeficiency 8