Guideline updates recommendations to manage adult rhinosinusitis

A new guideline updated recommendations to improve diagnosis, testing, and treatment of adult acute rhinosinusitis (ARS).

The guideline was issued by The American Academy of Otolaryngology-Head and Neck Surgery Foundation. Changes in content from the prior guideline issued in 2007 include extension of watchful waiting as an initial management strategy for uncomplicated acute bacterial rhinosinusitis (ABRS), changes in recommendations on first-line antibiotic therapy for ABRS, and new action statements on chronic rhinosinusitis (CRS) that focus on chronic conditions and modifying factors.

The recommendations include the following:

• Diagnose ABRS when symptoms or signs such as purulent nasal drainage accompanied by nasal obstruction, facial pain/pressure/fullness, or both persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms or if symptoms or signs of ARS become worse within 10 days after an initial improvement. (Strong recommendation)
• Do not order radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected. (Recommendation)
• Analgesics, topical intranasal steroids, and/or nasal saline irrigation may be recommended for symptomatic relief of viral rhinosinusitis or ABRS. (Option)
• Offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for uncomplicated ABRS. Watchful waiting should be offered only when there is assurance of follow-up such that antibiotic therapy is started if the patient's condition fails to improve by 7 days after ABRS diagnosis or if it worsens at any time. (Recommendation)
• If antibiotics are prescribed, use amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days for most adults. (Recommendation)
• If the patient doesn't improve with the initial management option by 7 days after diagnosis or worsens during initial management, reassess to confirm ABRS, exclude other causes of illness, and detect complications. If ABRS is confirmed in a patient managed with observation, then begin antibiotic therapy; if the patient was initially managed with an antibiotic, the antibiotic should be changed. (Recommendation)
• Distinguish CRS and recurrent ARS from ABRS and other causes of sinonasal symptoms. (Recommendation)
• Confirm CRS with objective documentation of sinonasal inflammation using anterior rhinoscopy, nasal endoscopy, or computed tomography. (Strong recommendation)
• Assess the patient with CRS or recurrent ARS for chronic conditions that would change management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia. (Recommendation)

The full guideline is available online in the April Otolaryngology-Head and Neck Surgery.