This is a summary of the ‘Clinical Practice Guideline: Adult Sinusitis’ from the American Academy of Otolaryngology-Head and Neck Surgery Foundation. This is an update of the 2015 version. Evidenc-based statements:
1a. Differential diagnosis of acute rhinosinusitis: Clinicians should distinguish presumed acute bacterial rhinosinusitis (ABRS) from acute rhinosinusitis (ARS) caused by viral upper respiratory infections and non-infectious conditions. A clinician should diagnose ABRS when (a) symptoms or signs of ARS (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 (b) symptoms or signs of ARS worsen within 10 days after an initial improvement (double worsening).
1b. Radiographic imaging and ARS: Clinicians should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected.
2. Symptomatic relief of viral rhinosinusitis (VRS): Clinicians may recommend analgesics, topical intranasal steroids and / or nasal saline irrigation for symptomatic relief of VRS.
3. Symptomatic relief of ABRS: Clinicians may recommend analgesics, topical intranasal steroids and / or nasal saline irrigation for symptomatic relief of ABRS.
4. Initial management of ABRS: Clinicians should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with 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 seven days after ABRS diagnosis, or if it worsens at any time.
5. Choice of antibiotic for ABRS: If a decision is made to treat ABRS with an antibiotic agent, the clinician should prescribe amoxicillin with or without clavulanate as first-line therapy for five to 10 days for most adults.
6. Treatment failure for ABRS: If the patient fails to improve with the initial management option by seven days after diagnosis or worsens during the initial management, the clinician should reassess the patient to confirm ABRS, exclude other causes of illness and detect complications. If ABRS is confirmed in the patient initially managed with observation, the clinician should begin antibiotic therapy. If the patient was initially managed with an antibiotic, the clinician should change the antibiotic.
7a. Diagnosis of chronic rhinosinusitis (CRS) or ARS: Clinicians should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms.
7b. Objective confirmation of a diagnosis of CRS: The clinician should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy or computed tomography.
8. Modifying factors: Clinicians should assess the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management such as asthma, cystic fibrosis, immunocompromised state and ciliary dyskinesia.
9. Testing for allergy and immune function: The clinician may obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent ARS.
10. CRS with polyps: The clinician should confirm the presence or absence of nasal polyps in a patient with CRS.
11. Topical intranasal therapy for CRS: Clinicians should recommend saline nasal irrigation, topical intranasal corticosteroids, or both, for symptom relief of CRS.
12. Antifungal therapy for CRS: Clinicians should not prescribe topical or systemic antifungal therapy for patients with CRS.
The article also includes an algorithm showing the interrelationship between the above key action statements.
