ARS: acute rhinosinusitis
ABRS: acute bacterial rhinosinusitis
CRS: chronic rhinosinusitis
VRS: viral rhinosinusitis
Updated clinical practice guidelines for adult sinusitis have just been published. Since sinusitis is almost always attended by inflammation of the nasal mucosa, the term rhinosinusitis is used through the document.
Rhinosinusitis is classified by duration: acute rhinosinusitis (ARS) lasts for less than four weeks, while chronic rhinosinusitis (CRS) lasts for more than 12 weeks. ARS can be further sub-divided into acute bacterial (ABRS) or viral (VRS) rhinosinusitis.
In the updated guidelines, that provide a background that supplies the rationale, purpose and action statement profiles, Rosenfield and colleagues list 14 recommendations. The first three relate to ARS:
1. Differential diagnosis. Clinicians need to secernate ABRS from that caused by either viral upper respiratory infections or non-infectious conditions.
2. Radiographic imaging. This is not required for a diagnosis of ARS unless a complication or alternate diagnosis is presaged.
3. Relief. Symptomatic relief can be provided for VRS by recommending analgesics, nasal saline irrigation and/or topical intranasal steroids.
The next four recommendations deal with ABRS.
4. Symptomatic relief can be provided for ABRS by recommending analgesics, nasal saline irrigation and/or topical intranasal steroids.
5. Initial management of uncomplicated ABRS should be one of “watchful waiting” without antibiotics. A prescription for antibiotic therapy should be provided and used only if the condition worsens at any time, or remains unchanged after 7 days.
6. To treat adult ABRS with antibiotics, amoxicillin with or without clavulanate should be prescribed for 5 to 10 days.
7. When initial treatment for ABRS fails to result in improvement then clinicians should
• reassess to confirm the diagnosis
• exclude other causes of illness
• check for complications
• change the antibiotic
The remaining six recommendations deal mainly with CRS.
8. Clinicians should differentiate between CRS, ARS and episodes of ABRS.
9. Anterior rhinoscopy, nasal endoscopy or computed tomography should be used to objectively confirm a clinical diagnosis of CRS.
10. In cases of CRS or recurrent ARS, a check on chronic conditions such as asthma, cystic fibrosis, ciliary dyskinesia and a compromised immune system should be done, since these conditions hinder management.
11. Testing for immune function and allergies should be considered in cases of CRS or ARS.
12. A check for nasal polyps should be done in patients with CRS.
13. Symptomatic relief for CRS can be provided by recommending saline nasal irrigation and/or topical intranasal corticosteroids.
14. Antifungal therapy, either topical or systemic, should not be prescribed for CRS.
Some of the highlights of the guidelines include a “decision tree” (downloadable to a PowerPoint slide) that is an aid to diagnosis and provides “explicit and actionable recommendations”, and a most welcome emphasis on patient education and counseling.
Rosenfeld RM, Piccirillo JF, et al. Clinical Practice Guideline (update): adult sinusitis executive summary. Otorhinolaryngology Head Neck Surgery 2015; 152(4): 598-609. (doi:10.1177/0194599815574247)