Publication Date: November 20, 2020
Last Updated: April 5, 2022


Grade A/B recommendations for medical management of ARS

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Intervention Policy Level Grade
ARS: Antibiotic Treatment Option: Consider watchful waiting in uncomplicated cases with institution after 7 days or with worsening/ mitigating circumstances. B
Pediatric ARS <10 days: Withholding Antibiotic Treatment Recommendation: Antibiotics should not be given for the first 10 days of uncomplicated pediatric ARS. If >10 days or complicated, amoxicillin- clavulanate is preferred antibiotic if not allergic. A
ARS: Intranasal Corticosteroids Strong Recommendation: Consider use in ARS A
ARS: Topical Saline Spray and Irrigation Option: Saline irrigation may be used in adjunct with antibiotics for acute bacterial rhinosinusitis. B
CRSsNP: Saline Irrigation, Drops, Sprays Recommendation: Saline irrigation improves symptoms, QoL and nasal endoscopy. Duration of should be greater than eight weeks. Hypertonic saline is more effective but may be more irritating than isotonic saline. There is no advantage of heated over room temperature saline. Devices with volume >60 ml bring greater benefits. B
CRSwNP: Oral Corticosteroids Strong recommendation: For short-term management of CRSwNP. Longer term use of is not supported by the literature and carries increased risk of harm. A
CRSsNP: Intranasal Corticosteroid Spray Option: Standard metered dose INCS could be used in treatment of CRSsNP, particularly if primary symptoms are that of rhinitis. A
CRSwNP: Intranasal Corticosteroid Spray Strong Recommendation: INCS are recommended for CRSwNP before or after sinus surgery. Consideration for twice daily dosing if initial treatment effect is small. A
CRSsNP: Corticosteroid Irrigations Recommended: Post-operative patients
Option: Non- surgical/medical management
CRSwNP: Non-Standard Corticosteroid Delivery If not controlled with INCS, strong recommendation for corticosteroid irrigation; recommendation for atomization/ nebulization.
Option: Exhalation delivery
CRSwNP: Corticosteroid eluting Implants Option: Corticosteroid-eluting implants can be considered as an option in a previously operated ethmoid cavity with recurrent nasal polyps. A
CRSwNP: Dupilumab (Biologic) Recommendation: May be considered for patients with severe CRSwNP who have not improved despite other medical and surgical treatment options. A
CRSsNP: Macrolide Antibiotics Option: Macrolides are an option for patients with CRSsNP. Optimal drug, dosage, and treatment duration are not known. B
CRSwNP: Macrolide Antibiotics Option: Macrolides are likely beneficial in CRSwNP. Optimal drug, dosage, and treatment duration are not known. B
CRSwNP: Non- Macrolide Antibiotics
(<3 weeks)
Recommendation against: Should generally not be prescribed for CRSwNP except in acute exacerbations. B (-)
CRSs/wNP: Topical Antibiotics Recommendation against: Topical antibiotics are not recommended for CRSs/wNP. A (-)
CRSs/wNP: Topical Antifungals Strong recommendation against: Topical antifungals are not recommended for CRSs/wNP. A (-)
CRSwNP: Anti- Leukotrienes Option: Montelukast is an option for CRSwNP patients either instead of or in addition to INCS. A
CRSs/wNP: Xylitol Irrigation Option postoperatively in CRSsNP and CRSwNP patients. B
CRSs/wNP: Colloidal Silver Recommendation against: CAg may have anti-bacterial properties in-vitro but lacks efficacy in clinical studies. B (-)
Option: Topical furosemide after ESS and in combination with an INCS may reduce the recurrence of nasal polyps B
CRSwNP (AERD): ASA Desensitization Recommendation: Aspirin desensitization should be considered in AERD after surgical removal of NPs to prevent recurrence. A



International Consensus Statement on Allergy and Rhinology: Rhinosinusitis 2021

Authoring Organizations