Last updated April 5, 2022

Rhinosinusitis

Recommendations

Grade A/B recommendations for medical management of ARS

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
A
CRSwNP: Non-Standard Corticosteroid Delivery If not controlled with INCS, strong recommendation for corticosteroid irrigation; recommendation for atomization/ nebulization.
Option: Exhalation delivery
B
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 (-)
CRSwNP:
Furosemide
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

AMT prior to surgical intervention

Intervention Policy Level Grade
AMT: CRSsNP INCS, Saline Irrigations, Antibiotics Recommendation: AMT prior to surgical intervention.
Option: Oral Corticosteroids
D
AMT: CRSwNP INCS, Saline Irrigations, Oral Corticosteroids (Single short course) Recommendation: AMT prior to surgical intervention.
Option: Antibiotics
AMT: Duration of 3–4 weeks Recommendation: Minimum of 3–4-week trial of AMT prior to surgical intervention

Grade A/B recommendations for surgical management of CRS

Intervention Policy Level Grade
Hypotensive Anesthesia Option: Controlled hypotension (MAP between 60–70 mmHg) is safe and improves the surgical field B
Patient selection to achieve a post- operative MCID Option: Patient selection for surgical intervention should take into consideration baseline patient reported symptom burden B
Extent of Surgery Option: Less extensive sinus interventions are likely reasonable options in patients with minimal OMC or maxillary sinus disease B
Image Guidance Option: Use in patients undergoing ESS, especially in the setting of anatomic complexity or the need for more advanced procedures B

Recommendations for postoperative care following ESS for CRS

Intervention Policy Level Grade
Saline irrigations Recommendation: for use of nasal saline irrigation B
Sinus cavity debridements Recommendation: for postoperative debridement B
Topical corticosteroids Strong Recommendation: for topical corticosteroids A
Oral antibiotics Option: for oral antibiotics B
Topical decongestants Recommendation against: topical decongestants N/A
Systemic corticosteroids Option: for systemic corticosteroids C
Mitomycin C Recommendation: against Mitomycin C B
Post- operative Packing Option: Although evidence does exist suggesting packing may reduce adhesion formation, it is limited and has not been compared to studies employing early and frequent debridement A
Post- operative Drug-eluting Implants Option: Corticosteroid- eluting stents can be considered in the postoperative ethmoidectomy cavity A

Recommendation Grading

Overview

Title

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis 2021

Authoring Organizations

Publication Month/Year

November 20, 2020

Document Type

Consensus

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Long term care, Outpatient, Operating and recovery room

Scope

Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D012852 - Sinusitis, D009298 - Nasal Polyps

Keywords

sinusitis, rhinosinusitis, nasal polyps

Source Citation

Orlandi RR, Kingdom TT, Smith TL, Bleier B, DeConde A, Luong AU, Poetker DM, Soler Z, Welch KC, Wise SK, Adappa N, Alt JA, Anselmo-Lima WT, Bachert C, Baroody FM, Batra PS, Bernal-Sprekelsen M, Beswick D, Bhattacharyya N, Chandra RK, Chang EH, Chiu A, Chowdhury N, Citardi MJ, Cohen NA, Conley DB, DelGaudio J, Desrosiers M, Douglas R, Eloy JA, Fokkens WJ, Gray ST, Gudis DA, Hamilos DL, Han JK, Harvey R, Hellings P, Holbrook EH, Hopkins C, Hwang P, Javer AR, Jiang RS, Kennedy D, Kern R, Laidlaw T, Lal D, Lane A, Lee HM, Lee JT, Levy JM, Lin SY, Lund V, McMains KC, Metson R, Mullol J, Naclerio R, Oakley G, Otori N, Palmer JN, Parikh SR, Passali D, Patel Z, Peters A, Philpott C, Psaltis AJ, Ramakrishnan VR, Ramanathan M Jr, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Sedaghat AR, Senior BA, Sindwani R, Smith K, Snidvongs K, Stewart M, Suh JD, Tan BK, Turner JH, van Drunen CM, Voegels R, Wang Y, Woodworth BA, Wormald PJ, Wright ED, Yan C, Zhang L, Zhou B. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol. 2021 Mar;11(3):213-739. doi: 10.1002/alr.22741. PMID: 33236525.