Adult sinusitis, also called rhinosinusitis, is a common condition encountered by clinicians affecting about 12% of adults in the U.S. every year. Rhinosinusitis can be classified as acute or chronic depending on how long symptoms are present. Acute rhinosinusitis (ARS) symptoms last less than four weeks and chronic rhinosinusitis (CRS) symptoms last more than 12 weeks. Viruses are the most common cause of ARS, but even bacterial ARS can resolve without intervention. Regardless, antibiotics are often prescribed for adults with ARS.
The American Academy of Otolaryngologist Head and Neck Surgery Foundation (AAO-HNS) recently updated their clinical practice guidelines on the diagnosis and treatment of adult sinusitis. This guidelines timeline will review the major changes that occurred since the AAO-HNS’s last published guideline in 2015. We encourage you to read the full guideline which can be found linked below.
Guidelines Referenced
- Clinical Practice Guideline (Update): Adult Sinusitis
- Publication: April 2015
- Clinical Practice Guideline: Adult Sinusitis Update
- Publication: July 2025
Major Changes and Key Takeaways (2015-2025)
- Some of the major changes to the updated 2025 adult sinusitis guideline includes the addition of three new recommendations:
- The first 2 involve the use of biologics for the treatment of CRS:
- A new recommendation against the routine use of biologics for CRS without polyps.
- A new recommendation to educate patients about the use of biologics for CRS with polyps.
- The last new recommendation advises against the routine use of antimicrobials for CRS without exacerbation or as a prerequisite to sinus imaging or surgery.
- The first 2 involve the use of biologics for the treatment of CRS:
- Aspirin exacerbated respiratory disease was added as a modifying factor for CRS or recurrent acute rhinosinusitis (RARS).
- The 2025 guideline removed the option of prescribing antibiotics as initial management of ARS, instead recommending watchful waiting without antibiotics.
- The duration of antibiotic therapy for bacterial ARS was changed from 5-10 days to 5-7 days.
- The time to reassess after treatment failure was also adjusted from seven days to 3-5 days after being on appropriate antibiotics.
Comparison of Recommendations
| Topic | 2015 | 2025 |
|---|---|---|
| Differential Diagnosis | Clinicians should distinguish presumed acute bacterial rhinosinusitis (ABRS) from ARS caused by viral upper respiratory infections and noninfectious 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). | Clinicians should distinguish presumed acute bacterial rhinosinusitis (ABRS) from acute rhinosinusitis caused by viral upper respiratory infections and noninfectious conditions. A clinician should diagnose ABRS when (a) symptoms or signs of acute rhinosinusitis (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 acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening). |
| 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. | Clinicians should not obtain radiologic imaging for patients who meet diagnostic criteria for acute rhinosinusitis unless a complication or alternative diagnosis is suspected. |
| Symptomatic Relief of viral rhinosinusitis (VRS) | Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of VRS. | Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of VRS. |
| Symptomatic Relief of ABRS | Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of ABRS. | Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of ABRS. |
| 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 7 days after ABRS diagnosis or if it worsens at any time. | Clinicians should offer watchful waiting (without antibiotics) for adults with uncomplicated ABRS with assurance of follow-up. The duration of watchful waiting may depend on the factors and timing under which the diagnosis was originally made. |
| 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 5 to 10 days for most adults. | 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 5-7 days for most adults. |
| Treatment Failure for ABRS | If the patient worsens or fails to improve with the initial management option by 7 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. | If the patient fails to improve or worsens despite being on an appropriate antibiotic for 3-5 days, the clinician should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications. If ABRS is confirmed, the clinician should change the antibiotic. |
| Diagnosis of CRS or Recurrent ARS | Clinicians should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms. | Clinicians should distinguish CRS and recurrent acute rhinosinusitis (RARS) from isolated episodes of acute bacterial rhinosinusitis and other causes of sinonasal symptoms. |
| 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. | 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. |
| 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. | Clinicians should assess the patient with chronic rhinosinusitis or recurrent acute rhinosinusitis for multiple chronic conditions that would modify management such as asthma, cystic fibrosis, immunocompromised state, aspirin-exacerbated respiratory disease, and ciliary dyskinesia. |
| 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. | The clinician may obtain testing for allergy and immune function in evaluating a patient with chronic rhinosinusitis or recurrent acute rhinosinusitis. |
| CRS with Polyps | The clinician should confirm the presence or absence of nasal polyps in a patient with CRS. | The clinician should confirm the presence or absence of nasal polyps in a patient with CRS. |
| Topical Intranasal Therapy for CRS | Clinicians should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. | Clinicians should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. |
| Antifungal Therapy for CRS | Clinicians should not prescribe topical or systemic antifungal therapy for patients with CRS. | Clinicians should not prescribe topical or systemic antifungal therapy for patients with CRS. |
| Biologics for CRS Without Polyps | Not Addressed | Clinicians should not routinely prescribe biologics (including, but not limited to, monoclonal antibodies such as dupilumab, mepolizumab, or omalizumab) for the treatment of adults with CRS without polyps. |
| Biologics for CRS With Polyps | Not Addressed | Clinicians or their designee should educate patients with CRS and nasal polyps about the role of biologics as a means to improve disease-specific quality of life when either prior medical and surgical therapy has failed OR when surgery is not a viable option because of disease status or patient preference. |
| Antimicrobials for CRS | Not Addressed | Clinicians should not routinely prescribe antimicrobial therapy for adults with CRS without acute exacerbation OR as a mandatory prerequisite for paranasal sinus imaging or surgery. |
In summary, over the last 10 years there have been some changes to the treatment of adult sinusitis, but a lot has remained the same. Supportive measures with pain control, nasal saline irrigation, and nasal corticosteroids remain important mainstays of treatment. Antibiotics should be used judiciously for the treatment of bacterial ARS, as most ARS is viral and will resolve spontaneously. Biologics are a new therapy that may benefit some patients who have CRS with nasal polyps.
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