The American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) released an updated replacement to their 2015 clinical practice guidelines on adult sinusitis, which itself was a replacement to guidelines published in 2007. As with previous versions, the guideline maintains a focus on adults clinically diagnosed with uncomplicated rhinosinusitis, which is the AAO-HNSF’s preferred term over “sinusitis” since sinusitis is almost always accompanied by inflammation of the contiguous nasal mucosa.

The 2025 AAO-HNSF Adult Sinusitis update integrates new information gathered from 194 systematic reviews, 133 randomized clinical trials, 14 other guidelines, a public comment period, and a journal peer review.

With the updated guideline’s collective recommendations highlighted below, we’re providing a brief rundown of key changes and each of the 17 evidence-based statements (including 3 brand new statements) to help you understand what’s new in the 2025 update.

Key Elements of the 2025 AAO-HNSF Adult Sinusitis Guidelines Update:
  • Three new evidence-bases statements (13A, 13B, 14)
  • Watchful waiting period extension (without antibiotic therapy) as the initial management strategy in generally healthy patients with uncomplicated mild-to-moderate acute rhinosinusitis, in lieu of an option to provide antibiotics or not to as noted in the prior guideline
  • For acute bacterial rhinosinusitis, the first-line antibiotic therapy recommendation was previously amoxicillin alone and it is now amoxicillin with or without clavulanate.
  • The duration of first-line antibiotic therapy was reduced to 5–7 days from 5–10 days.
  • Aspirin exacerbated respiratory disease was added as a chronic condition that affects the overall management of chronic rhinosinusitis.
  • A new recommendation discourages the use of empiric antibiotics for chronic rhinosinusitis when done only to satisfy third-party criteria for imaging or surgery.

Additional general changes include a refreshed emphasis on patient education; clarity on the recommended timeline for diagnosis, conservative management, and antibiotic treatment of acute bacterial rhinosinusitis; new action statements regarding managing chronic rhinosinusitis using biologics; clearer action statement profiles; and an algorithm to provide clarity to decision making and watchful waiting action statements.

Summary of the 14 Evidence-based Statements in the 2025 Update

Statement 1A: Differential Diagnosis of Acute Rhinosinusitis

  • 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). Strong Recommendation
  • Changes: None

Statement 1B: Radiologic Imaging and Acute Rhinosinusitis

  • Clinicians should not obtain radiologic imaging for patients who meet diagnostic criteria for acute rhinosinusitis unless a complication or alternative diagnosis is suspected. Recommendation (against imaging)
  • Changes: None

Statement 2: Symptomatic Relief of Viral Rhinosinusitis (VRS)

  • Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of VRS. Option
  • Changes: None

Statement 3: Symptomatic Relief of Acute Bacterial Rhinosinusitis (ABRS)

  • Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of ABRS. Option
  • Changes: None

Statement 4: Initial Management of Acute Bacterial Rhinosinusitis (ABRS)

  • 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. Recommendation
  • Changes: [previous version: 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. Recommendation]

Statement 5: Choice and Duration of Antibiotic for Acute Bacterial Rhinosinusitis (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 5-7 days for most adults. Recommendation
  • Changes: [previous version: 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. Recommendation]

Statement 6: Treatment Failure for Acute Bacterial Rhinosinusitis (ABRS)

  • 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. Recommendation
  • Changes: [previous version: 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. Recommendation]

Statement 7A: Diagnosis of Chronic Rhinosinusitis (CRS) or Recurrent Acute Rhinosinusitis (ARS):

  • Clinicians should distinguish CRS and RARS from isolated episodes of acute bacterial rhinosinusitis and other causes of sinonasal symptoms. Recommendation
  • Changes: None.

Statement 7B: Objective Confirmation of a Diagnosis of Chronic Rhinosinusitis (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. Strong Recommendation
  • Changes: None.

Statement 8: Modifying Factors

  • 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. Recommendation
  • Changes: [previous version: 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. Recommendation]

Statement 9: Testing for Allergy and Immune Function

  • The clinician may obtain testing for allergy and immune function in evaluating a patient with chronic rhinosinusitis or recurrent acute rhinosinusitis. Option
  • Changes: None.

Statement 10: Chronic Rhinosinusitis (CRS) with Polyps

  • The clinician should confirm the presence or absence of nasal polyps in a patient with CRS. Recommendation
  • Changes: None

Statement 11: Topical Intranasal Therapy for Chronic Rhinosinusitis (CRS)

  • Clinicians should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. Recommendation
  • Changes: None

Statement 12: Antifungal Therapy for Chronic Rhinosinusitis (CRS)

  • Clinicians should not prescribe topical or systemic antifungal therapy for patients with CRS. Recommendation (against therapy)
  • Changes: None

(NEW) Statement 13A: No Statement Title
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. Recommendation (against therapy)

(NEW) Statement 13B: No Statement Title

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. Recommendation

(NEW) Statement 14: No Statement Title

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. Recommendation (against therapy)

Sign up for alerts and stay informed on the latest published guidelines and articles.

Copyright © 2025 Guideline Central, all rights reserved.