Chronic rhinosinusitis (CRS) is defined as symptoms and objective findings of nasal and sinus inflammation lasting 12 weeks or longer. Approximately 4% of patients with CRS have nasal polyps. The presence of nasal polyps affects management and is associated with asthma and aspirin sensitivity.
In this guidelines side-by-side comparison, we look at the latest clinical practice guidelines from the American Academy of Otolaryngic Allergy (AAOA)/American Rhinologic Society (ARS), the American Academy of Allergy, Asthma, and Immunology (AAAAI)/American College of Allergy, Asthma, and Immunology (ACAAI) and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) on chronic sinusitis with nasal polyps. The recommendations made are meant to guide clinical practice, taking into consideration the unique desires and needs of individual patients.
Guidelines for Comparison
| Item | International Consensus Statement on Allergy and Rhinology: Rhinosinusitis 2021 | The Joint Task Force on Practice Parameters GRADE Guidelines for the Medical Management of Chronic Rhinosinusitis with Nasal Polyposis | Clinical Practice Guideline: Adult Sinusitis Update |
|---|---|---|---|
| Authoring Organization | American Academy of Otolaryngic Allergy and American Rhinologic Society | American Academy of Allergy, Asthma, and Immunology and American College of Allergy, Asthma, and Immunology | American Academy of Otolaryngology-Head and Neck Surgery |
| Publication Date | August 2021 | January 2023 | July 2025 |
| Graded Recommendations | Yes | Yes | Yes |
| Uses GRADE | No, uses aggregate grade of evidence. | Yes | Yes |
| Links | Summary / Full Text | Summary / Full Text | Summary / Full Text |
Key Takeaways
The AAOA/ARS and AAO-HNS guidelines address evaluation and management of both acute rhinosinusitis and CRSs with the AAOA/ARS being the most comprehensive of the two. The AAAAI/ACAAI guideline is much more focused addressing three treatments for chronic rhinosinusitis with nasal polyps (CRSwNP): corticosteroids, biologics, and aspirin therapy after desensitization.
Saline
- AAAAI/ACAAI did not address the use of nasal saline, but the other two guidelines were in agreement that nasal saline should be recommended for patients with CRSwNP.
Corticosteroids
- All three guidelines agree that intranasal corticosteroids should be used for CRSwNP.
- AAAAI/ACAAI does not address the mode of delivery of corticosteroids, but AAOA/ARS makes recommendations for corticosteroid irrigation, sprays, and drug-eluting implants.
- Both the AAOA/ARS and AAO-HNS guidelines also note that short course oral corticosteroids may be used for certain patients with CRSwNP.
Antibiotics
- The AAOA/ARS and AAO-HNS addressed antibiotic use for CRSwNP. Routine use is not recommended, however both recognized that macrolide antibiotics may be considered for some patients because of their anti-inflammatory effects.
Biologics
- The AAO-HNS recommendation on biologics is to educate patients with CRSwNP on the role of biologics in improving quality of life.
- Both the AAOA/ARS and AAAAI/ACAAI consider biologics an option for patients with CRSwNP. AAOA/ARS recommends specific biologics based on concomitant asthma type and severity.
Aspirin Therapy After Desensitization (ATAD)
- The AAO-HNS recommends evaluating patients with CRSwNP for aspirin-exacerbated respiratory disease (AERD), while the other two guidelines suggest considering ATAD for patients known to have AERD.
Antifungals
- Antifungals were not addressed by the AAAAI/ACAAI and were not recommended for use in patients with CRSwNP by the other two guidelines.
Comparison of Recommendations
| Treatment | AAOA/ARS | AAAAI/ACAAI | AAO-HNS |
|---|---|---|---|
| Saline | Nebulized saline (5 mL) treatment is an option for treating chronic rhinosinusitis with nasal polyps (CRSwNP), particularly patients with thick mucus. | Not Addressed | Clinicians should recommend saline nasal irrigation, topical intranasal corticosteroids, or both, for symptomatic relief of CRS. |
| Corticosteroids | Topical nasal corticosteroids (sprays or drops) are recommended for CRSwNP before or after sinus surgery. Consideration for twice daily dosing or additional short-term corticosteroid drop if initial treatment effect is small. Following sinus surgery, those patients with CRSwNP that have moderate-severe disease or are not controlled with simple INCS should be offered corticosteroid irrigation and/or atomized delivery. Corticosteroid-eluting implants can be considered as an option in a previously operated ethmoid cavity with recurrent nasal polyposis. Strong recommendation for the use of oral corticosteroids in the short-term management of CRSwNP. Longer term use of steroids for CRSwNP is not supported by the literature and carries an increased risk of harm to the patient. | In people with CRSwNP, the guideline panel suggests intranasal corticosteroids (INCS) rather than no INCS. | Clinicians should recommend saline nasal irrigation, topical intranasal corticosteroids, or both, for symptomatic relief of CRS. Additional supporting text: Standard medical therapy for CRSwNP is similar to that for CRS in general. Topical nasal steroid sprays are indicated for long-term treatment of nasal polyps in the setting of CRS. If no response is seen within 3 months, a short course of oral corticosteroids can be considered. Off-label topical corticosteroids in the nasal cavity such as budesonide, may also be beneficial. |
| Antibiotics | Short courses (<3 weeks) of non-macrolide antibiotics should generally not be prescribed for CRSwNP except in acute exacerbations. Practitioners should weigh the risks and benefits of extended courses (>3 weeks) of non-macrolide antibiotics for CRSwNP and know that the literature is sparse. In CRSwNP, macrolides may be beneficial, especially in neutrophil-dominant polyps or in those who are unresponsive to corticosteroids. | 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. Supporting text: The best evidence to date indicates that chronic topical or intravenous antibiotics for CRS with nasal polyps is not recommended, but select oral antibiotics, especially the macrolide class, may be beneficial because of their anti-inflammatory effects. |
| Biologics | Dupilumab may be considered for patients with severe CRSwNP who have not improved despite other medical and surgical treatment options. Mepolizumab: Consider as an option for severe CRSwNP with concomitant poorly controlled eosinophilic asthma. Reslizumab: Can be considered as an option for severe CRSwNP with concomitant poorly controlled eosinophilic asthma. Omalizumab: Consider for severe CRSwNP with concomitant poorly controlled allergic asthma. | In people with CRSwNP, the guideline panel suggests biologics rather than no biologics. | Clinicians or their designee should educate patients with CRS with 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. |
| Antifungal | Topical antifungal agents are not recommended for CRSsNP or CRSwNP. | Not Addressed | Clinicians should not prescribe topical or systemic antifungal therapy for patients with CRS. |
| Aspirin Therapy After Desensitization (ATAD) | Aspirin desensitization should be considered in AERD patients after surgical removal of NPs to prevent recurrence. | In people with AERD, the guideline panel suggests ATAD rather than no ATAD. | Clinicians should assess the patient with CRS or recurrent acute rhinosinusitis (RARS) for multiple chronic conditions that would modify management such as asthma, cystic fibrosis, immunocompromised state, aspirin-exacerbated respiratory disease, and ciliary dyskinesia. |
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