Recommendations

Document Overview

Design and created by Guideline Central in participation with the American Academy of Otolaryngic Allergy and American Rhinologic Society.

Rhinosinusitis

American Academy of Otolaryngic Allergy

American Rhinologic Society

Publication Date: Nov 19, 2020

Page Last Updated: May 5, 2026

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

Recommendation Grading

Document Overview

Document Title: International Consensus Statement on Allergy and Rhinology: Rhinosinusitis 2021

Authoring Societies

American Academy of Otolaryngic Allergy

American Rhinologic Society

Document Publication Date: Nov 19, 2020

Page Last Reviewed/Updated: May 5, 2026

Document Type: Consensus

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: onlinelibrary.wiley.com/doi/10.1002/alr.22741

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.

Supplemental Implementation Resources

Quick-Reference Guide

Document Scope, Criteria, and Use Cases

Scope: Assessment and Screening, Management, Treatment

Diseases/Conditions (MeSH)

D012852 - Sinusitis

D009298 - Nasal Polyps

Keywords: nasal polyps, rhinosinusitis, sinusitis

Inclusion Criteria: Male, Female, Adolescent, Adult, Child, Older Adult

Health Care Settings: Ambulatory, Long Term Care, Operating and Recovery Room, Outpatient

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Recommendation Development Processes & Methodology

Number of Source Documents: 2,501

Literature Search End Date: Sunday, June 30, 2019

Includes peer/external review process?: Yes

Includes public comment process?: No

Methodologist involvement?: Yes

Patient involvement?: No

Includes multi-disciplinary group?: Yes

Includes systematic review?: Yes

Grades quality of strength of evidence?: Yes

Grades quality of strength of recommendation?: Yes

Discloses funding source?: No

Discloses conflicts of interest?: Yes

Includes benefits/harms analysis with recommendations?: Yes

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

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

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

A	Directly based on meta-analysis of RCTs, Well-designed RCTs or diagnostic studies performed on a population similar to the guideline's target population
B	Directly based on RCTs or diagnostic studies with minor limitations; overwhelmingly consistent evidence from observational studies
C	Directly based on observational studies (case control and cohort design)
D	Directly based on expert opinions, case reports, nonsystematic reviews
LB	Laboratory based
NR	Not Rated

Rhinosinusitis

Recommendations

Grade A/B recommendations for medical management of ARS

AMT prior to surgical intervention

Grade A/B recommendations for surgical management of CRS

Recommendations for postoperative care following ESS for CRS

Recommendation Grading

Document Overview

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Recommendation Development Processes & Methodology