Approach

A key principle of treatment is identifying and treating underlying causes and confounding variables (e.g., allergic rhinitis, structural abnormalities). No single treatment regimen exists.

Medical treatment

Initial treatment recommended by American and European guidelines includes nasal saline irrigation and topical intranasal corticosteroids.[3][20][21][27]​​[28][29][30][31][32][33]​​​​ Corticosteroid nasal irrigations are recommended in postoperative patients and as an option for those undergoing non-surgical therapy.[3]​ Oral antibiotics may be considered depending on examination/endoscopic findings, and response to initial treatment. If used, antibiotics should ideally be based on cultures.[21]

No antibiotics are approved by the US Food and Drug Administration (FDA) for use in chronic rhinosinusitis. The rationale for treatment in chronic rhinosinusitis is to eradicate bacterial infection. Antibiotics are also used in the short term for acute exacerbations, with a treatment duration shorter than 4 weeks.[21] Longer term antibiotics (≥4 weeks) may be considered if nasal saline irrigation and topical intranasal corticosteroids have not led to an improvement in symptoms after 3 months, particularly if the patient’s main complaint is discharge and/or facial pain.[27] Prolonged antibiotics may be utilised in patients with persistent purulence, but the evidence is not very strong and it is not common in practice.[21] One systematic review recommended a short (<3 weeks) course of antibiotics as a treatment option, except for macrolides, for which there is evidence of effectiveness for longer courses in selected patients.[34] One Cochrane review found moderate-quality evidence of a modest improvement in disease-specific quality of life in adults with chronic rhinosinusitis, without polyps, who had received three months of a macrolide antibiotic.[35] Culture-directed antibiotic therapy is preferred, but broad-spectrum coverage is often used. 

The FDA has issued a safety warning regarding the use of fluoroquinolones, stating that serious side effects associated with this class of antibiotic outweigh the benefits for patients with rhinosinusitis, bronchitis, and uncomplicated urinary tract infections who have other treatment options.[36] The FDA advises that for patients with these conditions, fluoroquinolones should be reserved for those who do not have alternative treatment options.

Patients should be assessed for underlying chronic conditions that would modify management, e.g., allergic rhinitis, asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia.[20] Adjunctive therapies that can be considered include short courses of oral corticosteroids and decongestants. Leukotriene receptor antagonists can also be considered, particularly in the setting of asthma, polyps, or severe allergic rhinitis.[21][28][32][37]​​ The FDA has strengthened its warning for montelukast (a leukotriene receptor antagonist) about serious behaviour- and mood-related changes. This action has been taken after re-evaluating the risks and benefits of montelukast following a review of safety data. For allergic rhinitis, the FDA have determined that montelukast should be reserved for those who are not treated effectively with, or cannot tolerate, other allergy medicines.[38]

Oral corticosteroids may be used in preparation for surgery or acute exacerbations.[27] If the patient has allergic symptoms, then antihistamines are useful. Allergic consultation may be warranted with subsequent immunotherapy in eligible patients with chronic or recurrent rhinosinusitis, allergic rhinitis, or persistent rhinosinusitis despite surgery.[21] Patients with asthma need optimisation of their pulmonary treatment. Smoking cessation improves the efficacy of medical and surgical treatment. 

Surgical treatment

Patients who are still significantly symptomatic with evidence of sinus inflammation on the post-therapy computed tomography scan are surgical candidates. Endoscopic sinus surgery (ESS) is performed to reestablish sinus ventilation and drainage by making the sinus openings and passageways (such as the ostiomeatal complex) wider. [Figure caption and citation for the preceding image starts]: Pre-op planning at a surgical navigation workstationFrom the personal collection of Dr Raj Sindwani; used with permission [Citation ends].com.bmj.content.model.Caption@76b7b5c0 For patients with extensive disease, previous surgery, or need for surgery in anatomically sensitive areas (e.g., frontal or sphenoid sinuses), intra-operative surgical navigation (or image-guided surgery) is advocated.[39][40] Image guidance systems are beneficial for pre-operative planning, as well as localisation during surgery, which may make the procedure safer. [Figure caption and citation for the preceding image starts]: Image-guided endoscopic sinus surgery using an optical-based surgical navigation systemFrom the personal collection of Dr Raj Sindwani; used with permission [Citation ends].com.bmj.content.model.Caption@4c87d478 This technology is now widely available, but still not considered a requirement or standard of care. Potential surgical complications include bleeding, infection, brain injury or cerebrospinal fluid leak, orbital injury (bruising, double-vision, or blindness), residual or recurrent sinus disease, need for revision surgery, smell disturbances, and issues related to general anaesthesia. Major complications (which include violation of the intracranial cavity and orbit) are very rare (<1%). Conventional ESS is very well tolerated and results in no bruising or cuts on the face. Nasal packing is seldom used. Patients should expect a significant improvement in symptoms and an early return to work after only a brief recovery period.[41] One US otolaryngology guideline focusing on postoperative pain management suggests that there is limited to no requirement for opioid use following ESS, and that alternative medications such as non-steroidal anti-inflammatory drugs should be used first line for pain.[42] When counselling patients before surgery, it is important to note that nasal obstruction improves the most, facial pain and discharge improve moderately, while headache and hyposmia improve least.[43] Fatigue and body pain also improve after ESS.[44][45]

Revision surgery may be necessary in some patients. In non-polypoid patients, structural issues (such as scar formation in a critical area, lateralisation of the middle turbinate obstructing drainage) may contribute to failure of procedure with recurrence of symptoms after surgery. In patients with hyperplastic or polypoid chronic rhinosinusitis, recurrence of polyps (a frequent occurrence in this subset) may require revision surgery.

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