Table 1 Guideline Statements and Strengths for Acute Bacterial Rhinosinusitis and Chronic Rhinosinusitis

Acute Bacterial Rhinosinusitis

1: ABRS may be diagnosed on clinical grounds using symptoms and signs of more than 7 days duration.

2. Determination of symptom severity is useful for the management of acute sinusitis, and can be based upon the intensity and duration and impact on patient's quality of life.

3: Radiological imaging is not required for the diagnosis of uncomplicated ABRS. When performed, radiological imaging must always be interpreted in light of clinical findings as radiographic images cannot differentiate other infections from bacterial infection and changes in radiographic images can occur in viral URTIs.

Criteria for diagnosis of ABRS are presence of an air/fluid level or complete opacification. Mucosal thickening alone is not considered diagnostic. Three-view plain sinus X-rays remain the standard. Computed tomography (CT) scanning is mainly used to assess potential complications or where regular sinus X-rays are no longer available.

Radiology should be considered to confirm a diagnosis of ARBS in patients with multiple recurrent episodes, or to eliminate other causes.

4: Urgent consultation should be obtained for acute sinusitis with unusually severe symptoms or systemic toxicity or where orbital or intracranial involvement is suspected.

5: Routine nasal culture is not recommended for the diagnosis of ABRS. When culture is required for unusual evolution, or when complication requires it, sampling must be performed either by maxillary tap or endoscopically-guided culture.

6: The 2 main causative infectious bacteria implicated in ABRS are Streptococcus pneumoniae and Haemophilus influenzae.

7: Antibiotics may be prescribed for ABRS to improve rates of resolution at 14 days and should be considered where either quality of life or productivity present as issues, or in individuals with severe sinusitis or comorbidities. In individuals with mild or moderate symptoms of ABRS, if quality of life is not an issue and neither severity criterion nor comorbidities exist, antibiotic therapy can be withheld.

8: When antibiotic therapy is selected, amoxicillin is the first-line recommendation in treatment of ABRS. In beta-lactam allergic patients, trimethoprim-sulfamethoxazole (TMP/SMX) combinations or a macrolide antibiotic may be substituted.

9: Second-line therapy using amoxicillin/clavulanic acid combinations or quinolones with enhanced gram positive activity should be used in patients where risk of bacterial resistance is high, or where consequences of failure of therapy are greatest, as well as in those not responding to first-line therapy. A careful history to assess likelihood of resistance should be obtained, and should include exposure to antibiotics in the prior 3 months, exposure to daycare, and chronic symptoms.

10: Bacterial resistance should be considered when selecting therapy.

11: When antibiotics are prescribed, duration of treatment should be 5 to 10 days as recommended by product monographs. Ultra-short treatment durations are not currently recommended by this group.

12: Topical intranasal corticosteroids (INCS) can be useful as sole therapy of mild-to-moderate ARS.

13: Treatment failure should be considered when patients fail to respond to initial therapy within 72 hours of administration. If failure occurs following use of INCS as monotherapy, antibacterial therapy should be administered. If failure occurs following antibiotic administration, it may be due to lack of sensitivity to, or bacterial resistance to, the antibiotic, and the antibiotic class should be changed.

14: Adjunct therapy should be prescribed in individuals with ABRS.

15. Topical INCS may help improve resolution rates and improve symptoms when prescribed with an antibiotic.

16. Analgesics (acetaminophen or non-steriodal anti-inflammatory agents) may provide symptom relief.

17. Oral decongestants may provide symptom relief.

18. Topical decongestants may provide symptom relief.

19. Saline irrigation may provide symptom relief.

20. For those not responding to a second course of therapy, chronicity should be considered and the patient referred to a specialist. If waiting time for specialty referral or CT exceeds 6 weeks, CT should be ordered and empiric therapy for CRS administered. Repeated bouts of acute uncomplicated sinusitis clearing between episodes require only investigation and referral, with a possible trial of INCS. Persistent symptoms of greater than mild-to-moderate symptom severity should prompt urgent referral.

21: By reducing transmission of respiratory viruses, hand washing can reduce the incidence of viral and bacterial sinusitis. Vaccines and prophylactic antibiotic therapy are of no benefit.

22: Allergy testing or in-depth assessment of immune function is not required for isolated episodes but may be of benefit in identifying contributing factors in individuals with recurrent episodes or chronic symptoms of rhinosinusitis.

Chronic Rhinosinusitis

23: CRS is diagnosed on clinical grounds but must be confirmed with at least 1 objective finding on endoscopy or computed tomography (CT) scan.

24: Visual rhinoscopy assessments are useful in discerning clinical signs and symptoms of CRS.

25: In the few situations when deemed necessary, bacterial cultures in CRS should be performed either via endoscopic culture of the middle meatus or maxillary tap but not by simple nasal swab.

26: The preferred means of radiological imaging of the sinuses in CRS is the CT scan, preferably in the coronal view. Imaging should always be interpreted in the context of clinical symptomatology because there is a high false-positive rate.

27: CRS is an inflammatory disease of unclear origin where bacterial colonization may contribute to pathogenesis. The relative roles of initiating events, environmental factors, and host susceptibility factors are all currently unknown.

28: Bacteriology of CRS is different from that of ABRS.

29: Environmental and physiologic factors can predispose to development or recurrence of chronic sinus disease. Gastroesophageal reflux disease (GERD) has not been shown to play a role in adults.

30: When diagnosis of CRS is suggested by history and objective findings, oral or topical steroids with or without antibiotics should be used for management.

31: Many adjunct therapies commonly used in CRS have limited evidence to support their use. Saline irrigation is an approach that has consistent evidence of benefiting symptoms of CRS.

32. Use of mucolytics is an approach that may benefit symptoms of CRS.

33. Use of antihistamines is an approach that may benefit symptoms of CRS.

34. Use of decongestants is an approach that may benefit symptoms of CRS.

35. Use of leukotriene modifiers is an approach that may benefit symptoms of CRS.

36: Failure of response should lead to consideration of other possible contributing diagnoses such as migraine or temporomandibular joint dysfunction (TMD).

37: Surgery is beneficial and indicated for individuals failing medical treatment.

38: Continued use of medical therapy post-surgery is key to success and is required for all patients. Evidence remains limited.

39 Part A: Patients should be referred by their primary care physician when failing 1 or more courses of maximal medical therapy or for more than 3 sinus infections per year.

39 Part B: Urgent consultation with the otolaryngologist should be obtained for individuals with severe symptoms of pain or swelling of the sinus areas or in immunosuppressed patients.

40: Allergy testing is recommended for individuals with CRS as potential allergens may be in their environment.

41: Assessment of immune function is not required in uncomplicated cases.

42: Prevention measures should be discussed with patients.