Adult Sinusitis Guidelines Updated

Laurie Barclay, MD

April 03, 2015

The American Academy of Otolaryngology–Head and Neck Surgery Foundation has presented an updated clinical practice guideline on adult sinusitis, with a greater focus on patient education and patient preference, published April 1 in Otolaryngology–Head and Neck Surgery.

In the United States, sinusitis affects approximately one in eight adults, with more than 30 million diagnoses and $11 billion in direct costs per year. More than one in five antibiotics prescribed in adults are for sinusitis.

"More than ever before, there is a prominent role for shared decision-making between patients and clinicians when managing adult sinusitis — especially in deciding whether to use antibiotics for acute bacterial sinusitis or to instead try 'watchful waiting' to see if a patient can fight the infection on his or her own," guidelines chair Richard M. Rosenfeld, MD, MPH, said in a news release.

The update recommends watchful waiting for initial management of all patients with uncomplicated acute bacterial rhinosinusitis, regardless of severity, and not just for those with "mild" illness, as in the 2007 guideline.

"Intuitively clinicians often feel that sicker patients benefit more from antibiotics, but our recommendation is that watchful waiting or antibiotics are both appropriate," Dr Rosenfeld said. "This empowers patients and clinicians to use antibiotic judiciously, reserving antibiotics for cases that get worse or don't improve over time."

Another area benefitting from shared decision making is choice of symptomatic treatment, including analgesics, topical intranasal steroids, and nasal saline irrigation. The update includes a new algorithm to clarify decision-making and action statement relationships.

A multidisciplinary panel of experts in otolaryngology–head and neck surgery, infectious disease, family medicine, allergy and immunology, advanced practice nursing, and a consumer advocate updated this clinical guideline based on current evidence.

Additional changes from the 2007 guideline to the 2015 update include:

  • The addition of additional information regarding the role of analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of acute bacterial sinusitis.

  • Changed recommendation for the preferred agent when antibiotics are prescribed. The 2007 guideline called for amoxicillin alone, whereas the 2015 update recommends amoxicillin with or without clavulanate.

  • Inclusion of several recommendations for management of chronic rhinosinusitis, which was not addressed in the 2007 guideline. These include addition of asthma and of polyps as chronic conditions modifying chronic rhinosinusitis management, a recommendation for use of topical intranasal therapy (saline irrigations or corticosteroids), and a recommendation against using topical or systemic antifungal agents.

"The update group made strong recommendations that clinicians (1) should distinguish presumed [acute bacterial rhinosinusitis] from acute rhinosinusitis...caused by viral upper respiratory infections and noninfectious conditions and (2) should confirm a clinical diagnosis of [chronic rhinosinusitis] with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography," the authors write.

The American Academy of Otolaryngology–Head and Neck Surgery Foundation funded this guideline update and employs one of its authors. Some of the other guidelines authors reported various financial relationships with Scientific Development and Research, National Procedures Institute, Fetal Alcohol Spectrum of Disorders , Medtronic, Pathway–HC Pathways, Arthrocare, Baxter, and/or Greer Laboratories.

Otolaryngol Head Neck Surg. 2015;152:S1-S39. Full text

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