Rhinosinusitis (RS) is inflammation of the sinuses and nasal cavity, significantly impacting quality of life and healthcare costs, affecting over 12% of the U.S. population. It can be classified as acute, recurrent acute, or chronic, with varying symptoms and treatment options, including antibiotics for bacterial cases and intranasal steroids for chronic cases. The prevalence and treatment of chronic rhinosinusitis (CRS) highlight its complexity, with various potential modifying factors and a lack of definitive etiology.

1. Rhinosinusitis
O ve r vi e w , d i a g n o s i s a n d
m a n a g e m e n t

2. Introduction
• Rhinosinusitis (RS) is defined as inflammation
of the sinuses and nasal cavity
• Rhinosinusitis may be classified based on
duration
• The term, “rhinosinusitis” is preferred over
“sinusitis” because inflammation of the sinus
cavities is almost always accompanied by
inflammation of the nasal cavities
• RS is one of the most commonly diagnosed
diseases in the world and is believed to affect
more than 12% of the US population

3. RS impacts quality of life
• Rhinosinusitis is associated with significant
negative impact on quality of life
• It is also associated with high healthcare costs
due to medical visits, prescriptions and over
the counter medications, sinus surgeries and
missed days from work and school
• Vast majority of patients with RS see primary
care physicians
• Other specialists including allergists and
otolaryngologists also see patients with
rhinosinusitis, especially those that are difficult
to treat.

4. Classification: duration of symptoms and
inflammation
• Acute rhinosinusitis (ARS) is
defined as symptoms lasting less
than 12 weeks
• ARS is further classified based on
duration and presumed etiology as
• Viral rhinosinusitis (VRS)
• Acute bacterial rhinosinusitis
(ABRS)
• Recurrent acute rhinosinusitis
(RARS) consists of 3 or more
episodes of acute bacterial
rhinosinusitis (ABRS) in a year
• Chronic rhinosinusitis (CRS) is
defined as symptoms lasting longer
than 12 weeks and is further
classified based on clinical and
inflammatory patterns as
• CRS with nasal polyps (CRSwNP)
• CRS without nasal polyps
(CRSsNP)

5. Acute rhinosinusitis (ARS) and
recurrent acute rhinosinusitis
(RARS)
• Most ARS are viral in origin and improve on
their own
• It is important to distinguish viral from
bacterial RS so as to not prescribe
antibiotics unnecessarily for VRS
• ABRS is diagnosed when symptoms of an
upper respiratory tract infection persist
longer than 10 to 14 days or for at least 10
days beyond the onset of upper respiratory
symptoms
• ABRS is also likely when symptoms worsen
after an initial improvement
• Only about 2% of VRS become ABRS

6. ABRS: bacteriology and diagnosis
• Most common bacteria responsible for ABRS
are Streptococcus pneumoniae, Hemophilus
influenzae, and Moraxella catarrhalis.
• Staphylococcus aureus is also isolated in adults
with ABRS
• ABRS is primarily a clinical diagnosis and
radiographic imaging with a sinus computed
tomography (CT) scan is recommended only if a
complication or alternative diagnosis is suspected
• RARS presents similarly with three or more
episodes of acute rhinosinusitis however patients
are asymptomatic in between episodes of acute
infection.

7. ARS: Symptoms & PE
• Nasal congestion or obstruction, facial or dental
pain, purulent rhinorrhea, post nasal drainage,
headache and cough
• Additional signs associated with ABRS can
include fever, fatigue, hyposmia, ear fullness or
pressure
• HEENT exam
• Pulmonary evaluation
• Tenderness on palpation overlying the sinuses,
purulent nasal or oropharyngeal secretions
• Fever may or may not be present
• Attention should be paid to the periorbital and
cheek areas of the face to look for cellulitis or
extra sinus involvement
• Culture from the nasal cavity is not useful.

8. Therapy
• Supportive therapy with analgesics and
nasal saline irrigation may provide
symptomatic relief
• Topical decongestants may improve
symptoms but should not be used for
more than 3 to 5 consecutive days
• Topical intranasal steroids improve
symptoms and have shown a higher rate
of clinical success and more rapid
recovery when used with antibiotics

9. Antibiotic recommendations
• Antibiotics are recommended if symptoms of
rhinosinusitis last longer than 10 days
• If patients don’t improve by 7 days after
ABRS diagnosis or worsen after initial
improvement
• Antibiotics should be used earlier if there is
evidence of complications such as periorbital
swelling or redness
• Most guidelines recommend 10-14 days of
therapy with antibiotics.
• Endoscopic surgical intervention is required
when there is a risk of intracranial
complication or in a patient with periorbital or
intraorbital abscess

10. Antibiotics for acute bacterial rhinosinusitis
Primary antibiotic choice Secondary antibiotic choice
IDSA clinical practice guidelines
Amoxicillin-clavulonate Levofloxacin (if Type I hypersensitivity to ß
lactam in children or adults) Clindamycin (if
non-type 1 hypersensitivity in children)
Doxycycline (ß lactam allergy in adults)
Canadian guidelines
Amoxicillin
Amoxicillin/clavulonic acid or quinolones
(if risk of bacterial resistance is high)
Trimethoprim-sulfamethoxazole or a
macrolide (if ß lactam allergy)
AAO-HNS Clinical practice guideline (Update): Adult Sinusitis
Amoxicillin with or without clavulonate Doxycycline, levofloxacin or moxifloxacin (ß
lactam allergy)
American Academy of Pediatrics
Amoxicillin with or without clavulonate Cefdinir, cefuroxime, or ceftriaxone (non type-
1 or type-1 penicillin allergy) Fluoroquinolones

11. Chronic rhinosinusitis (CRS)
• Worldwide the prevalence of CRS
ranges from about 7% in Korea,
10% in Europe and 12% in the
United States
• The exact etiology of CRS is not
known and infection and
inflammation are believed to play a
role
• The diagnosis of CRS is made
when patients have symptoms
consistent with CRS for greater than
12 weeks in conjunction with
evidence of inflammation on
endoscopy and/or sinus CT scan

12. CRS Classification &
pathogenesis
• CRS is often categorized as CRS
without nasal polyps (CRSsNP)
and CRS with nasal polyps
(CRSwNP)
• The exact pathogenesis of CRS is
not known but inflammation with
eosinophils, neutrophils and
lymphocytes is associated with
CRS
• Th2 eosinophilic inflammation is
characteristic of nasal polyps from
• The role of bacteria is uncertain
especially in CRSwNP.

13. CRS symptoms
• facial pressure or pain
• post-nasal drainage
• nasal blockage
• Anosmia
• Hyposmia
• fatigue

14. Physical exam for CRS
• HEENT
• Pulmonary evaluation may also be
needed given the high rates of
coexistence of asthma
• Examination either by nasal endoscopy
or anterior rhinoscopy may show purulent
mucus or edema in the middle meatus or
ethmoid area or polyps.
• A sinus CT may be needed for objective
confirmation of sinonasal inflammation
and to distinguish CRS from other
conditions that have similar symptoms
(for example allergic rhinitis, atypical
facial pain).

15. Therapy
• Topical intranasal corticosteroids are recommended to decrease inflammation and are beneficial in
both CRSwNP and CRSsNP
• Short-term oral corticosteroids (for CRSwNP) help shrink nasal polyps and reduce inflammation
• Saline nasal irrigation is recommended for CRS and has shown to improve symptoms and quality of
life
• Antibiotics are used for acute exacerbations of CRS
• Aspirin desensitization, is a potential therapeutic option for patients with AERD. This procedure
consists of administration of incremental oral doses of aspirin over 1-2 days until a dose of 650mg
of aspirin can be taken
• Biologic therapies with monoclonal antibodies such as omalizumab (anti IgE)
• Functional endoscopic sinus surgery may be considered in patients who fail medical therapy.

16. Common modifying factors associated with rhinosinusitis
Asthma
Granulomatosis with polyangiitis (Wegner’s granulomatosis)
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
Immunodeficiencies: common variable immune deficiency, IgA deficiency, specific
antibody deficiency, acquired immunodeficiency syndrome (AIDS)
Genetic abnormalities: cystic fibrosis, ciliary dyskinesia, Young’s syndrome
Gastroesophageal reflux disease
Sleep apnea
Sarcoidosis
Allergic rhinitis

17. THANK YOU!