Published: April 3, 2015


Adapted from the April 2015 Supplement to Otolaryngology–Head and Neck Surgery. Read the guideline at

adultsinusitisAdapted from the April 2015 Supplement to Otolaryngology–Head and Neck Surgery. Read the guideline at

When the AAO-HNSF first released “Clinical Practice Guideline: Adult Sinusitis” in 2007, it was “the first to outline a clear, evidence-based strategy for watchful waiting (without antibiotics) for acute bacterial rhinosinusitis,” said Richard M. Rosenfeld, MD, MPH, who chaired both the 2007 guideline and the 2015 update, released this month as a supplement to Otolaryngology–Head and Neck Surgery.

“In the previous guideline, watchful waiting was suggested as an ‘option.’ We now have substantial new evidence that allows us to ‘recommend’ watchful waiting or antibiotic therapy for mild, moderate, or even severe acute bacterial rhinosinusitis,” said Dr. Rosenfeld. “This empowers patients and clinicians to use antibiotics judiciously, reserving them for cases that don’t improve after waiting or that begin to worsen.”

Other differences between the 2007 guideline and the 2015 update include:

  • more explicit details about the role of analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of acute bacterial rhinosinusitis;
  • a recommendation of amoxicillin with or without clavulanate when antibiotics are prescribed, whereas the prior guideline recommended amoxicillin alone;
  • several statements about chronic rhinosinusitis, the management of which was not discussed at all in the 2007 guideline.
Two posters about adult sinusitis were included with the April print issue of the Bulletin. Patient information has also been updated.Two posters about adult sinusitis were included with the April print issue of the Bulletin. Patient information has also been updated.

“Overall, the updated guideline has a greater focus on patient education and shared decision-making among patients and physicians,” Dr. Rosenfeld said.

Sinusitis affects about one in eight adults in the United States, resulting in more than 30 million annual diagnoses. This updated multidisciplinary guideline identifies quality improvement opportunities in managing adult rhinosinusitis and includes explicit, actionable recommendations to implement in clinical practice. The full guideline and patient information, as well as other resources, are available at

Guideline recommendations

Differential diagnosis of acute rhinosinusitis
Clinicians should distinguish presumed acute bacterial rhinosinusitis (ABRS) from acute rhinosinusitis (ARS) caused by viral upper respiratory infections and noninfectious conditions. A clinician should diagnose ABRS when (a) symptoms or signs of ARS (purulent nasal drainage accompanied by nasal obstruction, facial pain-pressure-fullness, or both) persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of ARS worsen within 10 days after an initial improvement (double worsening).

Radiographic imaging and acute rhinosinusitis
Clinicians should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected.

Symptomatic relief of viral rhinosinusitis (VRS)
Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of VRS.

Symptomatic relief of acute bacterial rhinosinusitis
Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of ABRS.

Initial management of acute bacterial rhinosinusitis
Clinicians should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS. Watchful waiting should be offered only when there is assurance of follow-up, such that antibiotic therapy is started if the patient’s condition fails to improve by seven days after ABRS diagnosis or if it worsens at any time.

Choice of antibiotic for acute bacterial rhinosinusitis
If a decision is made to treat ABRS with an antibiotic agent, the clinician should prescribe amoxicillin with or without clavulanate as first-line therapy for five to 10 days for most adults.

Treatment failure for acute bacterial rhinosinusitis
If the patient fails to improve with the initial management option by seven days after diagnosis, or worsens during the initial management, the clinician should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications. If ABRS is confirmed in the patient initially managed with observation, the clinician should begin antibiotic therapy. If the patient was initially managed with an antibiotic, the clinician should change the antibiotic.

Diagnosis of chronic rhinosinusitis (CRS) or recurrent acute rhinosinusitis
Clinicians should distinguish chronic rhinosinusitis and recurrent acute rhinosinusitis from isolated episodes of acute bacterial rhinosinusitis and other causes of sinonasal symptoms.

Objective confirmation of a diagnosis of chronic rhinosinusitis
The clinician should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography.

Modifying factors
Clinicians should assess the patient with CRS or recurrent acute rhinosinusitis for multiple chronic conditions that would modify management such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia.

Testing for allergy and immune function
The clinician may obtain testing for allergy and immune function in evaluating a patient with chronic rhinosinusitis or recurrent acute rhinosinusitis.

Chronic rhinosinusitis with polyps
The clinician should confirm the presence or absence of nasal polyps in a patient with CRS.

Topical intranasal therapy for chronic rhinosinuisitis
Clinicians should recommend saline nasal irrigation, topical intranasal corticosteroids, or both, for symptom relief of CRS.

Antifungal therapy for chronic rhinosinuisitis
Clinicians should not prescribe topical or systemic antifungal therapy for patients with CRS.

Guideline authors

Richard M. Rosenfeld, MD, MPH; Jay F. Piccirillo, MD; Sujana S. Chandrasekhar, MD; Itzhak Brook, MD, MSc; Kaparaboyna Ashok Kumar, MD, FRCS; Maggie Kramper, RN, FNP; Richard R. Orlandi, MD; James N. Palmer, MD; Zara M. Patel, MD; Anju Peters, MD; Sandra A. Walsh, BS (MdT); and Maureen D. Corrigan, BA.


The clinical practice guideline is provided for information and educational purposes only. It is not intended as a sole source of guidance in managing adults with rhinosinusitis. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition and may not provide the only appropriate approach to diagnosing and managing this program of care. As medical knowledge expands and technology advances, clinical indicators and guidelines are promoted as conditional and provisional proposals of what is recommended under specific conditions but are not absolute. Guidelines are not mandates; these do not and should not purport to be a legal standard of care. The responsible physician, in light of all circumstances presented by the individual patient, must determine the appropriate treatment.

Adherence to these guidelines will not ensure successful patient outcomes in every situation. The AAO-HNSF emphasizes that these clinical guidelines should not be deemed to include all proper treatment decisions or methods of care, or to exclude other treatment decisions or methods of care reasonably directed to obtaining the same results.



More from April 2015 - Vol. 34 No. 03

Dr. Curotta, nurse, and a happy patient at Baucau, East Timor.
Australian otolaryngology outreachExpanded from the print edition
By John Curotta, FRACS, Director of the Department ENT Surgery, Head of the Discipline ENT Surgery, Sydney University, Australia, and Immediate Past President of ASOHNS Australian otolaryngologists provide clinic and surgical ENT services mainly to South Pacific island nations, to Papua New Guinea, and to Timor Leste. Our humanitarian missions are tasked to those with the least ability to access care and to training, mentoring, and supporting those who will continue their care when we leave. The islands in the South Pacific, while beautiful, are small, remote, and very dispersed—Tonga, Vanuatu, Cook Islands, Solomon Islands (Guadalcanal), Samoa, Tuvalu, and Kiribati are visited. Kiribati is halfway from Australia to Hawaii, and has only 100,000 people on 33 islands totalling 350 square miles land (about six times the size of the District of Columbia) dotted over 1.35 million sq. miles of ocean. So there is little movement within the country and major difficulties for teams to get there, then get around. Timor Leste (East Timor), with a population of 1.1 million, is one of the newest nations. It shares a border with Indonesia, population 250 million. Four out of five Timorese live on less than US $2 per day. At Independence 12 years ago there was one doctor and the remains of a couple of hospitals and 90 percent of the population was unable to read or write. This is already down to 50 percent and the Guido Valdares National Hospital is running well with a strong educational ethos. Our ENT team consists of a surgeon, anaesthesiologist, audiologist, and a nurse or sometimes a surgical resident. The standard tour is one week, with four to five trips to Timor each year. Microscopes have been prepositioned but all other special equipment and medications are taken in. The first day or two is clinical assessment, including audiology, and usually 50 to 150 patients are seen and about 20 offered surgery. Four to five mastoidectomies and eight to 12 myringoplasties are done. Reinforcing instruction and training of ear care nurses, supplying medications, and reminding these people in remote places that they are not forgotten probably give more benefit than our few surgeries can accomplish.
Whether physicians like it or not, politics play a significant role in healthcare. It is tempting to ignore this fact, but to do so is a disservice to our patients and our profession. Accepting and embracing the situation allows us the opportunity to ensure that the impact of legislative policies on our patients is understood and that the voice of the physician is heard. Go, team, go Though physicians are thought to be independent, in fact we work in teams on a daily basis. Whether we are in the operating room or the office, we work with the anesthesiologists, nurses, techs, medical assistants, and administrative staff to achieve the ultimate goal of high quality, efficient patient care. We could not achieve our goals if we were not working together in a concerted effort. When it comes to advocacy, however, physicians struggle with pulling together, especially when compared to groups such as the trial attorneys or various nonphysician providers. Also, politics is a numbers game, and success is often quantified by who can garner the most signatures, who can raise the most money, or who has the greatest number of supporters. To increase the impact of our specialty’s message, we need clout in the form of numbers. To do this, we need to increase Academy member involvement in our legislative and political programs. Members of Congress are increasingly savvy at deciphering the number of otolaryngologists (constituents) represented by a particular initiative. So, every person who gets involved in AAO-HNS’ respective legislative or political programs ultimately helps us to achieve our goals. This “head count” is very important! Look for ways to participate in legislative and political advocacy, and show Members of Congress that all otolaryngologists are interested in protecting high-quality patient care. No ‘i’ in team Life teaches us that one-to-one interactions make the greatest impressions. By reaching out to a Member of Congress, we have the opportunity to make our message personal. There is also the opportunity to educate. Physicians have the best perspective of the impact governmental policy has on the delivery of healthcare. Our patients may feel the effects, but in most cases, they are not aware of the policies that lead to those outcomes. And though they vote on the policies, most Members of Congress are not intimately aware of the impact those policies have on patients and the practice of medicine. As physicians, we are the bridge between our patients and our legislators, and we owe it to our patients to advocate for their care. Fortunately, through the In-district Grassroots Outreach (I-GO) program, the Academy has staff dedicated to assisting otolaryngologists with arranging individualized interactions. These events can be tailored to each member’s comfort level and range from one-to-one meetings, practice visits, fundraising events, or larger town hall events. There is no “I” in team, but there is an “I” in I-GO! So, the answer to the question whether advocacy is an individual or team sport is … YES. By combining efforts on an individual basis that make our message personal with a collective voice to make sure we are heard, we can achieve our advocacy and patient care goals. *Contributions to ENT PAC are not deductible as charitable contributions for federal income tax purposes. Contributions are voluntary, and all members of the American Academy of Otolaryngology-Head and Neck Surgery have the right to refuse to contribute without reprisal. Federal law prohibits ENT PAC from accepting contributions from foreign nationals. By law, if your contributions are made using a personal check or credit card, ENT PAC may use your contribution only to support candidates in federal elections. All corporate contributions to ENT PAC will be used for educational and administrative fees of ENT PAC, and other activities permissible under federal law. Federal law requires ENT PAC to use its best efforts to collect and report the name, mailing address, occupation, and the name of the employer of individuals whose contributions exceed $200 in a calendar year.