title: Clinical practice guideline (update): adult sinusitis.
abstract: OBJECTIVE
  This update of a 2007 guideline from the American Academy of Otolaryngology--Head and Neck Surgery Foundation provides evidence-based recommendations to manage adult rhinosinusitis, defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. Changes from the prior guideline include a consumer added to the update group, evidence from 42 new systematic reviews, enhanced information on patient education and counseling, a new algorithm to clarify action statement relationships, expanded opportunities for watchful waiting (without antibiotic therapy) as initial therapy of acute bacterial rhinosinusitis (ABRS), and 3 new recommendations for managing chronic rhinosinusitis (CRS).
  
  
  OBJECTIVE
  The purpose of this multidisciplinary guideline is to identify quality improvement opportunities in managing adult rhinosinusitis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy for adult rhinosinusitis, promote appropriate use of ancillary tests to confirm diagnosis and guide management, and promote judicious use of systemic and topical therapy, which includes radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia.
  The update group made strong recommendations that clinicians (1) should distinguish presumed ABRS from acute rhinosinusitis (ARS) caused by viral upper respiratory infections and noninfectious conditions and (2) 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. The update group made recommendations that clinicians (1) should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS; (2) should prescribe amoxicillin with or without clavulanate as ﬁrst-line therapy for 5 to 10 days (if a decision is made to treat ABRS with an antibiotic); (3) should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management; (4) should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms; (5) should assess the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia; (6) should confirm the presence or absence of nasal polyps in a patient with CRS; and (7) should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. The update group stated as options that clinicians may (1) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis; (2) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation) for symptomatic relief of ABRS; and (3) obtain testing for allergy and immune function in evaluating a patient with CRS or recurrent ARS. The update group made recommendations that clinicians (1) should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected, and (2) should not prescribe topical or systemic antifungal therapy for patients with CRS.
authors.affiliation: Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, New York, USA richrosenfeld@msn.com.
authors.forename: Richard M
authors.initials: RM
authors.lastname: Rosenfeld
authors.affiliation: Department of Otolaryngology-Head and Neck Surgery, Washington University in St Louis, School of Medicine, St Louis, Missouri, USA.
authors.forename: Jay F
authors.initials: JF
authors.lastname: Piccirillo
authors.affiliation: New York Otology, New York Head and Neck Institute, New York, New York, USA.
authors.forename: Sujana S
authors.initials: SS
authors.lastname: Chandrasekhar
authors.affiliation: Department of Pediatrics, Georgetown University, Washington, DC, USA.
authors.forename: Itzhak
authors.initials: I
authors.lastname: Brook
authors.affiliation: Department of Family Medicine, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas, USA.
authors.forename: Kaparaboyna
authors.initials: K
authors.lastname: Ashok Kumar
authors.affiliation: Department of Otolaryngology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA.
authors.forename: Maggie
authors.initials: M
authors.lastname: Kramper
authors.affiliation: Division of Otolaryngology, University of Utah School of Medicine, Salt Lake City, Utah, USA.
authors.forename: Richard R
authors.initials: RR
authors.lastname: Orlandi
authors.affiliation: Department Otolaryngology, University of Pennsylvania Hospital, Philadelphia, Pennsylvania, USA.
authors.forename: James N
authors.initials: JN
authors.lastname: Palmer
authors.affiliation: Department of Otolaryngology Head & Neck Surgery, Emory University, Atlanta, Georgia, USA.
authors.forename: Zara M
authors.initials: ZM
authors.lastname: Patel
authors.affiliation: Department of Internal Medicine, Northwestern University Allergy Division, Chicago, Illinois, USA.
authors.forename: Anju
authors.initials: A
authors.lastname: Peters
authors.affiliation: Consumers United for Evidence-Based Healthcare, Davis, California, USA.
authors.forename: Sandra A
authors.initials: SA
authors.lastname: Walsh
authors.affiliation: AAO-HNS, Alexandria, Virginia, USA.
authors.forename: Maureen D
authors.initials: MD
authors.lastname: Corrigan
mesh_terms: D000047:Academies and Institutes; D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D006801:Humans; D010036:Otolaryngology / Q000379:methods*; D012220:Rhinitis / Q000175:diagnosis* / Q000628:therapy; D012852:Sinusitis / Q000175:diagnosis* / Q000628:therapy; D012955:Societies, Medical; D014481:United States; D057832:Watchful Waiting
chemical_list: D000900:Anti-Bacterial Agents
keywords: adult sinusitis; rhinosinusitis