Statement topic

Action recommendation

Level of evidence

Strength of recommendations

Study type

References

1.Definition:according to the duration

Acute rhinosinusitis (ARS) is considered when symptoms and signs are present less than 4 weeks.

Very low

Strong recommendation

Expert opinion

12,14

2.Diagnosis:symptoms

Acute rhinosinusitis (ARS) usually presents with multiple symptoms including nasal congestion or blockage, nasal drainage or postnasal drainage (PND), and facial pressure/pain.

Very low

Strong recommendation

Expert opinion

12,14

3.Diagnosis:parameters

Diagnosis is clinical and depends on symptoms and signs rather than radiology.

Very low

Conditional recommendation

Expert opinion

12,14

4.Diagnosis:Examination

A thorough physical examination that includes inspection, palpation of the maxillary and frontal sinus, as well as anterior rhinoscopy (evidence of inflammation, mucosal oedema, and discharge).

Very Low

Conditional recommendation

Expert opinion

12,15

5.Diagnosis:Investigations

Objective evidence of ARS on nasal endoscopy, antral puncture, or radiographic imaging (X-ray, ultrasonography, or CT) is not required for the diagnosis in uncomplicated cases

High

Strong Recommendation (against)

Systematic review

12,16

6.Diagnosis:Investigations

-ESR and CRP are inflammatory markers found to be elevated during ARS, but they are not routinely used for diagnosis because of their limited specificity.

-They may have some role in COVID-19 related symptoms

Moderate

Conditional recommendation

Systematic review

12,16

7. Differentiating viral from bacterial:

-Differentiating between Acute bacterial rhinosinusitis (ABRS) and acute viral rhinosinusitis (AVR) can be challenging even in the setting of endoscopy and cultures. Close follow-up of patient symptomology can often help in making the diagnosis, especially for patients that do not improve with supportive care.

-Duration is thought to be a key factor differentiating ABRS from AVR, with persistence of symptoms beyond 7-10 days or worsening of symptoms after 5 days being indicators of development of post-viral ABRS.

-Clinical factors associated with ABRS include without evidence:

Timing of the disease, worsening of the disease, purulent nasal discharge on rhinoscopy, localized unilateral pain, severe pain over the teeth and maxilla, and fever > 38˚C.

Moderate

Strong recommendation

Systematic review

12,17

8. Pathophysiology of ARS:-Anatomic variants and septal Deviation

-Nasal allergy

-Viruses

-Odontogenic rhinosinusitis

 -The evidence for association between ARS and anatomic variants is conflicting and limited and largely inferred from a small number of studies.

-Population-based studies seem to support an association between allergic rhinitis (AR) and ARS.

-The epidemiologic studies show that a subset of patients with viral URI will develop clinical ARS.

-The current literature demonstrates an absence of a well-designed and published investigation into the role of odontogenic infections in ARS.

 Moderate

Low

High

Very Low

 Conditional

Strong

strong

Conditional

 Systematic review

Cross sectional

Systematic review

Expert consensus

 18

19

20

21

9.Treatment: Antibiotics

- Consider initial watchful waiting in uncomplicated cases, with institution of antibiotic therapy if no improvement after 4-7 days or worsening at any time, or for mitigating circumstances with drug resistance e.g., including severe symptoms, immunocompromised state, concern for impending complications, suspected odontogenic source, prior antibiotics (1 month), prior hospitalization (5 days) and comorbidities.

-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

Moderate

Conditional recommendation

Systematic review

12,22,23

10.Choice of antibiotic for ABRS

-If a decision is made to treat ABRS with an antibiotic agent, the clinician should prescribe amoxicillin with clavulanate as first-line therapy for 5 to 10 d for most adults.

-Options after failing amoxicillin + clavulanate or for penicillin allergy include trimethoprim-sulfamethoxazole, doxycycline, or a fluoroquinolone.

Moderate

Conditional recommendation

Systematic review

12,22,23

11.Treatment:Corticosteroids (INC)

-Systemic Corticosteroids

-INCS can be used according to the doctor judgment as monotherapy in mild to moderate ARS or as adjuvant to antibiotic therapy in severe cases of ARS.

-Given the conflicting evidence, there is no recommendation for systemic corticosteroids in cases of uncomplicated ARS

High

Moderate

Strong recommendation

Strong recommendation

against

Systematic review

Randomized Controlled Trial

12,24,25

26

12.Topical saline spray and irrigation

Saline irrigation may be used in adjunct with antibiotics for ABRS.

Moderate

Strong recommendation

Systematic review

12,27

13. Decongestant

Decongestants are an option in ABRS. Decongestants can reduce congestion in patients with ABRS however side effects should be considered.

Moderate

Conditional recommendation

Systematic review

12,28

14.Antihistamimine

Antihistamines are an option in ABRS with comorbid AR and can be used to decrease symptoms of AR.

Moderate

Conditional recommendation

Systematic review

12,29

15.Others

no recommendation can be given for mucolytics, herbals in ABRS.

Very Low

No recommendation

Case series

12,30

16.Treatment: Adjuvants for VRS

-Clinicians may recommend:

Analgesics, topical intranasal steroids INC, and/or nasal saline irrigation NSI for symptomatic relief of VRS 

Moderate

Conditional recommendation

Systematic review

12,14,31

17.Treatment: Adjuvants for ABRS

- Clinicians may recommend analgesics, topical intranasal steroids, and/or NSI

Moderate

Conditional recommendation

Systematic review

12,14,31

18.Complications:

- In patients with ABRS suspected to have suppurative complications, axial, coronal and sagittal views with contrast-enhanced computed tomography (CT) is recommended to localize the infection and to guide further treatment.

-Magnetic resonance imaging (MRI) provides soft tissue visualization and is useful when there is concern for intracranial involvement. Magnetic resonance venography may be useful for evaluation of the cavernous sinus and other vasculature.

-The hallmarks of management are swift diagnosis, rapid initiation of broad-spectrum intravenous antibiotics, and in many cases surgical intervention.

-While endoscopic sinus surgery (ESS) is usually a sufficient approach for addressing orbital complications, open neurosurgical intervention is often required for even sub-centimeter intracranial abscess

Low

Conditional recommendation

Case series

12,32

19.Recurrent Acute Rhinosinusitis (RARS)

-Diagnosis:

-Treatment:

I-NC

2. Antibiotics

3. Endoscopic sinus surgery ESS /Balloon sinus dilatation (BSD)

- At least 4 attacks of ABRS are a required criterion

-Nasal endoscopy and/or CT imaging are an option during at least one episode of suspected RARS to appropriately confirm and diagnose RARS, and distinguish it from other diagnoses such as allergy exacerbation or primary headache syndromes.

-Consider immunologic testing, allergic testing, and bacterial culture in patients with concern for RARS

-Option for use of INCS spray for sinonasal symptoms during acute exacerbations of RARS.

-As in ABRS

-ESS or BSD is recommended for patients with RARS.

Low

Very low

Very Low

Very low

Low

Conditionnel recommandation

Conditionnel recommandation

Conditionnel recommandation

Conditionnel

Conditionnel Recommandation 

Systematic review

Expert opinion

Expert opinion

Expert opinion

Expert opinion

12,32,33

12,33

12,32,33

12,32,33

12,32,33