Rhinosinusitis: evidence and experience

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TL;DR

This Brazilian consensus guideline provides comprehensive, evidence-based recommendations for the diagnosis and management of acute and chronic rhinosinusitis in both adults and children. It emphasizes the importance of distinguishing viral from bacterial acute rhinosinusitis to reduce unnecessary antibiotic use, and highlights the role of topical corticosteroids and saline irrigation as first-line therapies for chronic rhinosinusitis. The guideline also details the pathophysiology, associated conditions, and surgical indications for refractory cases.

Full summary

5,297 CHARS

**Background** Rhinosinusitis (RS) is an inflammatory process of the nasal mucosa and paranasal sinuses, classified as acute (ARS; <12 weeks) or chronic (CRS; ≥12 weeks). Severity is graded using a visual analog scale (VAS) from 0 to 10 cm: mild (0-3 cm), moderate (>3-7 cm), and severe (>7-10 cm). This Brazilian consensus guideline, coordinated by Wilma T. Anselmo-Lima and Eulalia Sakano, synthesizes current evidence and expert experience to provide practical recommendations for diagnosis, medical and surgical treatment, and management of complications.

**Methods** The guideline was developed by a panel of Brazilian otorhinolaryngologists who reviewed the literature and existing international position papers (e.g., EPOS 2012). Recommendations are based on available evidence, with levels of evidence and grades of recommendation noted where applicable. The document covers ARS and CRS in adults and children, including definitions, classification, associated factors, clinical diagnosis, complementary examinations, medical and surgical treatment, and special considerations.

**Key Results** - **Acute Rhinosinusitis (ARS):** Viral ARS (common cold) typically lasts <10 days. Post-viral ARS is defined by symptom worsening after 5 days or persistence >10 days. Acute bacterial RS (ABRS) occurs in only 0.5% to 2% of post-viral cases. Diagnosis is clinical, based on ≥2 cardinal symptoms (nasal obstruction, rhinorrhea, facial pain/pressure, hyposmia) for >10 days or "double worsening." ABRS is suggested by ≥3 signs: purulent unilateral discharge, unilateral pain, fever >38°C, elevated ESR/CRP, or double worsening. Antibiotics are indicated only for moderate-to-severe ABRS or when symptoms fail to improve with symptomatic therapy. Amoxicillin (70-90 mg/kg/day) is first-line. Topical intranasal corticosteroids are recommended for post-viral RS and as monotherapy for mild ABRS. Nasal saline irrigation, oral/topical decongestants, NSAIDs, and mucolytics have limited evidence but may provide symptomatic relief. Complications (orbital, intracranial, bone) are rare but serious; orbital complications are classified by Chandler (groups 1-5). Treatment of orbital cellulitis requires IV antibiotics; surgical drainage is indicated for abscesses, visual loss, or failure of medical therapy. - **Chronic Rhinosinusitis (CRS):** CRS is defined by symptoms persisting ≥12 weeks. Prevalence in Europe is 10.9% (range 6.9%-27.1%), in South Korea 6.95%, and in São Paulo, Brazil 5.51%. CRS is phenotypically divided into CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP). Pathophysiology involves complex interactions between innate and adaptive immunity, with epithelial barrier dysfunction, altered TLR expression, and Th1/Th2/Th17 polarization. CRSwNP in Western populations is predominantly Th2/eosinophilic, while CRSsNP is Th1/neutrophilic. Biofilms (especially S. aureus and P. aeruginosa) are associated with worse postoperative outcomes. Genetic factors include CFTR mutations, HLA alleles, and polymorphisms in TLR2, IL-4, IL-6, IL-33, MMP-9, and TGF-β. Diagnosis is based on symptoms (nasal obstruction 83.7%, rhinorrhea 63.6%, hyposmia 46%, facial pain 18-80%) and nasal endoscopy; CT (Lund-Mackay score) is used for staging but not first-line. Medical treatment: topical corticosteroids are effective for CRSwNP (reduce polyp size and recurrence) and may benefit CRSsNP. Systemic corticosteroids are reserved for short-term use in severe CRSwNP. Long-term macrolide antibiotics may benefit select CRSsNP patients with normal IgE. Antileukotrienes (montelukast) are useful in allergic patients and those with aspirin-exacerbated respiratory disease (AERD). Aspirin desensitization is an option for AERD. Antifungals (topical or systemic) are not recommended due to lack of efficacy and side effects. Surgical treatment (endoscopic sinus surgery, ESS) is indicated for refractory cases. Postoperative care includes saline irrigation and topical corticosteroids; antibiotics are used only if purulent infection is present. - **Pediatric RS:** ARS in children is common; 4%-7.3% of URTIs progress to ABRS. Diagnosis is clinical (symptoms >10 days, double worsening, fever, purulent discharge). Amoxicillin (40-80 mg/kg/day) is first-line. CRS in children is less studied; adenoids may act as a bacterial reservoir. Medical treatment (topical corticosteroids, saline irrigation) is first-line; adenoidectomy with or without sinus lavage is considered before ESS.

**Clinical Implications** This guideline provides a practical framework for clinicians to differentiate viral from bacterial ARS, reducing unnecessary antibiotic prescriptions. For CRS, it emphasizes a stepwise approach: topical corticosteroids and saline irrigation as first-line, with systemic corticosteroids, antileukotrienes, or surgery reserved for refractory cases. The detailed discussion of pathophysiology and associated conditions (allergy, asthma, AERD, CF, immunodeficiency) highlights the need for individualized management. The recommendations for pediatric RS underscore the importance of conservative treatment and the role of adenoids. Overall, the guideline promotes evidence-based, multidisciplinary care to improve outcomes and quality of life in patients with rhinosinusitis.