Management of chronic rhinosinusitis without nasal polyposis in adults

CRSsNP: chronic rhinosinusitis without nasal polyposis; CRS: chronic rinosinusitis; CT: computed tomography; INCS: intranasal corticosteroids.

* Danger signs include prolonged or high fever, severe headache or meningeal signs, significant or recurrent epistaxis, and orbital signs/symptoms.

¶ An example regimen is prednisone 40 mg once daily for 5 days, then 20 mg once daily for 5 days, taken with food in the morning plus amoxicillin-clavulanate 875 mg/125 mg twice daily for 14 days, but different regimens may also be effective. Refer to UpToDate content on antibiotic management of CRS for a more detailed discussion of antibiotic choice. Refer to Lexicomp drug information for dosing, including dose adjustments for kidney impairment. Choice of antibiotics may be empiric but should be based on culture of material obtained endoscopically from a sinus cavity whenever possible.

Δ Surgery is most likely to provide benefit for patients who have not yet achieved adequate symptom control. Evidence for efficacy of extended macrolides and biologic therapies for CRSsNP is very limited, but some patients may wish to avoid surgery until medical options have been exhausted.

◊ Macrolide antibiotics are used in CRSsNP for their antiinflammatory properties. We prefer azithromycin over others because it has a better safety profile and fewer drug interactions than clarithromycin. A representative regimen is azithromycin 250 or 500 mg 3 times per week for 12 weeks.

§ Any of the biologics that are approved for asthma can be given to patients with both asthma and CRSsNP. Refer to UpToDate content on management of severe asthma for a discussion of choice of biologic therapy.

¥ Possible treatments include stepping up INCS therapy until symptoms resolve or a brief course of nonmacrolide antibiotics, oral glucocorticoids, or the combination. Refer to UpToDate content on management of CRSsNP exacerbations.