Management of atrophic rhinosinusitis

Daily nasal irrigations with normal or hypertonic saline*^¶: 200 mL lavage to each nare^Δ

Glucocorticoid lavage^¶:

Budesonide: 2 mL of budesonide nebulizer solution (0.25 mg/2 mL) in 1000 mL saline irrigation solution. Use 50 mL to each nare after saline lavage, twice daily.

Empiric irrigation with a topical nasal antibiotic for purulence (100 mL lavage to each nare after saline irrigation). Some concentrations^◊ recommended include^¶:

Mupirocin: 5 grams of 2% ointment (NOT nasal ointment or cream) in 1000 mL of saline irrigation solution. May be stored at room temperature.

Tobramycin: 80 mg in 1000 mL of saline irrigation solution. Refrigerate.

Clindamycin: 600 mg in 1000 mL of saline irrigation solution. Refrigerate.

Ceftazidime: 1 gram in 1000 mL of saline irrigation solution. Refrigerate. Use entire solution in 10 days or less.

Levofloxacin: 500 mg in 1000 mL of saline irrigation solution. Refrigerate. Use entire solution in 14 days or less.

Systemic antibiotics for acute infections

Nasal moisturizer: Intranasal application of petrolatum jelly or a personal lubricant product with a cotton pledget. Care must be taken to avoid inhaling to decrease risk for lipid pneumonia.

* Saline nasal irrigations may be performed once or twice per day, depending on the return. As long as lavage contains thick mucus or purulent material, we recommend lavage twice per day. When purulence is present, a second lavage with an antibiotic may be performed after completion of the first. We recommend all patient-made saline solutions be made in distilled water rather than tap water. Greater than 3% saline may cause nasal irritation.
¶ To decrease risk of infection, the preparation, use, storage, and expiration dates of all nasal irrigation solutions should be in accordance with local standards for pharmacy-compounded irrigation products. Note that antibiotic solutions may not contain adequate preservative or bactericide and may become contaminated.
Δ Lavages may be performed with NetiPots, squeeze bottles, (such as the NeilMed device), irrigation systems, or using a commercial lavage machine with or without a specialized nasal tip (HydroMed).
◊ Elliott KA, Stringer SP. Evidence-based recommendations for antimicrobial nasal washes in chronic rhinosinusitis. Am J Rhinol 2006; 20:1.

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Management of atrophic rhinosinusitis