Is Sinus Surgery Indicated for Recurrent Acute Rhinosinusitis?

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Background

Recurrent acute rhinosinusitis is clinically defined as having around four or more episodes per year of active sinus infection with asymptomatic periods in the interim. Clinical practice guidelines recommend a primary evaluation for an acute bacterial infection including a nasal endoscopy. To meet the criteria for acute rhinosinusitis, there must be presence of purulent nasal discharge or nasal obstruction and congestion. Initial treatment should include a preliminary period of several days of supportive care to confirm that the inflammation is not the result of a viral etiology, which would resolve without requiring antibiotics. If these symptoms are still present after this withhold period, suggested medical management includes a course of amoxicillin or Augmentin as well as a topical nasal steroid spray or an oral steroid. If medical management fails or infections recur, then a computed tomography (CT) scan of the sinuses and possible allergy testing are recommended. Despite the detail with which medical treatment of recurrent acute rhinosinusitis is described, the point at which surgery is indicated as an alternative to continual treatment with antibiotics and nasal or oral steroids is not well defined. Patients with recurrent acute rhinosinusitis reported the impact of disease on quality of life and productivity levels similar to those with chronic rhinosinusitis for whom surgery is indicated and well studied as an efficacious treatment. This dearth of literature regarding recurrent acute rhinosinusitis and its treatment makes it difficult to pinpoint the medical and economic threshold at which surgical intervention is indicated.

Best Practice

Surgical intervention to treat recurrent acute rhinosinusitis is indicated when patients have four to six episodes of acute sinusitis lasting four weeks or less each with asymptomatic periods in the interim. It is recommended that patients come into the office during an acute episode of rhinosinusitis for an in-person evaluation to confirm this diagnosis. Additionally, patients should be treated with at least one course of nasal steroid spray or oral steroid and have a CT of the sinuses before considering endoscopic sinus surgery. The extent of surgery typically includes maxillary antrostomy and bilateral anterior ethmoidectomy in addition to surgical treatment of any other disease noted on the patient’s CT scan (Laryngoscope. 2017;127:1255–1256).