Management of sinus disease frequently includes use of saline irrigations. Studies have shown improvement in symptoms and quality of life as well as decreased medication use [6, 25, 26]. Saline irrigations appear to help patients with rhinosinusitis by improving mucociliary clearance and thinning mucus as well as providing an anti-inflammatory effect [27, 28]. Both isotonic and hypertonic saline have been used for sinusitis. Limited data suggests that hypertonic saline may be superior to isotonic saline [27, 29, 30]. Two randomized clinical trials have demonstrated significant benefit with use of hypertonic saline irrigations, including improvement in sinus-related quality of life, symptoms, and mucociliary clearance [26, 31].

Another adjunct of sinusitis management is intranasal corticosteroids . The primary function of intranasal corticosteroids is a local anti-inflammatory effect which can in turn provide some symptomatic relief from ARS. Several randomized controlled studies have been performed evaluating the effects of intranasal corticosteroids in ARS [32, 33]. These studies have demonstrated reduced daily impact of ARS symptoms with intranasal corticosteroid use. A recent Cochrane review also demonstrated significant improvement of ARS symptoms with intranasal corticosteroid use [34]. A modest group of patients may even have complete resolution of symptoms. A number of different formulations of intranasal corticosteroids have been used for sinus complaints. A couple of commonly used formulations include fluticasone propionate 110 μg daily or twice daily or mometasone furoate 200 μg daily or twice daily. The adverse events associated with intranasal corticosteroids are relatively limited given the negligible systemic uptake of the medication. Intranasal corticosteroids have been shown to have no significant effect on glucose levels in diabetic patients [35]. There also does not appear to be any effect of intranasal corticosteroids on the hypothalamic-pituitary-adrenal axis [36, 37]. Even in pregnant patients, many clinicians still recommend continuing to use intranasal corticosteroids [38]. This is in stark contrast to oral corticosteroids, which are better known for their potential side effects.

Oral corticosteroids serve an important role in the management of nasal polyposis, which can develop in patients with chronic rhinosinusitis. The role of oral corticosteroids in acute rhinosinusitis remains less clear. Few studies have specifically addressed this therapy in acute rhinosinusitis, and there is significant variability in the dosage and length of therapy that is utilized [39]. In addition, many of these studies are confounded by antibiotic use. A Cochrane review meta-analysis failed to find significant evidence to support systemic corticosteroids as a monotherapy in ARS [40]. Although some studies did show a modest benefit with oral coritcosteroid use in combination with oral antibiotics, there was no clear consensus. In addition, short-course oral corticosteroid has been associated with adverse events, including gastrointestinal disturbances and insomnia [41]. Given the limited data demonstrating any benefit of use and potential side effect of use, oral corticosteroids are generally not used in uncomplicated ARS.

Antibiotics have traditionally played a role in the management of acute bacterial rhinosinusitis (ABRS) . As previously discussed, the challenge can be in differentiating viral and bacterial etiologies. Current practice guidelines suggest using the time course of symptoms to make this distinction [6].

Of note, some recent studies have cast doubt on the role of antibiotics in uncomplicated ARS, even in cases of bacterial infections. Many cases of ABRS will resolve spontaneously without antibiotics. In addition, there are adverse events associated with oral antibiotic use. Several randomized controlled trials have compared antibiotic use with placebo for ABRS [42–45]. Antibiotics as a first-line treatment for ARS was found to have limited benefit in terms of shortening the recovery period yet had considerable side effects [43]. For this reason, some have suggested a period of watchful waiting for uncomplicated ARS. Some clinicians and patients may find this period difficult due to the potential inconvenience, expense, and delay should watchful waiting fail. For this reason, recent clinical practice guidelines from the AAO-HNSF suggest providing a prescription once the diagnosis of ABRS is made but asking that the patient not fill the prescription unless symptoms worsen or persist longer than 7 days [6].

When antibiotics are deemed appropriate for use, the clinician must then select the appropriate regimen. Most research and consensus guidelines currently recommend amoxicillin with or without clavulanate for 5–10 days as first-line therapy for adults with uncomplicated ABRS [6]. With regard to dosage selection, higher-dose regimens may be more appropriate, as has been demonstrated with amoxicillin with clavulanate. Studies have found reduced nasopharyngeal carriage of pneumococcus with higher dose of amoxicillin with clavulanate [46]. Unfortunately, evidence suggests organisms are becoming increasingly resistant to penicillin-based antibiotics. In fact, penicillin-resistant pneumococcus was isolated in the middle meati of most adult and pediatric patients (72%) [47]. Clearly, antibiotic resistance is and will remain a serious concern in the treatment of acute bacterial sinus infections.

In some patients, first-line therapy will fail, and alternative antibiotics will need to be considered. Moreover, many patients are allergic to the first-line options. Consideration should be given to choosing an antibiotic with adequate coverage, particularly if a culture was obtained. Second-line drugs include trimethoprim-sulfamethoxazole, doxycycline, and a combination of clindamycin plus a third-generation oral cephalosporin [6]. Respiratory fluoroquinolones have also been used extensively, especially for patients with recalcitrant disease. Unfortunately, fluoroquinolones are associated with severe adverse events, including cardiac, musculoskeletal, and peripheral neuropathy. For this reason, they have recently fallen under the scrutiny of Food and Drug Administration (FDA) advisory committees [48]. As of 2016, a boxed warning was placed on use of fluoroquinolones for the purpose of treating sinusitis due to the risk of disabling and potentially irreversible adverse reactions. This will clearly discourage future use of these antibiotics for sinus disease. Perhaps further studies can refine the patient populations for whom the benefits of fluoroquinolones outweigh the risks. The duration of therapy for second-line therapies is typically similar to first-line regimens, with most recommending 10 days or less of therapy [2, 6]. Shorter courses are generally recommended due to less risk for side effects and greater patient compliance [2, 6].

Various additional therapies aimed at symptomatic relief have been used for ARS. These include decongestants, antihistamines, ipratropium bromide , and mucolytics . Although these therapies are often used by clinicians, there is relatively limited clinical data to confirm their efficacy. Decongestants act to improve nasal obstruction, one of the primary complaints associated with ARS. Unfortunately, randomized controlled studies have not been able to demonstrate a significant clinical benefit of using decongestants compared to placebo [31, 49]. Decongestants have relatively limited adverse events associated with their use over a short period of time. Prolonged use, on the other hand, can result in rebound nasal swelling and congestion when weaned from the decongestant, referred to as rhinitis medicametosa. Given the lack of clear clinical efficacy for ARS but limited side effect profile with short-course administration, consensus guidelines are unable to recommend or caution against use of decongestants for ARS [7]. Another medication proposed for use in ARS is antihistamines . Although antihistamines are thought to decrease nasal drainage, no significant benefit could be demonstrated from their use with adult ARS in several studies [2, 50]. Similarly, ipratropium and mucolytics have no definite evidence to support their use in ARS.

Intravenous (IV) antibiotics are rarely needed for uncomplicated ARS. On the other hand, they frequently serve a role in the management of complications of ARS. Broad-spectrum coverage should be considered. Cultures taken from purulent drainage should be obtained and used to further direct antibiotics selection. Consideration of local antimicrobial susceptibilities may also need to be factored into the decision. Intravenous antibiotics along with conservative measures can treat the majority of ARS complications without the need for surgical intervention. Surgery is typically reserved for severe complications of ARS or those patients with complications who fail appropriate IV antibiotic therapy.

During an episode of ARS, the sinonasal mucosa becomes edematous and hyperemic. The narrowed space and increased susceptibility to bleeding make surgery during this state more difficult. Moreover, nearly all cases of uncomplicated ARS resolve without surgical intervention. For this reason, there is very limited role, if any, for surgery in the management of uncomplicated ARS. Unfortunately, untreated or resistant bacterial species of ARS can develop complications which necessitate surgery. The goals of surgery are to decompress pressure on vital structures in the orbit or intracranially if present, drain any purulent fluid collection, obtain cultures to direct antibiotics, and facilitate future irrigation and drainage by expanding sinonasal access to the site of infection.

Surgery for orbital complications of ARS depends on the extent and severity of infection. As previously discussed, Chandler et al. described a classification for the severity of orbital complications from ARS [59]. Clinical and radiographic findings help to distinguish these complications. Most patients present early enough to be managed nonsurgically with antibiotics and other conservative measures. However, the formation of subperiosteal abscess or orbital abscess may require endoscopic sinus surgery to open the sinuses, drain the abscess, obtain cultures, and potentially decompress the orbit.

Subperiosteal abscesses usually result from extension of infection from the ethmoid sinuses to the periorbita adjacent to the lamina papyracea bone [60–62]. For this reason, subperiosteal abscess formation mostly occurs medial to the orbit. They account for approximately 12–17% of orbital infections [62–65]. Management of this complication is controversial, with some advocating for a more conservative approach with IV antibiotics and others encouraging rapid surgical drainage [62, 64, 66, 67]. Surgical intervention can usually be performed through a transnasal endoscopic approach with anterior ethmoidectomy and opening of the lamina papyracea bone (Fig. 7.2) [62]. This approach is preferable to an external approach due to the lower morbidity and superior cosmesis [64, 66]. Endoscopic surgery can be used even when the abscess extends partially superiorly or inferiorly to the orbit [68]. Further extension could require an external surgical approach to the orbit. Surgery is not always needed for adequate subperiosteal abscess management. In fact, medical therapy alone may be sufficient, particularly in younger patients. Patients who are younger than the age of nine appeared more likely to respond to medical therapy than older patients [62, 65, 69]. One possible reason for this difference could be that younger patients more often contain a single bacterial isolate within the subperiosteal abscess as opposed to older patients with polymicrobial isolates [69, 70].

Unlike subperiosteal abscesses, the presence of an orbital abscess usually necessitates surgical intervention. This is particularly the case if there is lack of improvement with antibiotic management or there is concurrent intracranial infection. The surgical approach required for adequate drainage of the abscess is dependent on positioning within the orbit. Purulent loculation located medially can potentially be addressed with a transnasal endoscopic approach, whereas a location farther from the lamina papyracea can be more challenging to access endoscopically and require and external approach.

Some patients who suffer from orbital complications of ARS also develop intracranial complications. One study found nearly half of patients with intracranial complications of rhinosinusitis had periorbital cellulitis or abscess [71]. Fortunately, intracranial complications are relatively rare, only identified in about 3–4% of adults and children admitted with ARS [72, 73]. Intracranial complications include meningitis and intracranial abscess. Aggressive management must be undertaken if one of these complications occurs. Intravenous antibiotic coverage should be utilized with selection of an agent that crosses the blood-brain barrier. Surgical intervention consists of drainage of the involved sinuses and evacuation of any coexistent abscess. An external approach to intracranial drainage can require a craniotomy or burr hole.

Some patients suffer from recurrent episodes of ARS. Recurrent ARS can significantly impair patient quality of life [74]. Management of this disease can be challenging with limited success using antibiotics and intranasal corticosteroids [75, 76]. Endoscopic sinus surgery has shown promising results, improving quality of life to near normal postoperatively [74, 77, 78].