2. Other symptoms
– Purulent rhinorrhea
– Fever
– Localized pain
– Elevated ESR/CRP
• Usually not indicated unless presenting complicating symptoms:
1. Periorbital swelling, neurologic issues (severe headaches, seizures, etc), visual deficits, decreased ocular movements
2. CT with contrast is imaging modality of choice; MRI may also be helpful
• Supportive for viral ARS
• Antibiotics for bacterial ARS
1. Amoxicillin/clavulanate as first line
2. Consider: cephalosporins, fluoroquinilones (if penicillin allergic)
• Surgery reserved for ARS with complications:
1. Subperiosteal and orbital abscess
2. Intracranial involvement (ie, meningitis, brain abscess, encephalitis, superior sagittal sinus, cavernous sinus thrombosis)
3. Pott’s puffy tumor
• Multiple theories exist:
1. Anatomic
2. Bacteriology
3. Biofilms
4. Adenoid hypertrophy
5. Nasal polyposis
6. Comorbid disease
– Allergic rhinitis
– Asthma
– GERD
– Immunodeficiency, cystic fibrosis, primary ciliary dyskinesia
• Waters’ view plain films: not recommended due to low sensitivity and specificity
• CT without contrast
1. To evaluate structure, development, and extent of disease
2. To assist with surgical planning
• Medical
1. Nasal steroid spray
2. Topical nasal saline irrigation
3. Antibiotics
– No clear efficacy, antibiotic choice, or duration
– 20-day course preferable to 10-day course
– Culture-directed for those who have not responded to empiric therapy
• Surgical
4. Adenoidectomy
– First-line surgery in children <12 years regardless of size
5. Functional endoscopic sinus surgery
6. Turbinoplasty or tonsillectomy – No clear benefit
Summary of Essential Statements Reaching Consensus
• Definition requires either endoscopic and/or CT findings of disease.
• Nasal endoscopy is an appropriate evaluation.
• Management differs from CRSwNP vs CRSsNP.
• Allergic rhinitis and adenoiditis are contributors to CRS.
• Culture-directed antibiotic therapy (20 days) may improve clinical response.
• Topical nasal steroids are beneficial.
• Topical saline irrigations are beneficial.
• Adenoidectomy is an effective first-line surgery.
• Endoscopic sinus surgery with image guidance is recommended—if medical therapy and adenoidectomy have failed.
• CT to assess structure, development, extent of disease, and surgical planning.
• Surgery does not distort facial growth.
• Postoperative debridement is not necessary.
Management Pathways
• ARS Management (Figure 18–1)
• CRS Management (Figure 18–2)
FIGURE 18–1. ARS Management.
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