This is one of only two strong recommendations within the guideline, and it is a change from the prior version’s diagnostic criteria of persistence of signs and symptoms for more than 10 days to emphasize failure to improve to reduce unnecessary tests or treatments for presumed viral infections.

ACEP has made similar statements in their 2014 Choosing Wisely recommendation on avoiding antibiotics in the ED for uncomplicated sinusitis: “Most patients with acute sinusitis do not require antibiotic treatment, because approximately 98 percent of acute sinusitis cases are caused by a viral infection and resolve in 10-14 days without treatment.”⁴

Statement 1B: Radiographic Imaging and Acute Rhinosinusitis

“Clinicians should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected.” (Recommendation)

This statement is graded as a recommendation against imaging for uncomplicated sinusitis, whether presumed bacterial or viral. Complications that clinicians should be mindful of include orbital, intracranial, or soft tissue involvement. Some alternative diagnoses to consider include malignancy or any noninfectious etiology of facial pain. If imaging is pursued, computed tomography and magnetic resonance imaging are the recommended modalities.

Statements 2 and 3: Symptomatic Relief of Viral Rhinosinusitis (VRS) and

Symptomatic Relief of Acute Bacterial Rhinosinusitis (ABRS):

“Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of VRS/ABRS.” (Option)

While listed only as an option for providers, this recommendation highlights that there are numerous supportive therapies available for symptomatic relief of uncomplicated sinusitis. Several reviews suggest there is minor improvement with nasal saline and topical intranasal steroids. Data are lacking for the use of oral decongestants, antihistamines, and analgesics, and their use may be left to patient and provider preference.

Statement 4: Initial Management of Acute Bacterial Rhinosinusitis (ABRS):

“Clinicians should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS. Watchful waiting should be offered only when there is assurance of follow-up, such that antibiotic therapy is started if the patient’s condition fails to improve by 7 days after ABRS diagnosis or if it worsens at any time.” (Recommendation)

This statement was based on pooled data showing very minimal improvement in cure rates at seven to 15 days when comparing antibiotic therapy (91 percent) to placebo (86 percent). Offering watchful waiting as a management strategy was previously graded as an option, but in light of recently included data published since the prior guideline, this statement was upgraded to a recommendation, predicated on reliable follow-up or strict return.