Medical and Surgical Management of Rhinosinusitis

Prologue

This homepage serves as a way to stay updated on published studies that are advancing the treatment of rhinosinusitis. The primary focus is not on biologics, but rather on determining the optimal medical therapy and the most suitable extent of surgery for patients. While numerous papers have been published addressing the best surgical management, to the best of our knowledge, no national guidelines establishing a surgical standard have been developed.

No more beating the bush: Clear, applicable, key statements for the management of acute- and chronic rhinosinusitis.

This document utilizes a system of random three-letter codes for references rather than sequential numbering. This approach is more suitable for an online guideline that is subject to continuous updates and restructuring, where chronological ordering would be impractical.

Fundign: No funding was received for this project.
Conflicts of interest, Mads Guldager: None.

Acute Rhinosinusitis

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Primary Chronic Rhinosinusitis

A key consideration for physicians treating CRS is to determine when surgical intervention offers a greater advantage than relying solely on medical therapy. Surgical management may be particularly beneficial for patients with specific CRS manifestations, such as fungal balls, CRSwNP with or without bony erosions, or findings like eosinophilic mucin(ref-hmt).

Using biologics as a first-line treatment for uncontrolled CRSwNP, instead of surgery, was, in a research paper, estimated to have an overwhelming budget impact. A budget impact analysis projected that the “less likely” scenario with 90% biologics as first-line treatment would increase costs by 1048%, while a “normal” scenario with 18% adoption would see a 184% rise (ref-qjx).

Primary, Diffuse

Diagnosis

CRSwNP: Scoring of nasal polyps should be done to monitor the patient’s response to treatment(ref-uer).

Key Action Statements
– Patients with bilateral pathology who fail appropriate medical therapy should undergo a biopsy of the pathology (e.g. polyps). This is to confirm the diagnosis. Histological examination should include assessment of inflammation, specifically quantifying eosinophils per high-power field when evidence of type-II inflammation.

Medical management

Local / topical …

Primary, Diffuse, Endotype-II, Eosinophilic Rhinosinusitis

Diagnosis

Histopathology: A correlation exists between higher eosinophil counts per HPF and greater disease severity. For example, tissue eosinophil levels above 5 cells/HPF have been associated with poorer endoscopy scores following ESS (ref-bsm). In cases where counts are higher than 10 cells/HPF, the association is with worse endoscopic and CT scores, as well as diminished improvements in quality of life(ref-dhy)(ref-for).

Key Action Statements
– Extensive surgery is recommended for generalized mucosa disease.

Surgical management

Surgical management of patients should aim for a personalized approach. While the CT scan reveals bony partitions that might hinder natural drainage pathways, it’s important to remember that any observed opacification offers only a glimpse and may not accurately represent the patient’s continuous status. The surgical extent should be tailored to the patient’s wishes and symptoms. However, we recommend that treating a general inflammatory condition of the mucosa, such as extensive chronic rhinosinusitis (eCRS), should aim to establish drainage pathways and optimize the potential delivery of topical agents.

As a recent paper proved, surgeons with a high-volume had lower revision rates. We recommend that ESS is performed at high-volume centres (>30 cases per year)(ref-cmu).

Surgical Extent for Patients with Primary, Diffuse eCRS:
Maxillary Antrostomy: This involves a complete uncinectomy, respecting the attachment of the uncinate process. A complete antrostomy should be performed, removing the fontanelle anteriorly to the lacrimal bone, superiorly to the level of the maxillary sinus ceiling, and posteriorly to the vertical plane of the back wall of the maxillary sinus.

Anterior and Posterior Ethmoidectomy: This requires the complete removal of the ethmoid bullae and all bony partitions. Care must be taken to respect the slope of the anterior skull base and the superior part of the basal lamella if the anterior ethmoidal artery is dehiscent.

Sphenoid Sinusotomy: A transnasal sphenoidotomy can be combined with a transethmoidal sphenoidotomy, or vice versa. The sphenoidotomy should be a IESSC 2a/2b with an opening exceeding 70% when assessed on the axial plane(ref-wfv)(ref-zkv).

Frontal Recess and Frontal Sinusotomy: A minimum of a Draf-IIb should be performed. Some studies found favorable outcomes performing a Draf-III with resection of the middle turbinates(ref-wfv)(ref-iqa). However, a systematic review found revisions and restenosis to be less frequent utilizing a Draf-IIb, though this was across all indications(ref-lgp).

Primary, Diffuse, Non-Endotype-II Rhinosinusitis

Medical management

A treatment regimen with peroral Roxithromycin 150mg a day for 3 months can be perscribed. It should be kept in mind that there is an increased risk of cardiac arrhythmias and nefro- and hepatotoxicity(ref-pkb). Following paraclinical examinations are recommended(ref-wsj).
Before initiation: ECG + (Liver – and Kidney tests)
Day 28: ECG + Blood samples (Liver- and Kidney tests)

Note: The reference (wsj) only states liver tests should be performed. Kidney is added as the precautions below are mentioned by The Danish Association of the Pharmaceutical Industry and Danish Medicines Information (Dansk Lægemiddel Information A/S pg Lægemiddelindustriforeningen – promedicin.dk)

Precautions (promedicin.dk)

• AV block, arrhythmias, or prolonged QT interval.
• Regular monitoring of kidney and liver function as well as blood values for treatment lasting longer than 14 days.

Secondary Chronic Rhinosinusitis

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Image Guided Surgery

For sinus and skull base surgery, the intraoperative use of IGS is endorsed in appropriately selected cases to aid surgeons in navigating complex anatomy. This endorsement is backed by expert consensus and a solid body of literature. The decision to use this technology rests with the operating surgeon.

Examples of when IGS might be appropriately utilized include(ref-pjs):

• Pathology involving the frontal, posterior ethmoid, or sphenoid sinuses.
• Distorted sinus anatomy, whether from development, prior operations, or injury.
• Revision cases.
• Skull base defect or CSF rhinorrhea.
• Pathology close to the skull base, eye socket, optic nerve, or carotid artery.
• Extensive sino-nasal polyposis.
• Sino-nasal neoplasms, both benign and malignant.

This technology is also known as navigation-based sinus surgery, computer-assisted sinus surgery, surgical navigation, or computer-guided imaging systems.

Abbreviations

ARS: Acute rhinosinusitis
CRS: Chronic rhinosinusitis
CRSsNP: Chronic rhinosinusitis without nasal polyps
CRSwNP: Chronic rhinosinusitis with nasal polyps
HPF: High-power field
IGS: Image-guided surgery

References

(bsm): Kountakis, S. E., Arango, P., Bradley, D., Wade, Z. K. & Borish, L. Molecular and Cellular Staging for the Severity of Chronic Rhinosinusitis. The Laryngoscope 114, 1895–1905 (2004).

(cmu): Lee, D. J. et al. Surgeon Case Volume Impacts Revision Rate of Endoscopic Sinus Surgery. Int Forum Allergy Rhinol (2025) doi:10.1002/alr.23602.

(dhy): Soler, Z. M., Sauer, D., Mace, J. & Smith, T. L. Impact of Mucosal Eosinophilia and Nasal Polyposis on Quality‐of‐Life Outcomes after Sinus Surgery. Otolaryngol.–head neck surg. 142, 64–71 (2010).

(for): Aslan, F., Altun, E., Paksoy, S. & Turan, G. Could Eosinophilia predict clinical severity in nasal polyps? Multidiscip Respir Med 12, (2017).

(hmt): Shin, J. J. et al. Clinical Practice Guideline: Surgical Management of Chronic Rhinosinusitis. Otolaryngol.–head neck surg. 172, (2025).

(iqa): Noller, M., Fischer, J. L., Gudis, D. A. & Riley, C. A. The Draf III procedure: A review of indications and techniques. World j. otorhinolaryngol.-head neck surg. 8, 1–7 (2022).

(lgp): Hirayama, Y. et al. Comparison of outcomes for Draf IIB vs Draf III in endoscopic frontal sinus surgery: a comprehensive systematic review and meta-analysis. Rhin 0, 0–0 (2025).

(lzf): Grayson, J. W., Hopkins, C., Mori, E., Senior, B. & Harvey, R. J. Contemporary Classification of Chronic Rhinosinusitis Beyond Polyps vs No Polyps. JAMA Otolaryngol Head Neck Surg 146, 831 (2020).

(pjs): American Academy of Otolaryngology – Head and Neck Surgery. Position Statement: Intra-Operative Use of Computer Aided Surgery [Internet]. American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). 2021 [Accessed June 5th 2025] at https://www.entnet.org/resource/position-statement-intra-operative-use-of-computer-aided-surgery/

(pkb): Albert, R. K. & Schuller, J. L. Macrolide Antibiotics and the Risk of Cardiac Arrhythmias. Am J Respir Crit Care Med 189, 1173–1180 (2014).

(qjx): Fieux, M. et al. The extra cost of biologics as first-line treatment in uncontrolled chronic rhinosinusitis with nasal polyps with no previous sinus surgery is overwhelming: a budget impact analysis. 63, (2025).

(wfv) Workman, A. D. et al. Assessing adequacy of surgical extent in CRSwNP: The Completion of Surgery Index. Int Forum Allergy Rhinol 15, 9–17 (2024).

(wsj) Smith, D. BTS guideline on long-term macrolides in adults with respiratory disease: not quite a panacea. Thorax 75, 405–406 (2020).

(uer) Gevaert, P. et al. European Academy of Allergy and Clinical Immunology position paper on endoscopic scoring of nasal polyposis. Allergy 78, 912–922 (2023).

(zkv) Albaharna, H. et al. A Novel International Endoscopic Sphenoid Surgery Classification (IESSC): A Delphi Consensus. Int Forum Allergy Rhinol (2025)