New Guidelines Outline When to Consider Sinus Surgery for Chronic Rhinosinusitis

The American Academy of Otolaryngology-Head and Neck Surgery Foundation published new clinical practice guidelines on May 27, 2025, for the surgical management of chronic rhinosinusitis. The guidelines, targeted for otolaryngologist-head and neck surgeons who manage adults with chronic rhinosinusitis, provided 11 evidence-based key action statements to inform the main surgery options for chronic sinus problems and additional treatments or follow-up procedures.

Approximately 11.6% of adults live with chronic rhinosinusitis, which contributes to 4.1 million annual ambulatory visits. A chronic rhinosinusitis diagnosis includes ≥ 2 of the following symptoms for ≥ 12 weeks: thick or discolored drainage from the front or down the back of the nose, nasal obstruction, facial pain, pressure, and fullness, or reduced sense of smell.

"Chronic rhinosinusitis doesn't just affect the nose—it can influence a person's general life. Patients can struggle with poor sleep, brain fog, depression, anxiety, and reduced productivity that ripples through their relationships and work or school performance," said Jennifer J. Shin, MD, SM, chair of the CPG Guideline Development Group, in a statement. "Many people don't realize that chronic rhinosinusitis can affect patients as much as diseases that have traditionally been viewed as life-threatening or more serious.”

Patients may need surgery for chronic rhinosinusitis if medications do not bring enough relief. For certain sinus diseases, a sooner surgery can help prevent worsening symptoms and reduce pain. Surgery works well for patients with fungal infections or nasal polyps, as well as those who get frequent infections, ongoing symptoms, or experience the worsening of other conditions, like asthma.

Shin noted that the updated guidelines are based on a wide variety of evidence, including systematic reviews, meta-analyses, randomized controlled trials, and observational studies.

A panel of 18 experts, representing the fields of rhinology, comprehensive otolaryngology, otolaryngic allergy, and otorhinolaryngological advanced practice provision, collaborated to develop these recommendations. They aimed to support excellent care before, during, and after sinus surgery. The guidelines also advised doctors to communicate treatment options and involve patients in shared decision-making.

The 11 evidence-based key action statements, paraphrased, were:

1. Confirm Diagnosis Pre-Surgery: Verify chronic rhinosinusitis diagnosis using established clinical criteria and assess surgical candidacy based on symptoms, disease features, quality of life, and prior treatments.
2. Avoid Unnecessary Antibiotics: Do not prescribe antibiotics if the patient lacks significant or persistent purulent nasal discharge on exam.
3. No Mandatory Therapy Prerequisites: Do not require a uniform regimen or duration of medical therapy (e.g., antibiotics, steroids, antihistamines) before approving surgery.
4. Identify Surgery Candidates: Prioritize surgery for patients unlikely to benefit from continued medical therapy, including those with polyps, bony erosion, eosinophilic mucin, or fungal balls.
5. Set Realistic Expectations: Counsel patients preoperatively about potential chronicity, relapse, and need for long-term medical management, tailored to chronic rhinosinusitis subtype.
6. Offer Surgery When Benefits Exceed Medical Therapy: Recommend surgery when benefits clearly outweigh nonsurgical management and expectations for long-term care are understood.
7. Obtain Computed Tomography (CT) for Surgical Planning: Acquire a fine-cut CT scan if not already available to guide surgical approach.
8. Avoid Surgery Based on Arbitrary CT Criteria: Do not determine surgical extent solely on minimal mucosal thickening, opacification, or outflow obstruction.
9. Preoperative Education: Educate patients on postoperative care, including pain, debridement, medications, activity, work return, follow-up, and possible revision surgery.
10. Ensure Adequate Surgical Extent for Severe Disease: For polyps, osteitis, bony erosion, or fungal disease, perform full sinus cavity exposure and tissue removal, or refer to a capable surgeon—avoid balloon/manual dilation alone.
11. Postoperative Follow-Up: Assess surgical outcomes at 3–12 months using history (symptoms, QOL, complications, therapy adherence, rescue meds) and nasal endoscopy.

“This [clinical practice guideline] does not apply to patients who have the primary diagnoses of acute rhinosinusitis, recurrent acute rhinosinusitis, rhinosinusitis complicated by intracranial or orbital spread, acute invasive fungal sinusitis (eg, mucormycosis), and odontogenic sinusitis,” the panel wrote.

References

1. Shin J, Wilson M, McKenna M, et al. Clinical Practice Guideline: Surgical Management of Chronic Rhinosinusitis. American Academy of Otolaryngology-Head and Neck Surgery Foundation, Vol.172, Supplement 2. 2025.

2. New clinical practice guideline for the surgical management of chronic rhinosinusitis in adults. EurekAlert! May 27, 2025. https://www.eurekalert.org/news-releases/1085145. Accessed May 27, 2025.