Chronic Sinusitis Flares: Better Treatments Needed

The persistent challenge of managing acute exacerbations of chronic rhinosinusitis (AECRS) is entering a critical phase. A recent review in Current Allergy and Asthma Reports doesn’t just highlight diagnostic inconsistencies and overtreatment – it signals a growing recognition that current approaches are failing patients and straining healthcare resources. This isn’t merely a refinement of existing protocols; it’s a call for a fundamental shift in how we understand and address these often-debilitating flares, particularly as antibiotic resistance continues to climb and the search for effective alternatives intensifies.

Chronic rhinosinusitis affects millions, manifesting as nasal congestion, facial pressure, and loss of smell. While the underlying condition is chronic, patients often experience acute flare-ups – historically labeled AECRS – that significantly impact quality of life. The problem? Until recently, “AECRS” was a loosely defined term. This lack of standardization has plagued clinical trials and real-world practice, making it difficult to accurately assess treatment efficacy. The review underscores a crucial point: we’ve been measuring the wrong things, or at least, measuring them inconsistently.

The discrepancy between reported exacerbations and documented treatment is particularly alarming. The cited 2025 study revealing that two-thirds of AECRS episodes go undocumented through medication prescriptions exposes a significant blind spot. Patients are experiencing flares, but these aren’t being captured in traditional data, leading to an underestimation of the disease burden and a missed opportunity for targeted intervention. This highlights the limitations of relying solely on treatment-based triggers for diagnosis and the need for more comprehensive patient-reported outcome measures.

The recent regulatory definition – acute worsening of symptoms lasting at least 3 days with escalation of care – represents progress, but isn’t a panacea. The reliance on treatment-seeking behavior still excludes patients who opt for observation or self-management. This is a critical consideration, as patient preferences and access to care play a significant role in how AECRS is managed.

The emerging understanding of AECRS pathophysiology is also reshaping the treatment landscape. The interplay of viral triggers, bacterial overgrowth (particularly Staphylococcus aureus and Pseudomonas aeruginosa), and immune dysregulation suggests a more nuanced approach is needed. The findings regarding elevated inflammatory markers like IL-5 and IL-6 open avenues for targeted therapies, while the role of the sinonasal microbiome is prompting exploration of interventions like bacteriophage therapy.

The Forward Look

The review’s emphasis on culture-guided therapy and alternatives to antibiotics is a clear indication of where the field is headed. Expect to see increased adoption of diagnostic tools that identify specific pathogens driving exacerbations, allowing for more tailored antibiotic prescriptions – or, ideally, avoidance of antibiotics altogether. The mention of bacteriophage therapy is particularly noteworthy. While still in its early stages, this approach – using viruses to target and kill bacteria – offers a promising alternative to traditional antibiotics, especially in the face of rising resistance. Furthermore, the push for standardized definitions will likely lead to more robust clinical trials and a clearer understanding of which treatments are truly effective.

However, the biggest challenge may lie in changing clinical practice. Overcoming the ingrained habit of reflexively prescribing antibiotics and steroids will require widespread education and the development of clear, evidence-based guidelines. The future of AECRS management isn’t just about new drugs; it’s about a paradigm shift towards more precise diagnosis, personalized treatment, and a greater emphasis on preventative strategies. Expect increased scrutiny from payers regarding antibiotic prescriptions for AECRS, incentivizing more judicious use and the adoption of alternative therapies. The REOPEN trials, and future studies building on their framework, will be pivotal in shaping these changes.

References

1. Frederick RM, Lam K, Han JK. Acute exacerbations of chronic rhinosinusitis. Curr Allergy Asthma Rep. Published online December 20, 2025. doi:10.1007/s11882-025-01239-0

2. Palmerrr JN, Adappa ND, Chandra RK, et al. Efficacy of EDS-FLU for chronic rhinosinusitis: two randomized controlled trials (ReOpen1 and ReOpen2). 2024;12(4):1049-1061. doi:10.1016/j.jaip.2023.12.016