Revisiting Recurrent Acute Rhinosinusitis: Where Does Allergy Fit In?

This review discusses current evidence on the epidemiology, pathophysiology, evaluation, and treatment of recurrent acute rhinosinusitis (RARS), with an emphasis on the role of comorbid allergic rhinitis (AR) as a key modifiable factor. We aim to clarify diagnostic challenges, highlight mechanistic links between AR and RARS, and discuss medical and surgical interventions while identifying gaps in research. RARS affects 1 in 3,000 adults annually, incurring substantial costs ($1,091–$1,207 per patient/year) and quality-of-life burdens. AR prevalence is markedly elevated in RARS (29%–57% in adults, 35%–53% in children), making it the strongest associated comorbidity. Mechanisms that may contribute to RARS include AR-induced mucosal edema leading to ostiomeatal obstruction, impaired mucociliary clearance, and upregulated Intercellular Adhesion Molecule-1 (ICAM-1) facilitating viral triggers. Medical management of RARS with therapies like intranasal corticosteroids, saline irrigations, and allergy treatment reduces symptoms and episode frequency in some patients. There is promising data investigating the possible role of immunotherapy in the pediatric population to reduce the frequency of episodes. Endoscopic sinus surgery yields greater, more sustained Sino-Nasal Outcome Test-22 improvements in refractory cases. RARS is a distinct entity driven by episodes of bacterial sinusitis, linked to AR via inflammatory pathways. While medical and allergy-directed therapies offer first-line benefits, surgery may provide relief in refractory patients. Critical gaps remain in prospective trials of standardized allergy testing, targeted pharmacotherapy, and allergen immunotherapy.