Chronic Rhinosinusitis

Background

• Chronic rhinosinusitis is a symptomatic inflammation of the nasal passages and paranasal sinuses lasting ≥ 12 weeks.
• Chronic rhinosinusitis is common with prevalence estimates ranging from 5% to 15%.

Evaluation

• Diagnose chronic sinusitis in adults if both (Strong recommendation):
  • 2 or more symptoms are present for ≥ 12 weeks:
    • at least 1 of either
      • nasal blockage, obstruction, or congestion
      • nasal discharge (either anterior or posterior nasal drip)
    • other possible symptoms
      • facial pain or pressure/fullness
      • reduction or loss of smell
  • inflammation documented by ≥ 1 of the following:
    • nasal endoscopy showing edema or purulent mucus in the middle meatus or ethmoid region (CRSsNP) or nasal polyps (CRSwNP)
    • computed tomography showing inflammation of the paranasal sinuses
• Diagnose allergic fungal rhinosinusitis based on the presence of 5 criteria:
  • atopic history
  • nasal polyposis
  • eosinophilic mucin without fungal invasion
  • positive fungal stain
  • characteristic findings on computed tomography
• Exclude other common disorders such as allergic rhinitis, recurrent acute sinusitis, and nonrhinogenic facial pain.
• Consider diagnostic evaluation for cystic fibrosis or immunocompromise as possible underlying conditions in patients with chronic rhinosinusitis.
• Consider bacterial cultures in patients with nasal/postnasal discharge refractory to multiple courses of empiric therapy. Cultures can be performed via maxillary tap or endoscopic culture of the middle meatus (do not use simple nasal swab).

Management

• Advise smoking cessation (Strong recommendation).
• Offer topical (intranasal) corticosteroids (such as fluticasone 2 sprays each nostril once daily) as first-line treatment (Strong recommendation).
• Offer nasal saline irrigation (often performed with at least 200 mL of isotonic or hypertonic saline per side) in patients without nasal polyps (Strong recommendation).
• Consider oral corticosteroids in patients with severe disease, especially patients with nasal polyps who have failed other therapies (Weak recommendation).
• Do not use antibiotics for the routine treatment of chronic rhinosinusitis, but consider short-term antibiotics during exacerbations in adults with chronic rhinosinusitis (Weak recommendation).
• Consider oral bacterial lysate (Broncho-Vaxom) as adjunctive therapy (Weak recommendation).
• In refractory cases, other adjuvant therapies may include sinus irrigation with:
  • manuka honey
  • surfactants (baby shampoo)
• Consider functional endoscopic sinus surgery (FESS) in patients with CRS (with or without nasal polyp) refractory to 3 months of medical treatment (Weak recommendation).
• Treatment of allergic fungal rhinosinusitis:
  • Initial treatment of AFRS usually includes functional endoscopic sinus surgery (FESS) in combination with sinonasal irrigations and standard postoperative topical and systemic steroids.
  • Consider postoperative nonstandard (off-label) topical nasal steroids, oral antifungals, and/or immunotherapy in patients with AFRS refractory to standard treatment.