ENT · Chronic Rhinosinusitis
The facts most likely to be tested
Press 1–5 to rate · ↑↓ to navigate
Chronic rhinosinusitis is defined as at least 12 weeks of sinonasal symptoms plus objective documentation of sinonasal inflammation; failure of medical therapy is an escalation/surgical criterion, not part of the diagnostic definition.
The diagnosis requires the presence of at least two of the four cardinal symptoms: mucopurulent drainage, nasal obstruction, facial pain/pressure/fullness, or decreased sense of smell.
Anterior rhinoscopy, nasal endoscopy (visualizing purulent secretions or polyps in the middle meatus), or Computed Tomography (CT) of the paranasal sinuses are the three guideline-accepted objective methods to confirm chronic rhinosinusitis; endoscopy is office-based and radiation-free, while CT best defines anatomic extent for surgical planning.
Nasal polyps are a common associated finding, particularly in patients with aspirin-exacerbated respiratory disease (AERD) and asthma.
First-line management for chronic sinusitis involves intranasal saline irrigation and intranasal corticosteroids to reduce mucosal inflammation.
Functional Endoscopic Sinus Surgery (FESS) is indicated for patients who remain symptomatic despite maximal medical therapy or who have significant anatomical obstruction.
Cystic fibrosis must be considered in pediatric or young adult patients presenting with recurrent or chronic sinusitis and nasal polyposis.
Vignette unlocked
A 34-year-old male presents with a 4-month history of persistent nasal congestion, thick yellow nasal discharge, and a diminished sense of smell. He has tried multiple courses of over-the-counter decongestants and antihistamines with minimal relief. Physical examination reveals pale, edematous nasal polyps bilaterally. He has a known history of asthma and reports wheezing after taking ibuprofen for a headache last month.
What is the most appropriate next step in the management of this patient's condition?
Intranasal corticosteroids and saline irrigation
The patient meets the diagnostic criteria for chronic rhinosinusitis with nasal polyposis, and the history of asthma and aspirin sensitivity suggests Samter's triad (AERD); initial management focuses on intranasal steroids and saline irrigation.
Full handout
High yield triage
Etiology / Epidemiology
Defined as inflammation >12 weeks. Associated with allergic rhinitis, nasal polyps, and asthma.
Clinical Manifestations
Persistent mucopurulent drainage, nasal obstruction, and facial pressure; double sickening is rare.
Diagnosis
Anterior rhinoscopy, nasal endoscopy, or CT sinus provide objective confirmation of sinonasal inflammation; none is designated a sole gold standard.
Treatment
Intranasal corticosteroids are first-line; surgery is reserved for refractory cases.
Prognosis
High recurrence rate; monitor for orbital cellulitis or intracranial extension.
Full handout
Epidemiology & Etiology
Chronic sinusitis affects patients with persistent inflammation despite medical therapy. Key risk factors include anatomic obstruction (deviated septum), immunodeficiency, and Samter's triad (asthma, aspirin sensitivity, nasal polyps). Chronic exposure to irritants like tobacco smoke is a major contributor.
Pertinent Anatomy
The ostiomeatal complex is the critical drainage pathway for the maxillary, ethmoid, and frontal sinuses. Obstruction here leads to stasis and chronic mucosal inflammation. Understanding this anatomy is essential for interpreting CT sinus findings.
Pathophysiology
Chronic inflammation leads to impaired mucociliary clearance and mucosal hypertrophy. This creates a cycle of obstruction, hypoxia, and secondary bacterial colonization. Persistent inflammation often results in the formation of nasal polyps, which further exacerbate the mechanical blockage.
Clinical Manifestations
Patients present with >12 weeks of nasal congestion, purulent discharge, and hyposmia. Red flags include visual changes, cranial nerve palsies, or severe headache, suggesting orbital or intracranial involvement. Unlike acute sinusitis, double sickening is not a classic feature.
Diagnosis
Diagnosis requires clinical symptoms for >12 weeks plus objective evidence of inflammation. Anterior rhinoscopy, nasal endoscopy, and CT sinus are the three accepted objective confirmation methods — CT best visualizes mucosal thickening/air-fluid levels and defines anatomic extent, while endoscopy can identify nasal polyps or purulent secretions in-office.
Treatment
Intranasal corticosteroids are the primary treatment to reduce inflammation. Saline irrigation is used as an adjunct. Systemic corticosteroids may be used for short-term polyp reduction, but surgery (functional endoscopic sinus surgery) is indicated for patients failing maximal medical therapy. In CRS with nasal polyps, biologics (dupilumab, omalizumab, mepolizumab) are an option when prior medical and surgical therapy have failed or surgery is not viable; biologics should not be routinely prescribed for CRS without polyps, and antibiotics should not be routinely prescribed for CRS without acute exacerbation.
Prognosis
Most patients achieve symptom control with long-term medical management. Key complications include orbital cellulitis, cavernous sinus thrombosis, and meningitis. Patients with Samter's triad require lifelong monitoring due to high recurrence rates.
Differential Diagnosis
Allergic rhinitis: sneezing and itchy eyes without purulent discharge
Acute bacterial rhinosinusitis: symptoms <4 weeks with double sickening
Nasal foreign body: unilateral foul-smelling discharge, common in children
Granulomatosis with polyangiitis: systemic symptoms and saddle nose deformity
Cocaine abuse: septal perforation and chronic mucosal crusting