What are the treatment options for Chronic Rhinosinusitis (CRS)?

From the Guidelines

The primary treatment for chronic rhinosinusitis involves a combination of nasal corticosteroid sprays and saline nasal irrigation, typically used daily for several months. This approach is supported by the most recent and highest quality study, which recommends saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS, based on a preponderance of benefit over harm 1.

Treatment Options

• Start with a nasal corticosteroid spray like fluticasone (Flonase) or mometasone (Nasonex), using 1-2 sprays in each nostril once or twice daily.
• Pair this with saline nasal irrigation using a neti pot or squeeze bottle, performed 1-2 times daily with sterile saline solution.
• For more severe cases, a short course of oral corticosteroids may be prescribed, such as prednisone 20-40 mg daily for 5-7 days.
• Antibiotics like amoxicillin-clavulanate or doxycycline may be added for 2-3 weeks if bacterial infection is suspected.

Rationale

These treatments work by reducing inflammation in the nasal passages and sinuses, improving mucus drainage, and clearing out irritants. Consistent use is key for managing symptoms and preventing recurrence. The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 also supports the use of nasal corticosteroids and saline irrigation as first-line treatments for CRS 1.

Additional Considerations

If symptoms persist despite medical therapy, endoscopic sinus surgery may be considered to improve sinus drainage and remove obstructions. Additionally, addressing underlying factors like allergies, environmental irritants, or structural issues (e.g., deviated septum) is crucial for long-term management of chronic rhinosinusitis. The definition of difficult-to-treat rhinosinusitis is also important to consider, which includes patients who have persistent symptoms despite appropriate treatment, including maximal medical therapy and surgery 1.

From the Research

Treatment Options for Chronic Rhinosinusitis (CRS)

The treatment options for Chronic Rhinosinusitis (CRS) include:

• Medical therapy, which is the initial treatment approach 2, 3, 4, 5, 6
• Topical intranasal corticosteroids, which are used to reduce inflammation and improve symptoms 3, 4, 5, 6
• Oral antibiotics, which may be prescribed in addition to topical corticosteroids 2
• Nasal saline irrigation, which can help improve symptoms and reduce inflammation 2
• Endoscopic sinus surgery, which may be recommended if medical treatment fails 3

Types of Intranasal Steroids

Different types of intranasal steroids can be used to treat CRS, including:

• First-generation intranasal corticosteroids (e.g. beclomethasone dipropionate, triamcinolone acetonide) 5
• Second-generation intranasal corticosteroids (e.g. ciclesonide, fluticasone furoate, fluticasone propionate, mometasone furoate) 5
• There is insufficient evidence to suggest that one type of intranasal steroid is more effective than another in patients with CRS 5

Efficacy of Intranasal Steroids

Intranasal corticosteroids have been shown to:

• Improve disease-specific health-related quality of life (HRQL) 6
• Reduce disease severity and improve symptoms such as nasal blockage, rhinorrhoea, and loss of sense of smell 6
• Increase the risk of epistaxis (nosebleed) 5, 6
• Have a moderate-sized benefit for nasal blockage and a small benefit for rhinorrhoea 6

Other Treatment Considerations

• The use of intranasal corticosteroids should be continued postoperatively if endoscopic sinus surgery is performed 3
• Care should be taken when using intranasal corticosteroids in selected populations such as children, pregnant women, and elderly patients 3