What are the causes and management options for chronic rhinosinusitis?

From the Guidelines

Chronic rhinosinusitis (CRS) should be managed with a comprehensive approach that includes daily saline nasal irrigation and intranasal corticosteroids as the mainstay of treatment, with consideration of additional therapies such as antihistamines, antibiotics, and oral corticosteroids based on individual patient needs and underlying conditions. The causes of CRS are multifactorial, including allergies, nasal polyps, bacterial or fungal infections, immune disorders, and anatomical abnormalities. Management of CRS should prioritize symptom relief and reduction of inflammation.

Key Components of Management

• Daily saline nasal irrigation using 240mL of lukewarm saline solution in each nostril to clear mucus and reduce inflammation
• Intranasal corticosteroids like fluticasone (2 sprays per nostril daily) or mometasone (2 sprays per nostril daily) to reduce inflammation and improve symptoms
• Antihistamines such as loratadine (10mg daily) or cetirizine (10mg daily) for patients with allergic components
• Antibiotics, such as amoxicillin-clavulanate (875/125mg twice daily for 10-14 days) or doxycycline (100mg twice daily for 10-14 days), for acute bacterial exacerbations
• Oral corticosteroids like prednisone (20-40mg daily for 5-7 days) for severe cases with nasal polyps
• Leukotriene modifiers such as montelukast (10mg daily) for patients with concurrent asthma

Surgical Options and Lifestyle Modifications

If medical therapy fails after 3-6 months, surgical options including functional endoscopic sinus surgery should be considered. Lifestyle modifications like avoiding irritants, managing allergies, and controlling underlying conditions such as asthma or GERD are essential for long-term management. This approach is supported by recent guidelines, including the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 1, which emphasizes the importance of a comprehensive treatment plan for CRS. Additionally, the clinical practice guideline update by the American Academy of Otolaryngology-Head and Neck Surgery Foundation 1 recommends saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. Older guidelines, such as those from 2005 1, also provide valuable insights into the management of CRS, but the most recent and highest quality evidence should be prioritized.

From the Research

Causes of Chronic Rhinosinusitis

• Chronic rhinosinusitis is an inflammatory disease of the paranasal sinuses that occurs in 1% to 5% of the U.S. population 2
• The exact cause of chronic rhinosinusitis is not fully understood, but it is believed to involve a combination of genetic, environmental, and immune system factors

Symptoms of Chronic Rhinosinusitis

• The disease is defined by the presence of at least two out of four cardinal symptoms, including facial pain/pressure, hyposmia/anosmia, nasal drainage, and nasal obstruction, for at least 12 consecutive weeks 2
• Objective evidence of chronic rhinosinusitis may be obtained on physical examination or radiography, preferably from sinus computed tomography 2

Management Options for Chronic Rhinosinusitis

• First-line treatment includes nasal saline irrigation and intranasal corticosteroid sprays 2, 3
• There may be a role for antibiotics in patients with evidence of an active, superimposed acute sinus infection 2, 4
• Endoscopic sinus surgery may be effective if medical management fails 2
• Biologics, such as monoclonal antibodies, have shown benefit in clinical studies, particularly for patients with nasal polyposis 5, 6
• Nasal irrigation with corticosteroids is beneficial and safe for the treatment of chronic rhinosinusitis 3

Treatment Considerations

• Patients not responding to first-line medical therapy should be referred to an otolaryngologist, and selected patients with a history suggestive of other comorbidities may also benefit from referral to an allergist or pulmonologist 2
• The use of off-label nasal steroid irrigations may be considered for patients with chronic rhinosinusitis, particularly those who have not responded to traditional treatments 3
• The management of acute exacerbation of chronic rhinosinusitis is still under debate, and antibiotic use may not provide additional benefit in all cases 4