From the Guidelines
Chronic rhinosinusitis (CRS) should be treated with a combination of saline nasal irrigation and topical intranasal corticosteroids, as this approach has been shown to provide symptom relief and improve quality of life. According to the most recent and highest quality study, the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 1, nasal irrigation with isotonic saline or Ringer’s lactate is recommended to thin and remove mucous, clear proteins that cause inflammation, and flush out irritants and bacteria from the nose and sinus cavities.
Treatment Options
- Daily saline nasal irrigation using a neti pot or squeeze bottle with 240mL of distilled water mixed with a saline packet
- Intranasal corticosteroids like fluticasone (Flonase) 1-2 sprays per nostril daily or mometasone (Nasonex) 2 sprays per nostril daily for at least 3 months
- For patients with allergic components, adding an antihistamine like cetirizine 10mg daily may help
- If symptoms persist despite these measures, a short course of oral antibiotics may be necessary, such as amoxicillin-clavulanate 875/125mg twice daily for 14 days or doxycycline 100mg twice daily for 10 days, particularly if bacterial infection is suspected
- For severe cases unresponsive to medical therapy, a short course of oral prednisone (20mg daily for 5-7 days) may be considered, followed by referral to an ENT specialist for possible endoscopic sinus surgery evaluation
Causes and Pathophysiology
The condition is driven by persistent inflammation that causes mucosal thickening, impaired mucus clearance, and potential bacterial colonization, which is why anti-inflammatory treatments form the cornerstone of therapy. As noted in the clinical practice guideline update: adult sinusitis 1, clinicians should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS, based on a preponderance of benefit over harm. Additionally, the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 1 highlights the importance of short courses of systemic corticosteroids in reducing the inflammatory response and improving symptoms in patients with chronic rhinosinusitis with nasal polyps.
Lifestyle Modifications
Lifestyle modifications including avoiding irritants like smoke, managing allergies, and controlling underlying conditions like asthma or GERD are also important in managing CRS. By addressing these factors and using a combination of saline nasal irrigation and topical intranasal corticosteroids, patients with CRS can experience significant improvement in their symptoms and quality of life.
From the Research
Causes of Chronic Rhinosinusitis (CRS)
- CRS is characterized by inflammation of the lining of the nose and paranasal sinuses, leading to nasal blockage, rhinorrhoea, facial pressure/pain, and loss of sense of smell 2
- The condition can occur with or without nasal polyps
- Predisposing factors include ciliary impairment, allergy, nasal polyposis, and immune deficiency 3
- Bacterial infection may also play a role in the development of CRS, although its exact impact is uncertain 4
Treatment Options for CRS
- Intranasal corticosteroids are widely used to treat CRS, with evidence showing improvement in disease severity and individual symptoms such as nasal blockage, rhinorrhoea, and loss of sense of smell 2
- Oral corticosteroids may also be used for short-term treatment, while corticosteroid-eluting implants are considered an option 5
- Saline solution rinses and nasal lavage with isotonic saline solutions are recommended to reduce mucosal inflammation and swelling 5, 3
- Systemic antibiotics such as amoxicillin/clavulanic acid, ciprofloxacin, and clarithromycin may be administered to patients with underlying bacterial infection 3, 4
- Biologic treatments such as dupilumab, omalizumab, mepolizumab, and reslizumab may be used for severe CRS, particularly in patients with concomitant uncontrolled asthma 5, 6
- Surgery may be considered for patients who do not respond to medical treatment, with the goal of widening the natural drainage openings of the sinuses and preserving the ciliated epithelium 3
Multidisciplinary Team Approach
- A multidisciplinary team (MDT) approach may be effective in optimizing the treatment and clinical management of CRS, reducing diagnostic delays and mitigating secondary disease burden 6
- An MDT approach can bring together specialists from different areas to provide comprehensive care and address under-recognized aspects of CRS 6