What is the management of chronic rhino sinusitis?

Management of Chronic Rhinosinusitis

The management of chronic rhinosinusitis should begin with intranasal corticosteroids and saline nasal irrigation as first-line therapy, with treatment escalation based on disease severity and the presence of nasal polyps. 1

Definition and Classification

Chronic rhinosinusitis (CRS) is defined as inflammation of the paranasal sinuses and nasal cavity lasting at least 12 consecutive weeks, characterized by at least two of the following symptoms:

• Nasal obstruction
• Nasal drainage
• Facial pain/pressure
• Hyposmia/anosmia

CRS is further classified into two main phenotypes:

• CRS without nasal polyps (CRSsNP)
• CRS with nasal polyps (CRSwNP)

First-Line Treatment

For All CRS Patients:

1. Intranasal corticosteroids (INCS) 1

   • Recommended dosage: Fluticasone propionate 50 mcg, 1-2 sprays in each nostril once or twice daily 2
   • Evidence level: A/Ib (strong recommendation based on randomized controlled trials)
   • Mechanism: Reduces mucosal inflammation and swelling

2. Saline nasal irrigation 1, 3

   • Frequency: 1-2 times daily
   • Evidence level: A/Ib
   • Mechanism: Improves mucociliary clearance, removes secretions and inflammatory mediators

Treatment Algorithm Based on Severity and Phenotype

For CRS without Nasal Polyps (CRSsNP):

Mild Disease (VAS 0-3):

1. Topical intranasal corticosteroids
2. Nasal saline irrigation
3. If no improvement after 3 months, escalate to moderate/severe treatment

Moderate/Severe Disease (VAS >3-10):

1. Continue intranasal corticosteroids and saline irrigation
2. Consider long-term macrolide therapy (e.g., roxithromycin) for 12 weeks 1
3. If no improvement after 3 months:
   • Add short course of oral corticosteroids
   • Obtain CT scan
   • Evaluate for surgical candidacy

For CRS with Nasal Polyps (CRSwNP):

Mild Disease (VAS 0-3):

1. Topical corticosteroid spray for 3 months
2. If beneficial, continue and review every 6 months
3. If no improvement, add short course of oral corticosteroids

Moderate Disease (VAS >3-7):

1. Topical corticosteroid drops for 3 months
2. If beneficial, continue and review every 6 months
3. If no improvement, add oral corticosteroids and consider CT scan for surgical evaluation

Severe Disease (VAS >7-10):

1. Short course of oral corticosteroids plus topical corticosteroids for 1 month
2. If no improvement, obtain CT scan and evaluate for surgical candidacy

Role of Antibiotics

The role of antibiotics in CRS is controversial 1:

• May be useful for acute exacerbations of CRS
• Recent evidence suggests amoxicillin-clavulanate may not provide additional benefit over topical intranasal steroids alone for acute exacerbations 4
• If prescribed, consider high-dose amoxicillin-clavulanate, cefuroxime, cefpodoxime, or cefprozil 1

Assessment for Modifying Factors

Evaluate patients with CRS for conditions that may modify management 1:

• Allergic rhinitis (consider antihistamines if present)
• Asthma
• Cystic fibrosis
• Immunocompromised state
• Ciliary dyskinesia
• Anatomical variations

When to Consider Surgery

Consider surgical intervention when 1:

1. Medical therapy fails after appropriate trials
2. CT scan shows evidence of ostiomeatal complex obstruction
3. Presence of obstructing nasal polyps despite medical therapy including oral corticosteroids
4. Presence of significant anatomical abnormalities (e.g., nasal septal deviation)

Important Caveats and Pitfalls

1. Avoid prolonged use of topical decongestants as they can cause rhinitis medicamentosa
2. Avoid routine use of antibiotics without evidence of acute bacterial infection 1, 4
3. Avoid antifungal agents as their role has not been established 1
4. Recognize that CRS is heterogeneous - treatment response varies among patients
5. Continue medical therapy after surgery to prevent recurrence 5

Special Considerations

• For patients with allergic rhinitis and CRS, consider additional antihistamine therapy 1
• For patients with aspirin-exacerbated respiratory disease (AERD), avoid NSAIDs
• Functional endoscopic sinus surgery (FESS) should preserve ciliated epithelium as much as possible 5

The management of CRS requires a stepwise approach based on disease severity, phenotype, and response to therapy. Intranasal corticosteroids and saline irrigation form the cornerstone of treatment, with additional therapies added based on individual patient response and disease characteristics.