What is the next step in managing nasal congestion with decreased sense of smell, intermittent nasal discharge, and headaches that worsen during winter months, following an upper respiratory infection one year ago?

Management of Chronic Rhinosinusitis with Decreased Sense of Smell

The next step in managing this case of chronic rhinosinusitis should be to initiate intranasal corticosteroid therapy as the first-line treatment, combined with saline nasal irrigation. 1

Clinical Diagnosis

• The patient's presentation is consistent with chronic rhinosinusitis (CRS), defined by:
  • Symptoms lasting more than 12 weeks (patient reports 4 months of symptoms) 1
  • Key symptoms including nasal congestion, decreased sense of smell, intermittent nasal discharge, and headaches 1
  • Seasonal worsening during winter months suggests possible allergic component 1
  • History of preceding upper respiratory infection, which is a common trigger for CRS 1

Initial Treatment Approach

First-Line Therapy:

• Intranasal corticosteroids:

  • Recommended as primary treatment for CRS symptoms 1
  • Effectively reduces nasal congestion, inflammation, and improves sense of smell 2
  • Twice-daily dosing is more effective than once-daily for symptom control 1
  • Options include fluticasone propionate, mometasone furoate, or budesonide 3

• Saline nasal irrigation:

  • Should be used concurrently with intranasal corticosteroids 1
  • Helps clear mucus, reduce inflammation, and improve medication delivery 1
  • Can be performed with isotonic or hypertonic saline solutions 1

Diagnostic Evaluation

If symptoms persist after 4 weeks of initial therapy, proceed with:

• Nasal endoscopy:

  • To evaluate for presence of nasal polyps, purulent discharge, or anatomical abnormalities 1
  • Allows better visualization of the posterior nasal cavity and sinus drainage pathways 1
  • Essential for distinguishing between CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP) 1

• CT scan of sinuses:

  • Not recommended as initial step but should be considered if symptoms persist despite medical therapy 1
  • Coronal sinus CT with cuts through the ostiomeatal complex to clarify extent of disease 1
  • Objective documentation of inflammation is required for definitive diagnosis of CRS 1

Additional Treatment Options

Second-Line Therapies:

• Short course of oral corticosteroids:

  • Consider if severe symptoms persist or nasal polyps are identified on endoscopy 1
  • Particularly effective for improving sense of smell in CRS with nasal polyps 1
  • Should be followed by maintenance therapy with intranasal corticosteroids 1

• Leukotriene modifiers:

  • Montelukast (10mg daily) may be considered as add-on therapy to intranasal corticosteroids 1
  • Can improve symptoms of headache and sense of smell in some patients 1

• Nasal decongestants:

  • Short-term use (≤3 days) may help with severe congestion 1
  • Should be used cautiously to avoid rebound congestion 1
  • Can be combined with intranasal corticosteroids for better initial symptom relief 1

Special Considerations

• Decreased sense of smell:

  • A cardinal symptom of CRS, particularly CRS with nasal polyps 1
  • May improve with intranasal corticosteroids, but often requires longer treatment duration 2
  • If no improvement after 4-6 weeks, consider short course of oral corticosteroids 1

• Seasonal worsening:

  • Suggests possible allergic component that may benefit from antihistamines during exacerbations 1
  • Consider allergy testing if symptoms have clear seasonal pattern 1

• Headaches:

  • Common in CRS but should improve with appropriate treatment of underlying inflammation 1
  • Persistent headaches despite treatment warrant further evaluation 1

When to Consider Referral to ENT

• Failure to respond to 4-6 weeks of appropriate medical therapy 1
• Suspected anatomical abnormalities (septal deviation, turbinate hypertrophy) 1
• Presence of nasal polyps requiring surgical evaluation 1
• Recurrent acute exacerbations of CRS despite medical management 1
• Unilateral symptoms or other concerning features suggesting possible neoplasm 1

Monitoring and Follow-up

• Reassess symptoms after 4 weeks of initial therapy 1
• If improvement occurs, continue intranasal corticosteroids as maintenance therapy 1
• If minimal or no improvement, proceed with nasal endoscopy and consider CT imaging 1
• Long-term management focuses on controlling inflammation and preventing exacerbations 1