What is the diagnosis and management of chronic rhinosinusitis?

Diagnosis and Management of Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) requires both symptom persistence for at least 12 weeks and objective evidence of inflammation through nasal endoscopy or CT imaging for definitive diagnosis. 1, 2

Diagnosis

Diagnostic Criteria

• CRS is defined as inflammation of the paranasal sinuses and nasal cavity persisting for more than 12 weeks 1, 2
• Diagnosis requires at least 2 of the following symptoms for ≥12 weeks:
  • Nasal obstruction/blockage/congestion
  • Anterior or posterior mucopurulent drainage
  • Facial pain/pressure/fullness (more common in CRS without nasal polyps)
  • Decreased sense of smell (more common in CRS with nasal polyps) 1
• Objective confirmation of inflammation is mandatory through at least one of:
  • Nasal endoscopy showing purulent mucus, edema, or nasal polyps
  • CT scan showing inflammation of the paranasal sinuses 1, 2

Diagnostic Testing

• Nasal endoscopy is recommended as the first-line objective test for all patients with suspected CRS 1
• CT scan with fine-cut protocol should be obtained for surgical planning and when endoscopy is not available or inconclusive 1, 2
• Allergy testing should be performed in patients with CRS whose symptoms are not easily controlled with saline irrigations and intranasal medications 1, 2
• Immunologic testing (IgG, IgA, IgM levels, specific antibody responses) should be considered in patients with recurrent or refractory infections 1, 2

CRS Subtypes

• CRS with nasal polyps (CRSwNP)
• CRS without nasal polyps (CRSsNP)
• Allergic fungal rhinosinusitis (AFRS) - requires:
  • Presence of allergic mucin with eosinophils
  • Positive fungal-specific IgE
  • Evidence of fungi in sinus contents
  • No histologic evidence of invasive fungal disease 1

Management

Medical Management

• First-line therapy:

  • Saline nasal irrigation (high-volume) - reduces inflammation and improves mucociliary clearance 2, 3
  • Intranasal corticosteroids - reduce inflammation and polyp size 2, 4, 3

• Second-line therapy:

  • Short courses of systemic corticosteroids (particularly effective for CRS with nasal polyps) 2, 3
  • Antibiotics should be reserved for acute bacterial exacerbations with evidence of infection 1, 2

• Additional therapies:

  • Antileukotrienes may be considered for patients with concurrent asthma 3
  • Antihistamines only if concurrent allergic rhinitis is present 1
  • Antifungal therapy is not recommended for routine CRS management 2

Biologic Therapies

• For severe CRSwNP, FDA-approved biologics include:
  • Omalizumab (anti-IgE)
  • Mepolizumab (anti-IL-5)
  • Dupilumab (anti-IL-4Rα) 5
• These therapies can improve quality of life, reduce need for systemic corticosteroids, and decrease need for revision surgery in appropriate patients 5

Surgical Management

• Indications for surgery:

  • Failure of appropriate medical therapy
  • CRS subtypes with polyps, osteitis, bony erosion, or fungal disease 1
  • When anticipated benefits exceed those of continued medical management alone 1

• Surgical approach:

  • Endoscopic sinus surgery (ESS) with full exposure of the sinus cavity and removal of diseased tissue is preferred over balloon dilation alone for cases involving polyps, osteitis, bony erosion, or fungal disease 1
  • Surgery should not be planned solely based on minimal mucosal thickening or sinus opacification on CT 1

Post-Treatment Follow-up

• Follow-up assessment between 3-12 months after surgery is essential to:
  • Document symptom relief and quality of life improvements
  • Evaluate for complications
  • Assess adherence to therapy
  • Determine need for rescue medications
  • Perform nasal endoscopy to evaluate healing 1

Special Considerations

• CRS is often a chronic condition requiring long-term management; patients should be counseled about potential for relapse and need for ongoing medical therapy 1, 6
• Underlying conditions that may contribute to CRS should be identified and treated:
  • Allergic rhinitis
  • Immunodeficiency
  • Aspirin-exacerbated respiratory disease
  • Cystic fibrosis
  • Ciliary dysfunction 1, 7
• Comorbid asthma often improves with effective CRS management 1, 5

Common Pitfalls to Avoid

• Diagnosing CRS based on symptoms alone without objective evidence of inflammation 2
• Relying solely on CT findings without correlation to symptoms 1
• Failing to identify and manage underlying contributing conditions 2, 7
• Not providing adequate post-surgical medical therapy, which is essential for long-term disease control 1, 6
• Using antifungal therapy routinely in CRS without specific indications 2