Management of Chronic Rhinosinusitis
Clinicians should recommend saline nasal irrigation and topical intranasal corticosteroids as first-line therapy for chronic rhinosinusitis, with both treatments providing Grade A evidence for symptom relief and improved quality of life. 1
Initial Diagnostic Confirmation
Before initiating treatment, confirm the diagnosis with objective evidence of sinonasal inflammation through one of three modalities: nasal endoscopy, anterior rhinoscopy, or CT imaging 1. This step is critical because self-reported symptoms alone lead to overdiagnosis and inappropriate management 1.
Assess for nasal polyps in every patient with chronic rhinosinusitis, as their presence fundamentally changes treatment approach and prognosis 1. Large polyps are visible with a nasal speculum, but small polyps in the middle meatus require nasal endoscopy 1. If you cannot perform endoscopy, refer the patient to someone who can 1.
Identify Modifying Factors
Evaluate for chronic conditions that alter management strategy 1:
- Asthma: Present in many patients with chronic rhinosinusitis; treating the sinusitis may improve asthma control 1
- Cystic fibrosis: Requires specialized management 1
- Immunocompromised state: Affects treatment choices and prognosis 1
- Ciliary dyskinesia: Fundamentally changes disease trajectory 1
Consider allergy testing, particularly in patients with recurrent acute exacerbations, though the evidence for allergy management improving rhinosinusitis outcomes is limited 1.
First-Line Medical Management
Saline Nasal Irrigation
Use high-volume saline irrigation daily as it improves symptom scores with a standardized mean difference of 1.42 (95% CI, 1.01 to 1.84) compared to no treatment 2. This intervention is safe, inexpensive, and available over-the-counter 1.
Topical Intranasal Corticosteroids
Prescribe intranasal corticosteroids for all patients unless contraindicated 1. The evidence is Grade A from systematic reviews of randomized controlled trials 1. These medications:
- Improve overall symptom scores (SMD, -0.46 [95% CI, -0.65 to -0.27]) 2
- Reduce polyp scores (SMD, -0.73 [95% CI, -1.0 to -0.46]) in patients with nasal polyps 2
- Decrease polyp recurrence after surgery (relative risk, 0.59 [95% CI, 0.45 to 0.79]) 2
Proper administration technique is essential 1:
- Shake the bottle well
- Look down toward the floor
- Use the right hand for the left nostril and left hand for the right nostril
- Aim toward the outer wall, NOT the nasal septum
- Do not sniff hard after administration
For patients with nasal polyps or post-surgical patients, consider corticosteroid nasal irrigations (budesonide or mometasone) rather than sprays alone, as they provide superior paranasal sinus penetration 3. While this is off-label use, multiple clinical trials support improved efficacy over sprays 3.
Duration of Initial Therapy
Continue saline irrigation and intranasal corticosteroids for at least 3 months before reassessing 1. The natural history of chronic rhinosinusitis is unknown, so treatment duration should be determined through shared decision-making with patients 1.
Management Based on Nasal Polyp Status
Chronic Rhinosinusitis WITH Nasal Polyps
For mild symptoms (VAS 0-3): Continue intranasal corticosteroids for 3 months; if improved, continue with follow-up every 6 months 1.
For moderate symptoms (VAS >3-7): Use topical corticosteroid drops for 3 months 1. If no improvement, add a short course of oral corticosteroids for 1 month 1. Systemic corticosteroids reduce polyp size for up to 3 months after a 3-week course (P < .001) 2.
For severe symptoms (VAS >7-10): Start with a short course (1 month) of oral corticosteroids 1.
Consider leukotriene antagonists as adjunctive therapy, as they improve nasal symptoms compared to placebo in patients with nasal polyps (P < .01) 2.
Do NOT use antibiotics routinely in chronic rhinosinusitis with nasal polyps, as they are not recommended for this phenotype 1.
Chronic Rhinosinusitis WITHOUT Nasal Polyps
After initial therapy with saline irrigation and intranasal corticosteroids, if symptoms persist, consider a 3-month course of macrolide antibiotics 2. This improves quality of life at 24 weeks after therapy (SMD, -0.43 [95% CI, -0.82 to -0.05]) 2.
Alternatively, doxycycline for 3 weeks may reduce inflammation and improve symptoms 2.
What NOT to Do
Do NOT prescribe topical or systemic antifungal therapy for chronic rhinosinusitis 1. This is a Grade A recommendation against their use based on systematic reviews showing lack of efficacy, significant cost, and adverse effects 1.
Do NOT use antihistamines unless the patient has documented allergic rhinitis as a comorbid condition 1. There is no evidence supporting antihistamines for chronic rhinosinusitis itself 1.
Avoid prolonged use of topical decongestants (beyond 3-5 days) due to risk of rhinitis medicamentosa, though they may temporarily improve ostial patency 1.
Surgical Considerations
Refer for surgical evaluation when 1:
- Symptoms persist after 3 months of appropriate medical therapy
- CT imaging shows extensive disease
- Patient has chronic rhinosinusitis with polyps showing bony erosion, eosinophilic mucin, or fungal balls
- Quality of life remains significantly impaired despite maximal medical management
Surgery should include full exposure of the sinus cavity and removal of diseased tissue, not just balloon dilation, particularly when polyps, osteitis, bony erosion, or fungal disease is present 1.
Continue intranasal corticosteroids postoperatively to reduce recurrence 2, 4. Topical corticosteroids reduce polyp recurrence after surgery by 41% 2.
Follow-Up and Monitoring
Reassess patients between 3 and 12 months after initiating therapy or after surgery 1. Document:
- Symptom relief and quality of life changes
- Nasal endoscopy findings
- Adherence to therapy
- Need for rescue medications
- Complications or adverse effects 1
Counsel patients about realistic expectations: Chronic rhinosinusitis is a chronic disease that may require long-term medical management even after surgery, with potential for relapse or need for revision surgery 1.