What is the treatment for chronic rhinosinusitis?

Treatment of Chronic Rhinosinusitis

Start all patients with chronic rhinosinusitis on high-volume saline nasal irrigation plus intranasal corticosteroid spray as first-line therapy, regardless of whether nasal polyps are present. 1

Confirm the Diagnosis First

Before initiating treatment, you must document objective evidence of sinonasal inflammation through nasal endoscopy, anterior rhinoscopy, or CT imaging—clinical symptoms alone are insufficient for diagnosis. 1 During this evaluation, specifically assess for the presence or absence of nasal polyps, as this fundamentally alters your treatment algorithm and prognosis. 1

First-Line Medical Therapy (All Patients)

Saline Nasal Irrigation

• Prescribe high-volume saline irrigation daily (not just nasal spray), as this provides substantial symptom improvement with a standardized mean difference of 1.42 compared to no treatment. 1
• The volume matters—high-volume irrigation is more effective than simple saline sprays for chronic rhinosinusitis. 2

Intranasal Corticosteroids

• Prescribe intranasal corticosteroids for all patients unless contraindicated, with evidence showing improvement in overall symptom scores (SMD -0.46). 1, 3
• Use for at least 8-12 weeks before assessing efficacy, as symptomatic relief takes time. 2
• Demonstrate proper technique: Hold the spray in the opposite hand relative to the nostril being treated (right hand for left nostril), aim away from the septum, keep head upright, and shake the bottle before each use. 2 This technique reduces epistaxis risk fourfold compared to ipsilateral technique. 2
• Expect nasal blockage to improve most (MD -0.40), followed by rhinorrhea (MD -0.25) and loss of smell (MD -0.19). 3

Expected Adverse Effects

• Epistaxis occurs more frequently with intranasal corticosteroids (RR 2.74), but this typically manifests as minor streaks of blood rather than significant bleeding. 3
• Local irritation rates are similar to placebo. 3

Treatment Based on Nasal Polyp Status

Chronic Rhinosinusitis WITH Nasal Polyps

• Add a short course (1 month) of oral corticosteroids if symptoms are moderate-to-severe or if initial therapy with topical steroids fails after 3 months. 1 Oral steroids reduce polyp size for up to 3 months after a 3-week course. 1
• Do NOT use antibiotics routinely—they are not recommended for chronic rhinosinusitis with nasal polyps. 1
• Consider topical corticosteroid drops (rather than spray) for moderate symptoms, as drops may provide better distribution. 2

Chronic Rhinosinusitis WITHOUT Nasal Polyps

• Consider a trial of antibiotics (minimum 3 weeks) effective against H. influenzae, mouth anaerobes, and S. pneumoniae if bacterial infection is suspected. 2
• The role of antibiotics in chronic rhinosinusitis without polyps remains controversial, but some evidence supports extended courses (3-4 months) for persistent bacterial-induced inflammation. 2

What NOT to Do

Do NOT prescribe antifungal therapy (topical or systemic) for chronic rhinosinusitis—this is a Grade A recommendation against use based on systematic reviews showing no efficacy, significant cost, and adverse effects. 2, 1 The only exceptions are invasive fungal sinusitis or allergic fungal sinusitis. 2

Do NOT prescribe antihistamines unless the patient has documented comorbid allergic rhinitis—there is no evidence supporting antihistamines for chronic rhinosinusitis itself. 1

Do NOT use topical nasal decongestants (like oxymetazoline) for more than 5 days, as prolonged use causes rhinitis medicamentosa. 2

When to Refer for Surgery

Refer for surgical evaluation when:

• Symptoms persist after 3 months of appropriate medical therapy with documented adherence. 1
• CT imaging shows extensive disease. 1
• Patient has chronic rhinosinusitis with polyps showing bony erosion, eosinophilic mucin, or fungal balls. 1
• Anatomic obstruction is present that appears amenable to endoscopic sinus surgery. 2

Surgery should involve 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. 2 Continue intranasal corticosteroids postoperatively. 4, 5

Special Considerations

Comorbid Asthma

• Evaluate all patients for asthma, as it is present in many patients with chronic rhinosinusitis and may improve with treatment of the sinusitis. 1
• Be cautious about total corticosteroid burden when patients use both intranasal and inhaled corticosteroids. 4

Consider Specialized Evaluation For:

• Cystic fibrosis, immunocompromised state, or ciliary dyskinesia—these require specialized management. 1
• Pregnant patients, as they require modified treatment approaches. 2

Follow-Up Timeline

Reassess patients between 3 and 12 months after initiating therapy, documenting symptom relief, quality of life changes, nasal endoscopy findings, adherence to therapy, and any complications or adverse effects. 1 If no improvement after 3 months of first-line therapy, escalate treatment or refer for surgical evaluation. 2