What is the treatment for chronic sinusitis related rhinitis?

Treatment of Chronic Sinusitis-Related Rhinitis

For chronic rhinosinusitis with associated rhinitis symptoms, initiate treatment with daily high-volume saline nasal irrigation combined with intranasal corticosteroid sprays for at least 8-12 weeks, as these are the only therapies with Grade A evidence for symptom improvement and quality of life benefits. 1

Confirm the Diagnosis First

Before initiating treatment, you must confirm chronic rhinosinusitis with objective evidence through one of three methods: nasal endoscopy, anterior rhinoscopy, or CT imaging to document sinonasal inflammation. 2, 1 This step is critical because treatment strategies differ significantly based on whether nasal polyps are present.

Specifically assess for the presence or absence of nasal polyps, as this fundamentally changes your treatment approach and prognosis. 2, 1

Identify Modifying Conditions

Evaluate for chronic conditions that alter management strategy before starting treatment 2, 1:

• Asthma: Present in many patients with chronic rhinosinusitis and may improve with sinusitis treatment 1
• Cystic fibrosis, immunocompromised state, or ciliary dyskinesia: These require specialized management and affect treatment choices 2, 1
• Allergic rhinitis: If present, patients should be evaluated for IgE sensitization to inhalant allergens, as this may require additional allergen-specific therapy 2

First-Line Medical Therapy

Saline Nasal Irrigation

Prescribe high-volume saline irrigation daily, which improves symptom scores with a standardized mean difference of 1.42 (95% CI, 1.01 to 1.84) compared to no treatment. 1 This enhances mucociliary clearance and improves sinus drainage. 3

Intranasal Corticosteroids

Prescribe intranasal corticosteroids for all patients unless contraindicated, with evidence showing improvement in overall symptom scores (SMD, -0.46 [95% CI, -0.65 to -0.27]). 1

• Duration: Use for a minimum of 8-12 weeks because of the time needed for symptomatic relief and to assess benefit. 2
• Proper administration is critical: Demonstrate or describe the correct technique, as patients may not know how to properly deliver medication to the nasal cavity. 2, 1
• Dose considerations: Lower doses have similar effectiveness but fewer side effects compared to higher doses. 4 Higher doses increase the risk of epistaxis (RR 2.06,95% CI 1.20 to 3.54) without clear additional benefit. 4
• Long-term safety: Long-term use has not been shown to affect systemic cortisol levels or increase risk of lens opacity or elevated intraocular pressure. 2

Available intranasal corticosteroids include fluticasone propionate, mometasone furoate, ciclesonide, and fluticasone furoate, with no clear evidence that one is superior to another. 2, 4

Treatment Based on Nasal Polyp Status

If Nasal Polyps Are Present

Consider a short course of oral corticosteroids for 1 month, as they reduce polyp size for up to 3 months after a 3-week course (P < .001). 1, 5 This is particularly useful when rapid symptomatic improvement is needed. 5

If Nasal Polyps Are Absent

Continue with saline irrigation and intranasal corticosteroids as outlined above. 1

Antibiotic Therapy: When and How

The role of antibiotics in chronic rhinosinusitis is controversial and should be used selectively. 2

For chronic sinusitis with evidence of bacterial infection, the following regimen has shown efficacy in prospective descriptive studies 2:

• Minimum 3 weeks of an antibiotic effective against H. influenzae, mouth anaerobes, and S. pneumoniae
• Minimum 3 weeks of an older-generation antihistamine/decongestant (A/D) combination twice daily
• 5 days of a nasal decongestant (such as oxymetazoline) twice daily

Important caveat: Do NOT use antibiotics routinely in chronic rhinosinusitis with nasal polyps, as they are not recommended for this phenotype. 1

When cough disappears with antibiotic therapy, continue intranasal corticosteroids for 3 months. 2

What NOT to Do

Do NOT prescribe topical or systemic antifungal therapy for chronic rhinosinusitis—this is a Grade A recommendation against their use based on systematic reviews showing lack of efficacy, significant cost, and adverse effects. 2, 1

Do NOT use antihistamines unless the patient has documented allergic rhinitis as a comorbid condition, as there is no evidence supporting antihistamines for chronic rhinosinusitis itself. 1

Do NOT routinely prescribe oral or nasal decongestants for chronic sinusitis, as there are no prospective, randomized, double-blind studies proving efficacy in chronic sinusitis. 2

When Medical Therapy Fails

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
• Documented chronic sinus infection appears refractory to medical therapy and anatomic obstruction amenable to endoscopic sinus surgery is present 2

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

Follow-Up Strategy

Reassess patients between 3 and 12 months after initiating therapy, documenting 1:

• Symptom relief
• Quality of life changes
• Nasal endoscopy findings
• Adherence to therapy
• Complications or adverse effects

Continue intranasal corticosteroids postoperatively if surgery is performed. 2, 5

Common Pitfalls to Avoid

• Inadequate treatment duration: Many patients and clinicians discontinue intranasal corticosteroids too early; emphasize the need for at least 8-12 weeks of therapy. 2
• Improper medication technique: Failure to educate patients on proper administration of intranasal steroids significantly reduces efficacy. 2
• Overuse of nasal decongestants: Prolonged use (>5 days) can lead to rhinitis medicamentosa (rebound congestion). 2
• Inappropriate antibiotic use: Antibiotics have limited role in chronic rhinosinusitis without clear evidence of acute bacterial superinfection. 2
• Missing comorbid conditions: Failure to identify and treat underlying asthma, allergic rhinitis, or immunodeficiency can lead to treatment failure. 2, 1