Nasal Congestion with Decreased Sense of Smell for 4 Months: Next Step
Order a CT scan of the paranasal sinuses to confirm chronic rhinosinusitis (CRS) and guide further management. 1, 2
Diagnostic Rationale
Your patient meets the diagnostic criteria for chronic rhinosinusitis, defined as symptoms persisting ≥12 weeks (this patient has 4 months of symptoms). 1 The combination of nasal congestion and decreased sense of smell are two of the four cardinal symptoms required for CRS diagnosis. 1
Symptoms alone are insufficient for CRS diagnosis—objective documentation of inflammation through CT imaging or nasal endoscopy is mandatory. 1, 2 Symptoms have only 37-73% sensitivity for CRS diagnosis, making imaging critical for confirmation. 1, 2
Why CT Imaging is the Next Step
- CT is the gold standard for radiologic confirmation of CRS, demonstrating mucosal inflammation, sinus ostial obstruction, and anatomical variants that guide treatment decisions. 2
- Smell loss lasting 4 months indicates significant disease that warrants objective evaluation, as reduced sense of smell can indicate CRS disease severity and is often associated with chronic inflammation requiring more than conservative management. 3
- CT provides essential information about whether the patient has CRS with nasal polyps (CRSwNP) versus CRS without nasal polyps (CRSsNP), which fundamentally changes treatment approach. 1
Initial Medical Management While Awaiting Imaging
Start intranasal corticosteroids immediately—they are the most effective single agent for controlling both nasal congestion and improving sense of smell in CRS. 4, 5
Specific regimen:
- Fluticasone propionate 2 sprays per nostril once daily for the first week, then 1-2 sprays per nostril once daily as needed. 6
- Mometasone furoate 200 μg twice daily is equally effective and showed significant improvement in nasal obstruction, rhinorrhea, and sense of smell at 4 months in multiple trials. 5
Add nasal saline irrigation as adjunctive treatment to improve mucociliary clearance. 4
Important Caveats About Intranasal Corticosteroids
- It takes several days to reach maximum effect—patients must use regularly for optimal benefit. 6
- Duration matters: If symptoms persist beyond 6 months of daily use, the patient should be re-evaluated. 6
- Smell improvement may be incomplete: Most studies show that while intranasal corticosteroids can improve olfactory sensation in CRS, effects are usually transient and incomplete. 7
What NOT to Do
Do not start antibiotics empirically. 2 The 4-month duration without fever, facial pain, or purulent discharge makes acute bacterial sinusitis unlikely. 2 Antibiotics are only indicated if symptoms persist or worsen after 3 weeks of appropriate medical therapy with intranasal corticosteroids. 4
Do not add montelukast. The EPOS 2020 guidelines found no significant additional effect from adding montelukast to intranasal corticosteroids, and the steering group does not recommend its use unless patients cannot tolerate nasal corticosteroids. 5
Do not use topical antifungals. Multiple studies show no benefit for quality of life, symptoms, or disease signs in CRS patients. 5
Subsequent Management Based on CT Results
If CT Confirms CRSwNP (Nasal Polyps Present):
- Continue intranasal corticosteroids as first-line therapy. 5
- Consider short-term systemic corticosteroids (e.g., prednisolone 35 mg reducing by 5 mg every second day over 14 days) if marked mucosal edema is present. 5, 4
- If medical therapy fails after 3-6 months, refer to Otolaryngology for consideration of endoscopic sinus surgery. 4, 1
- For severe, recurrent CRSwNP, consider biologic therapy with dupilumab, which showed clinically significant improvements in SNOT-22 scores (mean difference -19.61), smell scores (UPSIT improvement of 10.83 points), and nasal polyp scores at 4-6 months. 5
If CT Confirms CRSsNP (No Polyps):
- Continue intranasal corticosteroids with nasal saline irrigation. 5
- Refer to Otolaryngology if symptoms persist beyond 12 weeks despite appropriate medical therapy or if anatomical abnormalities are identified. 4, 1
- Consider allergy testing, as up to 60% of patients with recurrent or difficult-to-treat CRS have significant allergic sensitivities to perennial allergens. 1
Red Flags Requiring Urgent Referral
Refer immediately to Otolaryngology if any of the following develop: