What are the treatment options for a patient with chronic rhinosinusitis?

Treatment Options for Chronic Rhinosinusitis

Begin with large-volume (150-250 ml) hypertonic (2%) saline irrigation twice daily combined with intranasal corticosteroid spray (fluticasone propionate 200 mcg daily or mometasone furoate) as first-line therapy for all patients with chronic rhinosinusitis. 1, 2

Initial Medical Management Algorithm

For CRS Without Nasal Polyps (Mild Symptoms, VAS 0-3)

• Start intranasal corticosteroids plus large-volume hypertonic saline irrigation twice daily 1, 2
• Large-volume nasal douches are superior to sprays or nebulizers for distributing solution to the maxillary sinuses and frontal recess, removing inflammatory mediators, biofilms, and antigens 2
• Reassess symptoms at 4 weeks; if improvement occurs, continue both treatments and consider reducing corticosteroid dose to 100 mcg daily 2
• If no improvement after 3 months, obtain bacterial culture and initiate long-term macrolide therapy (e.g., erythromycin) 1
• Consider CT imaging at this stage to evaluate disease extent 1
• If still no response after another 3 months of macrolide therapy, proceed to CT evaluation and surgical consultation 1

For CRS Without Nasal Polyps (Moderate/Severe Symptoms, VAS >3-10)

• Immediately start intranasal corticosteroids, large-volume hypertonic saline irrigation, bacterial culture, AND long-term macrolide therapy 1
• If no response after 3 months, obtain CT scan and refer for surgical evaluation 1

For CRS With Nasal Polyps (Mild Symptoms, VAS 0-3)

• Begin topical corticosteroid spray for 3 months 1
• If beneficial, continue and review every 6 months 1
• If no improvement, add short course of oral corticosteroids (5-7 days) 1
• If still no improvement after 1 month, obtain CT scan and assess as surgical candidate 1
• If improved after oral steroids, switch to topical corticosteroid drops and review after 3 months 1

For CRS With Nasal Polyps (Moderate/Severe Symptoms, VAS >3-10)

• Start topical corticosteroid drops for 3 months immediately 1
• Consider adding oral corticosteroids early in treatment course 1
• For severe refractory CRS with nasal polyposis that fails medical therapy, biological agents are indicated 3

Critical Medication Details

Intranasal Corticosteroids

• Fluticasone propionate starts providing relief within the first day, but requires several days to build up to full effectiveness 4
• Does NOT cause rebound congestion unlike nasal decongestant sprays 4
• Can be used for up to 6 months in patients ≥12 years old, or up to 2 months per year in children 4-11 years old 4
• Does not cause drowsiness 4
• Produces significant decreases in total nasal symptom scores including rhinorrhea, nasal obstruction, and congestion 2

Saline Irrigation Specifics

• Use hypertonic (2%) concentration rather than isotonic 2
• Volume must be 150-250 ml per irrigation 2
• Frequency: twice daily 2
• Shows progressive benefit over months with significantly better results at 3,6,9, and 12 months compared to no irrigation 2
• Consider adding xylitol (12 g in 240 ml water once daily) if inadequate response after 4 weeks 2
• Sodium hyaluronate addition (9 mg in saline twice daily) can reduce crusting and secretions 2

Antibiotic Therapy

• Antibiotics should only be used for patients with evidence of active, superimposed acute bacterial infection 5
• For acute exacerbations: minimum 5-7 days of antibiotic therapy 6
• For chronic disease with bacterial infection: long-term therapy >12 weeks may be necessary 6
• Options include amoxicillin/clavulanic acid, ciprofloxacin, clarithromycin, or trimethoprim/sulfamethoxazole 7
• Long-term macrolide therapy (erythromycin) has anti-inflammatory and immune-mediating properties beyond antimicrobial effects 1

Common Pitfalls to Avoid

Nasal Decongestant Sprays

• NEVER use topical nasal decongestants beyond 5-7 days 2
• Prolonged use causes rhinitis medicamentosa (rebound congestion) with increased risk of complications 2
• Fluticasone propionate does NOT cause this rebound effect and can be used long-term 4

Premature Surgical Referral

• Approximately 70-80% of CRS patients respond adequately to appropriate medical treatment 6
• Surgery should be reserved for patients who do not satisfactorily respond to medical treatment 6
• Ensure adequate trial of medical therapy before surgical consideration 6

Inadequate Medical Therapy Duration

• Intranasal corticosteroids require several days to weeks for maximum effect 2
• Saline irrigation shows progressive benefit over months, not immediate results 2
• Allow minimum 3-month trial before declaring medical therapy failure 1

Surgical Indications

When to Refer for Surgery

• Failure of appropriate medical therapy after 3-6 months 1
• Presence of nasal polyps, osteitis, bony erosion, or fungal disease 1
• Severe pan-sinus disease with structural abnormalities 6
• Recurrent acute rhinosinusitis requiring 3-4 courses of antibiotics yearly despite medical management 6

Surgical Approach Requirements

• When sinuses involve polyps, osteitis, bony erosion, or fungal disease, surgery MUST include full exposure of the sinus cavity and removal of diseased tissue, NOT just balloon or manual ostial dilation 1, 6
• Balloon sinuplasty alone is inappropriate for advanced sinus disease requiring comprehensive surgical approaches 1, 6
• The extent of surgery should be tailored to the extent of disease rather than limited to ostial dilation when more extensive pathology exists 6
• CT scan with fine-cut protocol is required for surgical planning 1

Postoperative Management

• Continue medical treatment (intranasal corticosteroids and saline irrigation) post-surgery 7
• Routine follow-up between 3-12 months after surgery to assess outcomes through history and nasal endoscopy 1
• Medical treatment should be continued long-term to prevent recurrence 7

Special Populations

Primary Ciliary Dyskinesia (PCD)

• Conservative therapy focuses on relieving symptoms with sinonasal irrigation, topical steroids, and long-term antibiotics 1
• Prolonged macrolide therapy produces marked improvement due to anti-inflammatory properties 1
• Endoscopic sinus surgery may be required when medical therapy fails 1
• Pediatric patients should visit otolaryngologist every 6 months; adults visit when needed 1

Patients with Underlying Allergy

• Additional treatment with antihistamines should be considered 7
• Allergy testing is valuable for patients with long-standing or recurrent symptoms uncontrolled by topical saline and intranasal corticosteroids 1

Patients with Asthma Comorbidity

• CRS is associated with bronchial asthma in 20-45% of cases 3
• Treatment of CRS may improve lower airway outcomes 1
• Inhalation therapy with steroids is NOT recommended for lower airway inflammation in PCD except in patients with concomitant asthma 1