Treatment of Chronic Rhinosinusitis When Nasal Congestion is the Primary Symptom
Start with intranasal corticosteroid sprays combined with daily nasal saline irrigation as first-line therapy for chronic rhinosinusitis patients whose primary complaint is nasal congestion. 1
Initial Medical Management
The cornerstone treatment approach consists of:
- Intranasal corticosteroid sprays (such as mometasone furoate, fluticasone propionate, or beclometasone dipropionate) are the primary pharmacologic intervention to reduce mucosal inflammation and swelling 2
- Daily nasal saline irrigation with isotonic saline solutions enhances mucociliary clearance and improves sinus drainage 2, 1
- Short-term nasal decongestants (oxymetazoline) may temporarily improve sinus aeration, but should be limited to avoid rebound congestion 2
When to Add Antibiotics
Systemic antibiotics (amoxicillin/clavulanic acid, ciprofloxacin, clarithromycin, or trimethoprim/sulfamethoxazole) should only be added when there is evidence of an active, superimposed acute bacterial infection 2, 1. Do not routinely prescribe antibiotics for chronic rhinosinusitis without signs of acute infection.
Addressing Comorbidities
- If allergic rhinitis is present, add antihistamines to the regimen, as allergy treatment appears to improve outcomes particularly in surgical candidates 3, 2
- Screen for aspirin sensitivity, as these patients have more severe disease but still benefit from treatment 3
- Consider immunodeficiency testing in refractory cases, as humoral immunodeficiency is not uncommon in patients with treatment-resistant chronic rhinosinusitis 3
Escalation to Biologic Therapy
For severe, refractory chronic rhinosinusitis with nasal polyps (CRSwNP) not responding to maximal medical therapy, dupilumab 300 mg every 2 weeks is the most effective biologic option. 4
- Dupilumab demonstrates superior efficacy compared to mepolizumab and omalizumab in reducing nasal polyp size and improving nasal congestion 4
- Dupilumab efficacy is maintained regardless of baseline nasal airflow impairment (PNIF < 120 L/min vs ≥ 120 L/min) 5
- Biologics significantly reduce nasal polyp size, improve nasal congestion, restore sense of smell, and reduce need for surgery or systemic corticosteroids 4
Surgical Intervention
If symptoms persist after aggressive medical treatment (typically 8-12 weeks), refer to otolaryngology for endoscopic sinus surgery 2, 1. Surgery should be functional, widening natural drainage openings while preserving ciliated epithelium 2. Continue medical treatment post-operatively to prevent recurrence 2.
Key Clinical Pitfall
Patient perception of nasal congestion correlates only weakly with objective nasal airflow measurements (Spearman coefficient -0.348), meaning subjective symptom severity may not accurately reflect actual nasal patency 5. However, this does not diminish the validity of treating the patient's primary complaint—focus on symptom improvement as the therapeutic endpoint.