In an otherwise healthy adult with nasal congestion, facial pressure/fullness, post‑nasal drip, and purulent drainage lasting ≥12 weeks, how should chronic rhinosinusitis be diagnosed and treated?

Chronic Rhinosinusitis: Diagnosis and Treatment

Diagnose chronic rhinosinusitis clinically when this patient has ≥2 cardinal symptoms (including nasal congestion OR discharge as mandatory) persisting ≥12 weeks, then confirm with nasal endoscopy or CT scan, and treat first-line with daily intranasal corticosteroids plus high-volume saline irrigation—antibiotics are only indicated if there is evidence of acute bacterial superinfection, not for the chronic inflammation itself. 1, 2

Diagnostic Criteria

Clinical Diagnosis (Symptom-Based)

The European Position Paper on Rhinosinusitis (EPOS) 2020 defines chronic rhinosinusitis as presence of ≥2 symptoms for ≥12 weeks, with one symptom being either nasal blockage/obstruction/congestion OR nasal discharge (anterior/posterior drip) as mandatory, plus any of the following: 1

• Facial pain/pressure (present in this patient)
• Reduction or loss of smell (present in this patient)

This patient meets clinical criteria with three cardinal symptoms: nasal congestion, purulent drainage/post-nasal drip, and facial pressure/fullness lasting ≥12 weeks. 1

Objective Confirmation Required

For definitive diagnosis beyond primary care, obtain objective evidence through either: 1, 2

• Nasal endoscopy showing mucopurulent discharge from middle meatus, edema/mucosal obstruction in middle meatus, or nasal polyps 1, 2
• CT scan of sinuses (fine-cut protocol without contrast) demonstrating mucosal thickening or sinus opacification—though minimal thickening involving only 1-2 walls without ostial involvement is unlikely to represent true rhinosinusitis 1

Important caveat: Symptom-based diagnosis alone overestimates prevalence due to overlap with allergic and non-allergic rhinitis, so screen for allergic symptoms (sneezing, watery rhinorrhea, nasal itching, itchy watery eyes) to differentiate. 1

Phenotype Classification

Once confirmed, classify as: 1

• Chronic rhinosinusitis without nasal polyps (CRSsNP): No visible polyps in middle meatus on endoscopy (after decongestant if needed)
• Chronic rhinosinusitis with nasal polyps (CRSwNP): Bilateral endoscopically-visualized polyps in middle meatus

First-Line Treatment Algorithm

Step 1: Initiate Maintenance Therapy

Begin immediately with: 2, 3, 4

• Intranasal corticosteroids (e.g., fluticasone, mometasone) daily—this is the cornerstone of medical management for reducing inflammation 3, 4
• High-volume saline irrigation (not just spray)—enhances mucociliary clearance and improves sinus drainage 2, 3, 4

Step 2: Assess for Acute Bacterial Superinfection

The purulent discharge in this patient requires careful interpretation: 2, 5

• Green/thick discharge indicates mucopurulent inflammation but does NOT automatically mean bacterial infection—it reflects neutrophil influx that occurs in both viral and bacterial processes 5
• Consider antibiotics ONLY if there is evidence of acute bacterial superinfection superimposed on chronic disease, such as: 2, 5
  • Severe worsening of symptoms with high fever (≥39°C) for ≥3 consecutive days
  • "Double-sickening" pattern (initial improvement followed by acute worsening)
  • Persistent severe symptoms despite 10-14 days of appropriate medical therapy

If acute bacterial component is suspected: 2

• Use amoxicillin or amoxicillin-clavulanate for 10-14 days (first-line beta-lactams)
• Consider extending to 4 weeks for chronic infectious sinusitis with anaerobic involvement
• Target organisms: S. aureus, anaerobic bacteria (Bacteroides, Fusobacterium), gram-positive streptococci

Critical pitfall to avoid: Do not prescribe antibiotics for chronic rhinosinusitis based solely on purulent discharge—antibiotics are ineffective for chronic inflammatory disease without active bacterial infection and contribute to resistance. 5, 3

Step 3: Adjunctive Therapies

Add as needed for symptom control: 6, 3

• Intranasal antihistamine (azelastine) if allergic component suspected
• Short-term oral/topical decongestants (≤3-5 days maximum to avoid rhinitis medicamentosa) 6
• Oral corticosteroids (short course) for severe exacerbations—reserve for patients not responding to intranasal steroids 4

When to Obtain Imaging

CT scan indications: 1, 2

• Medical therapy failure after appropriate trial (3+ months of intranasal corticosteroids and saline irrigation)
• Consideration for endoscopic sinus surgery
• Suspected complications (orbital involvement, intracranial extension)
• Recurrent acute bacterial sinusitis (≥4 episodes/year)

Do not obtain imaging initially unless complications suspected—diagnosis and initial treatment are clinical. 1, 2

Referral to Otolaryngology

Refer to ENT if: 1, 2, 3

• Symptoms persist despite 3+ months of appropriate medical therapy (intranasal corticosteroids + saline irrigation + up to 2 short courses of antibiotics or systemic corticosteroids)—this defines "difficult-to-treat rhinosinusitis" 1
• Recurrent acute bacterial sinusitis (≥3-4 episodes per year) 2
• Suspected complications (periorbital edema, diplopia, severe headache, cranial nerve palsies) 1
• Consideration for functional endoscopic sinus surgery (FESS) when anticipated benefits exceed nonsurgical management 1, 4

The 2025 American Academy of Otolaryngology guideline emphasizes: Obtain fine-cut CT scan for surgical planning if not already available, and educate patients that surgery is adjunctive—not curative—requiring ongoing medical management postoperatively. 1

Quality of Life Considerations

Chronic rhinosinusitis significantly impairs quality of life through: 1, 3

• Olfactory dysfunction affecting safety (detecting smoke, spoiled food) and emotional well-being
• Sleep disturbance, cognitive dysfunction, decreased productivity impacting work/family function
• Chronic facial pain and nasal obstruction reducing daily functioning

Treatment goal: Achieve disease control (not cure) to optimize quality of life, with most patients responding to medical management alone. 1, 4

Common Pitfalls to Avoid

• Do not diagnose based on symptoms alone—overlap with rhinitis requires objective confirmation via endoscopy or CT 1
• Do not prescribe antibiotics for chronic inflammation—only for documented acute bacterial superinfection 2, 5
• Do not use prolonged topical decongestants (>3-5 days)—causes rebound rhinitis medicamentosa 6
• Do not delay ENT referral if symptoms persist beyond 3 months of appropriate medical therapy 1, 2
• Do not assume purulent discharge equals bacterial infection—this reflects inflammation, not necessarily infection 5