What is the appropriate evaluation and treatment for an adult with chronic sore throat and sinus pressure lasting more than 12 weeks?

Chronic Sore Throat and Sinus Pressure: Evaluation and Management

Initial Diagnostic Approach

This presentation meets criteria for chronic rhinosinusitis (CRS), which requires objective confirmation through CT imaging or nasal endoscopy before initiating treatment. 1

Confirm the Diagnosis

• Symptom duration ≥12 weeks with at least 2 of the following cardinal symptoms (one must be nasal blockage/obstruction OR nasal discharge): nasal congestion, nasal discharge (anterior/posterior drip), facial pain/pressure, or decreased sense of smell 1, 2

• Symptoms alone are insufficient for diagnosis (only 37-73% sensitivity), and up to 35% of CRS patients have normal endoscopic findings, making objective documentation mandatory 3, 2, 4

• Obtain CT scan of paranasal sinuses without contrast as the gold standard for confirming CRS, demonstrating mucosal thickening, sinus opacification, polyps, and anatomical variants that guide treatment decisions 1, 3, 4

• Consider nasal endoscopy to visualize the middle meatus for purulent discharge, mucosal edema, or nasal polyps, which provides better visualization than anterior rhinoscopy 1, 2

Exclude Alternative Diagnoses

• Screen for allergic symptoms (sneezing, watery rhinorrhea, nasal itching, itchy watery eyes) as up to 60% of patients with recurrent or difficult-to-treat CRS have significant allergic sensitivities to perennial allergens 1, 2, 4

• Assess for modifying factors: allergic rhinitis, asthma (84-100% of asthma patients have abnormal sinus CT findings), immunodeficiency, cystic fibrosis, ciliary dyskinesia, aspirin-exacerbated respiratory disease, or anatomic abnormalities 1, 3, 2, 4

• Evaluate for gastroesophageal reflux disease (GERD) as a potential contributing factor, though evidence is limited 1

Initial Medical Management

Start intranasal corticosteroids immediately as first-line therapy, as they are the most effective single agent for controlling nasal congestion and improving sense of smell in CRS. 2, 5, 6

First-Line Therapy

• Intranasal corticosteroids: Fluticasone propionate 2 sprays per nostril once daily for the first week, then 1-2 sprays per nostril once daily, OR mometasone furoate 200 μg twice daily 2, 5, 6

• High-volume saline irrigation daily (improves symptom scores with standardized mean difference of 1.42 [95% CI, 1.01-1.84]) to improve mucociliary function, decrease mucosal edema, and mechanically rinse infectious debris and allergens 1, 2, 6

Additional Therapy Based on CT Findings

• If CT confirms CRS with nasal polyps: Continue intranasal corticosteroids and consider a short course (1-3 weeks) of systemic corticosteroids (e.g., oral prednisolone) if marked mucosal edema is present 2, 5, 6

• If CT confirms CRS without nasal polyps: Continue intranasal corticosteroids and saline irrigation; consider a 3-month course of macrolide antibiotic (improved quality of life at 24 weeks with standardized mean difference of -0.43 [95% CI, -0.82 to -0.05]) 6

• For patients with nasal polyps: Consider leukotriene antagonists (improved nasal symptoms compared to placebo, P < .01) or a 3-week course of doxycycline (reduced polyp size for 3 months after treatment, P < .001) 2, 6

What NOT to Do

• Do NOT add montelukast to intranasal corticosteroids unless patients cannot tolerate nasal corticosteroids, as it has no significant additional effect 2

• Do NOT prescribe topical antifungals, as multiple studies show no benefit for quality of life, symptoms, or disease signs 2

• Do NOT prescribe antibiotics empirically without evidence of acute bacterial superinfection (purulent discharge with fever, facial pain, or "double worsening" within 10 days) 1, 7

• Do NOT use prolonged topical decongestants (e.g., oxymetazoline) beyond 3-5 days due to risk of rhinitis medicamentosa 5

When to Consider Surgery

Refer for functional endoscopic sinus surgery if symptoms persist despite adequate medical therapy (intranasal corticosteroids, saline irrigation, and up to 2 short courses of antibiotics or systemic corticosteroids in the last year), as this defines "difficult-to-treat rhinosinusitis." 1

• Surgery improves symptoms and quality of life in over 75% of patients and is particularly beneficial for patients with comorbid asthma, as treating CRS can improve asthma control and reduce exacerbations 1, 3

• CT imaging is essential for surgical planning to identify anatomic variants and abnormalities that increase risk for intracranial, intraorbital, and vascular injury 1

• For severe, recurrent CRS with nasal polyps refractory to medical therapy and surgery, consider biologic therapy with dupilumab, which showed clinically significant improvements in symptom scores, smell scores, and nasal polyp scores at 4-6 months 2

Critical Pitfalls to Avoid

• Do NOT diagnose CRS based on symptoms alone without objective confirmation through CT or endoscopy, as many conditions mimic CRS symptoms 3, 2, 4

• Do NOT obtain radiographic imaging for acute rhinosinusitis (<4 weeks duration), as CT cannot distinguish bacterial from viral etiology 1, 4, 7

• Counsel patients that smoking significantly worsens long-term surgical outcomes and increases risk of sinusitis 1

• Maintain high suspicion for invasive fungal sinusitis in immunocompromised patients (neutropenia, hematologic malignancies, poorly controlled diabetes, organ transplant, systemic steroids/chemotherapy) presenting with acute rhinosinusitis symptoms, orbital symptoms, or headache, and obtain MRI with and without contrast if suspected 4