From the Guidelines
Chronic rhinosinusitis should be treated with daily saline nasal irrigation and topical intranasal corticosteroids as the first line of therapy. This approach is based on the most recent and highest quality evidence available, including the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 1. The use of saline nasal irrigation helps to thin and remove mucous, clear proteins that cause inflammation, and flush out irritants and bacteria from the nose and sinus cavities.
Key Components of Treatment
- Daily saline nasal irrigation using a neti pot or squeeze bottle with 240ml of distilled water mixed with a saline packet
- Topical intranasal corticosteroids like fluticasone (Flonase) 1-2 sprays per nostril daily or mometasone (Nasonex) for at least 3-4 weeks to see benefits
- For patients with allergic components, adding an antihistamine like cetirizine 10mg daily may help
- If symptoms persist, a short course of oral antibiotics may be prescribed, commonly amoxicillin-clavulanate 875/125mg twice daily for 10-14 days, especially if bacterial infection is suspected
Additional Considerations
- Lifestyle modifications are also important, including avoiding irritants like smoke, managing allergies, and maintaining good humidity levels
- For severe cases unresponsive to medical therapy, oral corticosteroids like prednisone 30mg daily for 5-7 days might be used, followed by referral to an ENT specialist for possible endoscopic sinus surgery
- The goal of treatment is symptom management rather than complete cure in many cases, as chronic rhinosinusitis is often a chronic condition with periods of exacerbation and remission, as supported by the clinical practice guideline update on adult sinusitis 1.
From the Research
Definition and Symptoms of Chronic Rhinosinusitis
- Chronic rhinosinusitis is characterized by nasal purulence accompanied by malaise, postnasal drip, and nasal dryness or crusting 2
- It is defined by the presence of at least two cardinal symptoms (nasal blockage, obstruction, or congestion; anterior or posterior nasal drainage; facial pain or pressure; and hyposmia) for at least three consecutive months, with objective findings on imaging or nasal endoscopy 3
Treatment Options for Chronic Rhinosinusitis
- Pharmacologic treatment, with local or systemic corticosteroids, such as mometasone furoate, fluticasone propionate, beclometasone dipropionate, or oral prednisolone, coupled with nasal lavage with isotonic saline solutions, are the cornerstones of disease management 2
- Systemic antibiotics, including amoxicillin/clavulanic acid, ciprofloxacin, clarithromycin, and trimethoprim/sulfamethoxazole (cotrimoxazole), are often administered to patients with chronic sinusitis and underlying bacterial infection 2
- First-line treatment comprises nasal saline irrigation and intranasal corticosteroids 3
- Biologics, such as dupilumab, omalizumab, mepolizumab, and benralizumab, may have a future role in the treatment of chronic rhinosinusitis, especially for patients with nasal polyps or comorbid conditions such as atopic dermatitis, asthma, or eosinophilic esophagitis 3, 4
Surgical Management of Chronic Rhinosinusitis
- Surgery should be considered if symptoms persist after aggressive medical treatment 2
- Surgery should be functional and involve widening the natural drainage openings of the sinuses and preserving the ciliated epithelium as much as possible 2
- In patients with nasal polyposis, surgery is more aggressive, involving removal of the diseased polypous mucosa 2
- Surgical management tailored to the underlying disease process improves clinical outcomes in chronic rhinosinusitis with or without nasal polyposis 4
Special Considerations
- Care should be taken when using intranasal corticosteroids in selected populations, such as children, pregnant women, and elderly patients, especially in those patients with comorbid conditions such as asthma 5
- Identifying patients who have chronic rhinosinusitis with nasal polyps or comorbid conditions is especially important to ensure they are referred to a specialist for consideration of biologic therapy 3