What are the recommended management, imaging, and treatment steps for chronic rhinosinusitis?

Management of Chronic Rhinosinusitis

Begin with intranasal corticosteroids and large-volume hypertonic saline irrigation (150-250 ml, 2% solution) twice daily as first-line therapy for all patients with chronic rhinosinusitis, regardless of subtype. 1, 2, 3

Initial Diagnostic Verification

Before initiating treatment, confirm the diagnosis meets established criteria:

• Verify at least two cardinal symptoms present for ≥12 consecutive weeks: nasal obstruction/congestion, purulent nasal discharge (anterior or posterior), facial pain/pressure, or hyposmia/anosmia 1, 4

• Document objective evidence of inflammation through anterior rhinoscopy, nasal endoscopy, or CT imaging—symptoms alone are insufficient 2, 5, 4

• Assess disease subtype as this fundamentally alters management: CRS without polyps, CRS with polyps, allergic fungal rhinosinusitis, eosinophilic mucin CRS, or fungal balls 1

Medical Management Algorithm

For Mild Symptoms (VAS 0-3):

• Intranasal corticosteroids (fluticasone propionate 200 mcg daily or mometasone furoate) plus large-volume hypertonic saline irrigation twice daily 1, 2, 3

• Reassess at 3-4 weeks—if improving, continue therapy and reduce corticosteroid dose to 100 mcg daily; if no improvement, escalate to moderate/severe protocol 1, 3

For Moderate to Severe Symptoms (VAS >3):

• Continue intranasal corticosteroids and saline irrigation 1, 2

• Add short course of oral corticosteroids (typically prednisone for 1-3 weeks) if nasal polyps are present 1, 6

• Obtain bacterial culture if significant purulent discharge is present on examination 1

• Consider long-term macrolide therapy (e.g., erythromycin or clarithromycin for 12+ weeks) for patients without purulent discharge 1, 7

Critical pitfall: Do NOT prescribe antibiotics without visible purulent nasal discharge on examination—this is a strong recommendation to avoid unnecessary antibiotic exposure 1

Medical Therapy Failure (After 3 Months):

• Obtain CT scan with fine-cut protocol if not already performed 1, 2

• Evaluate for surgical candidacy based on symptoms, disease characteristics, quality of life impact, and response to medical therapy 1

Imaging Recommendations

Obtain CT scan with fine-cut protocol for all surgical candidates to examine paranasal sinuses for surgical planning 1, 2

• CT is the preferred imaging modality when radiographic evaluation is needed 2, 5

• Do NOT plan surgical extent solely based on arbitrary mucosal thickening thresholds or sinus opacification percentages—clinical presentation and disease subtype should guide decisions 1, 8

Surgical Indications

Offer surgery when anticipated benefits exceed continued medical management alone, particularly for specific high-risk subtypes. 1

Subtypes Requiring Early Surgical Consideration:

• CRS with nasal polyps plus bony erosion 1
• Eosinophilic mucin rhinosinusitis 1
• Allergic fungal rhinosinusitis 1
• Fungal balls 1
• Severe polyposis with complete sinus obstruction 1
• Neo-osteogenesis (osteitis) causing outflow obstruction 1

Critical principle: Do NOT require a predefined "one-size-fits-all" duration of medical therapy before surgery—this delays care and allows disease progression in patients who will not respond to medical management 1

Surgical Approach:

When polyps, osteitis, bony erosion, or fungal disease are present, perform complete sinus surgery with full cavity exposure and diseased tissue removal—NOT just balloon dilation or ostial widening alone. 1, 8

• Balloon sinuplasty is inadequate for advanced disease and leads to treatment failure requiring revision surgery 8

• Address anatomical abnormalities (septal deviation, turbinate hypertrophy) concurrently when contributing to symptoms 8

Patient Counseling Requirements

Before surgery, counsel patients about realistic expectations: 1

• CRS is a chronic condition with potential for relapse regardless of treatment
• Long-term medical management will likely be necessary post-operatively
• Postoperative care includes debridement, continued medications, activity restrictions, and regular follow-up
• Revision surgery may be needed in some cases

Common Pitfalls to Avoid

• Prescribing antibiotics without purulent discharge on examination—this is explicitly discouraged 1

• Delaying surgery in patients with fungal balls, eosinophilic mucin, or bony erosion while pursuing prolonged medical therapy 1

• Using balloon sinuplasty for patients requiring comprehensive sinus surgery 1, 8

• Failing to assess for comorbidities (asthma, immunodeficiency, ciliary dyskinesia) that modify management 2

• Stopping medical therapy after surgery—maintenance treatment should continue postoperatively 7, 5

• Using nasal decongestant sprays beyond 5-7 days, which causes rebound congestion (rhinitis medicamentosa) 3

Treatment Efficacy Expectations

Approximately 37-48% of patients respond adequately to medical therapy and avoid surgery 6. Patients with more severe baseline symptoms are less likely to respond to medical management alone and should be identified early for surgical intervention 1, 6. The evidence shows that early surgery in appropriately selected patients (particularly those with polyps, bony erosion, or eosinophilic mucin) provides superior outcomes compared to delayed surgical intervention 1.