Chronic Rhinosinusitis

Definition

• Inflammation of the nasal and sinus mucosa lasting >12 weeks

• Requires ≥2 of the following: nasal obstruction/congestion, mucopurulent nasal discharge (anterior/posterior), facial pain/pressure, and reduced/lost sense of smell

• Symptoms must persist despite medical therapy

Contributing Factors

• Bacterial infection

• Allergic rhinitis or other atopic conditions

• Nasal polyps or anatomical variations (e.g. septal deviation)

• Cystic fibrosis or other mucociliary dysfunction

• Overuse of topical decongestants (rhinitis medicamentosa)

• Environmental irritants (occupational dust, pollution)

Common Differentials

• Chronic bacterial rhinosinusitis

• Rhinitis medicamentosa

• Nasal polyps

• Allergic rhinitis

• Nasopharyngeal carcinoma

• Cluster headaches

History

• Rhinorrhoea, nasal congestion, facial pain/pressure, anosmia or hyposmia

• Postnasal drip or cough

• Triggers such as seasonal allergens, pollutants

• Check for red flag features (unilateral obstruction, epistaxis, orbital symptoms)

Management

Initial Treatment

• Saline nasal irrigation (isotonic or hypertonic)

• Intranasal corticosteroids (e.g. Mometasone 50 mcg, 2 sprays each nostril daily)

• Short-term oral decongestants or antihistamines for flare-ups

• Intranasal ipratropium bromide for prominent rhinorrhoea

• Avoid prolonged use of topical decongestants to prevent rebound congestion

Referral Criteria

• Symptoms persisting after 1 month of optimal medical therapy

• Suspicion of nasal polyps, sinus abnormalities, or obstructive anatomy on exam

• Recurrent or severe cases requiring imaging or endoscopic evaluation

Additional Considerations

• CT sinus if failure to improve after 1 month or concerning features (suspected malignancy, orbital extension)

• Allergen testing (IgE levels or skin prick tests) if allergic triggers suspected

• Consider dual therapy (intranasal steroids plus short-course oral steroids) for severe inflammation

• Specialist referral for possible functional endoscopic sinus surgery (FESS) if medical therapy is inadequate

Chronic Rhinosinusitis with Nasal Polyps

Management

• Short course of oral corticosteroids (e.g. Prednisolone 25 mg daily for 5–10 days) to reduce polyp size

• Long-term intranasal steroids to maintain control and prevent recurrence

• Nasal endoscopy to confirm polyp location and extent

• Surgical polypectomy or FESS if polyps are obstructive or refractory

• Aspirin desensitisation in aspirin-exacerbated respiratory disease (AERD)

• Biologic therapy (e.g. dupilumab) may be considered for severe, persistent nasal polyps

Chronic Rhinosinusitis without Nasal Polyps

Management

• Intranasal steroids and saline irrigation as first-line

• Short-course oral corticosteroids only if significant mucosal inflammation or acute exacerbations

• Antibiotics generally reserved for evidence of bacterial superinfection (purulent discharge, fever, marked localised pain)

• Referral for imaging or ENT opinion if no improvement

Red Flag Symptoms

• Orbital cellulitis (peri-orbital swelling, pain, impaired eye movement)

• Intracranial complications (severe headache, focal neurological signs)

• Unilateral nasal obstruction with facial pain or bleeding (consider malignancy)

Key Points

• Chronic rhinosinusitis significantly impacts quality of life, contributing to fatigue and sleep disruption

• Combined medical therapies (intranasal steroids plus saline irrigation) are more effective than monotherapy

• Regular review of treatment adherence and technique (e.g. correct nasal spray administration) is essential

• Early referral to ENT indicated if suspicion of complications, anatomical abnormality, or failure of conservative measures