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Chronic rhinosinusitis

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Updated 2023 AAFP, 2022 ACR, 2020 EPOS, 2019 EAACI, and 2018 AAO-HNSF guidelines for the diagnosis and management of chronic rhinosinusitis.

Background

Overview

Definition
CRS is defined as the evidence of inflammation in the sinonasal mucosa for > 12 weeks characterized by sinus pressure, nasal congestion, rhinorrhea, and decreased sense of smell.
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Pathophysiology
A complex interplay of host factors (defects in mechanical, innate, and adaptive components of immune system) and environmental factors (allergens, toxins, microbial agents) have been implicated in the development of CRS.
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Disease course
Clinical manifestations of persistent sinus pressure, nasal congestion, rhinorrhea, and a decreased sense of smell.
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Prognosis and risk of recurrence
CRS is not associated with increased mortality.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of chronic rhinosinusitis are prepared by our editorial team based on guidelines from the American Academy of Allergy, Asthma & Immunology (AAAAI/ACAAI 2023), the American Academy of Family Physicians (AAFP 2023), the American College of Radiology (ACR 2022), the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS2020 2020), the ...
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Screening and diagnosis

Diagnostic criteria: as per AAFP 2023 guidelines, diagnose CRS in the presence of at least 2 of the following cardinal symptoms for ≥ 3 continuous months and objective criteria on nasal endoscopy or CT:
nasal blockage, obstruction, or congestion
anterior or posterior nasal drainage
facial pain or pressure
hyposmia.
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Diagnostic investigations

Nasal endoscopy: as per ICAR-RS 2016 guidelines, perform nasal endoscopy in conjunction with history and physical examination in the evaluation for CRS.
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  • Diagnostic imaging

  • Allergy and immune function testing

  • Nasal culture

  • Screening for comorbidities

Medical management

Nasal irrigation: as per AAFP 2023 guidelines, offer nasal saline irrigations as first-line therapy to improve sinonasal symptoms in patients with CRS.
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  • Intranasal corticosteroids

  • Oral corticosteroids

  • Leukotriene receptor antagonists

  • Antihistamines

  • Decongestants

  • Mucolytics

  • Biologic agents

  • Antibiotic therapy (short-term)

  • Antibiotic therapy (long-term)

  • Antibiotic therapy (topical)

  • Antifungal therapy

  • Other therapies

Therapeutic procedures

Balloon sinuplasty: as per AAO-HNSF 2018 guidelines, consider offering balloon dilation to improve short-term quality-of-life outcomes in patients with limited CRS without polyps. Consider performing balloon dilation as an adjunct to functional endoscopic sinus surgery in patients with chronic sinusitis without nasal polyps.
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Perioperative care

Preoperative medical therapy: as per ICAR-RS 2016 guidelines, administer appropriate medical therapy with the following for a duration of at least 3-4 weeks before offering surgical intervention:
a trial of intranasal corticosteroids, saline irrigations, and a single short course of oral corticosteroids in patients with CRS with nasal polyps (antibiotics are an option)
intranasal corticosteroids, saline irrigations, and antibiotics with CRS without nasal polyps (oral corticosteroids are an option).
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  • Postoperative drug administration

Surgical interventions

Endoscopic sinus surgery, indications: as per RS-CEG 2011 guidelines, offer surgery in patients failing medical therapy.
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continue medical therapy after surgery in all patients.
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  • Endoscopic sinus surgery (technical considerations)

  • Endoscopic sinus surgery (corticosteroid-eluting stents)

Specific circumstances

Pediatric patients: as per EPOS2020 2020 guidelines, offer saline irrigations in pediatric patients with CRS.
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  • Patients with allergic fungal rhinosinusitis

  • Patients with aspirin-exacerbated respiratory disease (diagnosis)

  • Patients with aspirin-exacerbated respiratory disease (medical therapy)

  • Patients with aspirin-exacerbated respiratory disease (aspirin therapy after desensitization)

  • Patients with aspirin-exacerbated respiratory disease (endoscopic sinus surgery)

Follow-up and surveillance

Management of treatment failure: as per AAFP 2023 guidelines, consider referring patients not improving after a minimum of 3-4 weeks, preferably at least 8 weeks, of first-line medical management for surgical evaluation.
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