Describe chronic rhinosinusitis with its assessment and management.

Definition and Phenotypes

• Chronic rhinosinusitis (CRS) is inflammation of the nose and paranasal sinuses lasting 12 weeks or more, with at least two symptoms — one being nasal blockage or discharge — together with objective evidence on endoscopy or CT.
• The objective requirement matters.
• The four cardinal symptoms are nasal blockage, nasal discharge (anterior or postnasal), facial pain or pressure, and reduction or loss of smell — with at least one of blockage or discharge required

Assessment and Management

• Assessment — a full history with duration, the four symptoms, and their impact; and specific enquiry about asthma, aspirin sensitivity, allergy, smoking and previous surgery
• Nasal endoscopy in every case, which is what converts a symptom complex into a diagnosis
• CT of the sinuses in the coronal plane, but performed after a course of maximal medical treatment, so it shows persistent rather than reversible disease — and interpreted with the symptoms, never alone
• Investigate the contributing factors — allergy testing; immunoglobulins and vaccine responses where infections are recurrent; sweat chloride and ciliary studies in a child or where suggested; ANCA where there is crusting or destruction; and dental assessment in unilateral maxillary disease
• Medical treatment IS the foundation, and surgery IS for its failure
• 1. Intranasal corticosteroid is the mainstay, used long-term and regularly. Technique and adherence determine success, and should be checked before the drug is changed
• 2. Saline irrigation, in high volume.
• Steroid can be added to the irrigation fluid in refractory disease, delivering far more drug to the sinus mucosa than a spray
• 3. A course of oral corticosteroid for severe polyposis or a marked exacerbation — highly effective, but limited by systemic effects and not for repeated long-term use
• 4. Antibiotics — a short course for an acute exacerbation, guided by culture; and low-dose long-term macrolide (such as clarithromycin for 12 weeks) in CRSsNP with normal IgE, acting through an anti-inflammatory and immunomodulatory rather than antibacterial effect
• 5. Treat the contributors — allergy, asthma, reflux, dental disease; and stop smoking, without which little else works
• 6. Leukotriene antagonists in aspirin-exacerbated disease; and aspirin desensitisation in selected patients with AERD.
• 7. Biologics — the major recent advance: dupilumab (anti-IL-4/13), omalizumab (anti-IgE) and mepolizumab (anti-IL-5) for severe type-2 CRSwNP.
• Surgery — functional endoscopic sinus surgery (FESS) is indicated where maximal medical treatment for an adequate period has failed, and for complications, mucocele, fungal ball and suspected neoplasm
• Its principle is to restore ventilation and natural drainage by relieving obstruction at the osteomeatal complex, allowing the diseased mucosa to recover — hence mucosa is preserved, not stripped
• Surgery does not cure the underlying inflammation: medical treatment must continue afterwards, and a patient who stops their steroid spray after surgery will relapse — which must be explained before the operation, not after
• Postoperative care determines the result — douching, debridement of crusts, and topical steroid
• Counsel realistically — smell recovers least reliably, and polyps recur in a substantial proportion, particularly with asthma and aspirin sensitivity
• Twelve weeks is the dividing line between acute and chronic disease, and it should be stated in the definition
• Objective findings are required, on endoscopy or CT.
• Facial pain alone is not sinusitis, and is midfacial segment pain or migraine
• Polyps mean blockage and anosmia, whereas disease without polyps gives pain and discharge
• Type-2 eosinophilic disease responds to steroid and to biologics, whereas neutrophilic disease responds to surgery and macrolides
• Ask every patient about asthma and aspirin; the triad changes the prognosis and the treatment entirely
• Scan after medical treatment, not before, so the CT shows persistent rather than reversible disease
• Read the scan with the symptoms; incidental mucosal thickening is common and treating a scan helps nobody
• High-volume saline irrigation genuinely works and should be done before the steroid spray, not after
• Check spray technique before changing the drug; most apparent failure is technique or adherence