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Otolaryngology›Condition·Updated Jul 11, 2026·v1

Chronic Rhinosinusitis

Chronic rhinosinusitis is a chronic inflammatory condition of the sinonasal mucosa lasting ≥12 weeks, classified by phenotype (with/without polyps) and endotype (type 2 vs non-type 2). Diagnosis requires objective confirmation via nasal endoscopy or CT. First-line therapy includes intranasal corticosteroids and saline irrigation. Surgery is indicated for medically refractory cases, and biologics are effective for severe CRSwNP. The disease is chronic with high recurrence rates, but phenotype-directed management improves outcomes.

Moderate Evidence450 references·10,790 words·44 min read·v1
chronic rhinosinusitissinusitisnasal polypsotolaryngologytype 2 inflammationbiologics

Quick Reference

RxDrug of choiceIntranasal corticosteroids (e.g., fluticasone 2 sprays each nostril daily).
AltAlternativesLarge-volume saline irrigation; for CRSwNP, budesonide-added irrigations; biologics (dupilumab 300 mg q2w, mepolizumab 100 mg q4w, tezepelumab 210 mg q4w) for severe disease.
⊘AvoidRoutine oral corticosteroids for CRSsNP; systemic or topical antifungals; prolonged macrolide antibiotics; non-dihydropyridine CCBs (not relevant but avoid in asthma).
DxTest of choiceNasal endoscopy for diagnosis; non-contrast coronal CT (Lund-Mackay score ≥4) for surgical planning and confirmation if endoscopy equivocal.
ScKey scoreLund-Mackay CT score, SNOT-22 (MCID 8.9), Nasal Polyp Score (0-8), Modified Lund-Kennedy endoscopic score.
→When to referTo otolaryngology for ESS when symptoms persist despite 8-12 weeks of optimal medical therapy, or for biologic therapy in severe CRSwNP. Also refer for suspected complications (orbital, intracranial).
CRS management is phenotype- and endotype-driven: intranasal steroids and saline irrigation are first-line, surgery for medically refractory cases, and biologics for severe type 2 disease. Avoid unnecessary antibiotics and antifungals.
Chronic rhinosinusitis (CRS) is a chronic inflammatory condition of the sinonasal mucosa lasting ≥12 weeks, affecting 4-10% of adults. It is classified by phenotype (with or without nasal polyps) and inflammatory endotype (type 2 vs non-type 2), which drives treatment decisions. First-line management includes intranasal corticosteroids and large-volume saline irrigation. Endoscopic sinus surgery (ESS) is reserved for medically refractory cases, and biologics (dupilumab, mepolizumab, tezepelumab) are effective for severe CRSwNP. The disease is chronic with high recurrence, but phenotype-directed therapy improves outcomes.

Overview and Recommendations

Background

  • •CRS affects approximately 5% of the adult population, with significant geographic variation, and is defined by persistent inflammation of the sinonasal mucosa lasting 12 weeks or longer. The disease is not a single entity but encompasses distinct phenotypes, CRS with nasal polyps (CRSwNP) and without (CRSsNP), that differ in pathophysiology, clinical presentation, and treatment response.
  • •The underlying inflammatory endotype determines disease behavior: type 2 inflammation (driven by IL-4, IL-5, IL-13, and epithelial alarmins like TSLP) dominates CRSwNP and is associated with eosinophilia, polyps, and comorbid asthma or NSAID intolerance. Non-type 2 CRS (Th1/Th17) is more common in CRSsNP and may be linked to neutrophilic inflammation.
  • •CRS carries substantial morbidity, including olfactory dysfunction (up to 78% on objective testing), sleep disturbance, and a bidirectional relationship with depression and anxiety. Untreated, only 8% of patients achieve disease control, and the annual cost of care is high.
  • •Key modifiable risk factors include obesity (OR 1.33), smoking, and occupational exposures; asthma and allergic rhinitis are common comorbidities. Mendelian randomization has confirmed causal roles for sedentary time, depression, and GERD.
  • •The paradigm of CRS management has shifted from broad antimicrobial use to phenotype- and endotype-directed therapy, with biologics targeting specific inflammatory pathways for severe disease.

Evaluation

  • •Suspect CRS in any patient with two or more cardinal symptoms, nasal obstruction, anterior/posterior mucopurulent discharge, facial pain/pressure, or olfactory disturbance, persisting for ≥12 weeks.
  • •Ask about the duration and quality of facial pain (bilateral, dull ache worse with bending), severity of nasal congestion, and any fluctuation in smell. Also inquire about asthma, NSAID intolerance, and history of sinus surgery.
  • •Examine the nasal cavity with anterior rhinoscopy and, most importantly, nasal endoscopy to visualize the middle meatus, sphenoethmoidal recess, and olfactory cleft. Endoscopic findings of polyps, mucopurulent discharge, or mucosal edema confirm the diagnosis.
  • •Document the endoscopic severity using the Modified Lund-Kennedy score, which grades polyps, edema, and discharge on a 0-2 scale per side (total 0-12). The Nasal Polyp Score (0-4 per nostril) is used for polyp-specific assessment.
  • •Order a non-contrast coronal CT of the paranasal sinuses if endoscopy is not diagnostic or if surgical planning is needed. A Lund-Mackay score ≥4 is consistent with CRS; a score of 0 essentially excludes it.
  • •Assess for the eosinophilic endotype with blood eosinophil count (cutoff ≥0.16 × 10⁹/L has 85% sensitivity for eosinophilic CRS), total IgE, and fractional exhaled nitric oxide (FeNO). Tissue biopsy at surgery can confirm >70 eosinophils/HPF.
  • •Consider imaging for complications if there is unilateral disease, orbital signs, forehead swelling, or neurological symptoms. Contrast-enhanced CT or MRI is indicated for suspected fungal ball, neoplasm, or intracranial extension.
  • •Screen for associated conditions: in patients with nasal crusting, septal perforation, or saddle-nose, check c-ANCA for granulomatosis with polyangiitis. In children or adults with recurrent pneumonia, evaluate for cystic fibrosis (sweat chloride, CFTR genetics) or primary ciliary dyskinesia (nasal nitric oxide, genetics).
  • •Evaluate symptom burden with the SNOT-22 questionnaire; a clinically meaningful change is ≥8.9 points. Also assess sleep quality (Sleep-SNOT subdomain) and screen for depression (PHQ-2).
  • •Differentiate from other causes of nasal obstruction: allergic rhinitis, structural nasal obstruction, and odontogenic sinusitis (unilateral disease with foul odor should prompt dental evaluation).

Management

  • •Initiate first-line medical therapy with intranasal corticosteroids (e.g., fluticasone 2 sprays each nostril daily) and large-volume saline irrigation (≥150 mL per nostril once or twice daily). These are the cornerstone of treatment for all phenotypes.
  • •For patients with CRSwNP, consider adding high-volume steroid irrigations (e.g., budesonide 0.5 mg/2 mL in 240 mL saline twice daily) to reduce polyp size and improve symptoms; this is especially effective after surgery.
  • •Prescribe a short course of oral corticosteroids (e.g., prednisone 30-40 mg daily for 5-10 days) only for acute exacerbations of CRSwNP or allergic fungal sinusitis; avoid routine use in CRSsNP as it provides no benefit and increases adverse effects.
  • •For acute exacerbations (AECRS), use watchful waiting for mild cases; if antibiotics are prescribed, give amoxicillin with or without clavulanate 500-875 mg BID for 5-10 days. For recurrent or refractory cases, obtain culture-directed antibiotics via middle meatal swab.
  • •Refer for endoscopic sinus surgery (ESS) when symptoms persist despite 8-12 weeks of optimal medical therapy, or when complications (orbital abscess, Pott's puffy tumor, intracranial extension) are present. Do not require a predefined duration of medical therapy before considering surgery.
  • •Perform ESS using a graded approach; the LOEM system (Lamella Ostium Extent Mucosa) guides extent. Extended procedures (LOEM 3-4) reduce revision rates and improve symptom scores compared to limited surgery.
  • •In the perioperative period, continue saline irrigation and consider steroid-releasing sinus implants to reduce adhesions and polyp recurrence. Avoid routine postoperative oral corticosteroids in CRS without polyps.
  • •For patients with severe CRSwNP (high polyp burden, recurrence after surgery, or requiring systemic corticosteroids), initiate biologic therapy. First-line options include dupilumab 300 mg subcutaneously every 2 weeks, mepolizumab 100 mg every 4 weeks, or tezepelumab 210 mg every 4 weeks. These significantly reduce polyp size, improve smell, and lower the need for surgery.
  • •Monitor response to biologics with SNOT-22, Nasal Polyp Score, and olfactory testing at 16-24 weeks. Discontinue if no improvement after 6 months; consider switching to another biologic if inadequate response.
  • •Avoid using systemic or topical antifungals for routine CRS, they show no benefit and increase adverse events. Do not prescribe macrolide antibiotics (e.g., clarithromycin) for CRS, as the MACRO trial found no benefit over placebo.
  • •Manage comorbidities: treat asthma and allergic rhinitis concurrently, refer for sleep study if Sleep-SNOT ≥17.5, and screen for pneumococcal antibody deficiency (consider PPSV23 vaccination if nonprotective titers).
  • •Counsel patients that CRS is a chronic condition: only 35-40% achieve well-controlled disease, and polyp recurrence after ESS is 35-40% at 18 months. However, biologics can achieve remission in up to 77% of patients.
  • •Discharge criteria for acute exacerbations: resolution of fever, improvement in pain, and no signs of orbital or intracranial complications. For planned surgery, ensure patient understands the need for postoperative irrigations and follow-up.

Board Review — High Yield

  • •Type 2 inflammation, Dominates CRSwNP; driven by IL-4, IL-5, IL-13; responds to dupilumab, mepolizumab, tezepelumab.
  • •Lund-Mackay score ≥4, Radiographic criterion for CRS on CT.
  • •Modified Lund-Kennedy score, Preferred endoscopic grading system; excludes scarring/crusting, highest reliability.
  • •SNOT-22 MCID, ≥8.9 points defines clinically meaningful change.
  • •Dupilumab 300 mg q2w, Most effective biologic for CRSwNP in network meta-analysis.
  • •MACRO trial, Clarithromycin no better than placebo for CRS; ESS superior to continued medical therapy alone.
  • •EPOS 2020 uncontrolled CRS, ≥3 of: symptoms, rescue medication, mucosal disease in the prior month.
  • •Pott's puffy tumor, Frontal bone abscess with intracranial involvement in 38% of adults; requires urgent surgical drainage.
  • •CFTR modulators (elexacaftor-tezacaftor-ivacaftor), First-line for CRS in cystic fibrosis; improve sinonasal and pulmonary outcomes.
  • •Biologic therapy reduces surgery need, Tezepelumab reduced surgery rate to 0.5% vs 22.1% placebo in WAYPOINT trial.

Deep Dive — Evidence Details

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