Chronic Rhinosinusitis

 

Am Fam Physician. 2017 Oct 15;96(8):500-506.

  Patient information: See related handout on chronic rhinosinusitis, written by the author of this article.

Author disclosure: No relevant financial affiliations.

Chronic rhinosinusitis is an inflammatory disease of the paranasal sinuses that occurs in 1% to 5% of the U.S. population. It may significantly decrease quality of life. Chronic rhinosinusitis is defined by the presence of at least two out of four cardinal symptoms (i.e., facial pain/pressure, hyposmia/anosmia, nasal drainage, and nasal obstruction) for at least 12 consecutive weeks, in addition to objective evidence. Objective evidence of chronic rhinosinusitis may be obtained on physical examination (anterior rhinoscopy, endoscopy) or radiography, preferably from sinus computed tomography. Treatment is directed at enhancing mucociliary clearance, improving sinus drainage/outflow, eradicating local infection and inflammation, and improving access for topical medications. First-line treatment is nasal saline irrigation and intranasal corticosteroid sprays. There may be a role for antibiotics in patients with evidence of an active, superimposed acute sinus infection. If medical management fails, endoscopic sinus surgery may be effective. Patients not responding to first-line medical therapy should be referred to an otolaryngologist, and selected patients with a history suggestive of other comorbidities (e.g., vasculitides, granulomatous diseases, cystic fibrosis, immunodeficiency) may also benefit from referral to an allergist or pulmonologist.

Chronic rhinosinusitis is an inflammatory condition of the paranasal sinuses that most often causes chronic sinonasal symptoms. In the United States, chronic rhinosinusitis has an estimated prevalence of 1% to 5%. It is a readily treatable disease that is responsible for direct and indirect health care expenses totaling billions of dollars every year in the United States.1,2 Because the pathophysiology of chronic rhinosinusitis in children is distinct from that in adults, and the medical and surgical approach differs significantly between children and adults,3 this review focuses on adult chronic rhinosinusitis.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The diagnosis of chronic rhinosinusitis is based on the presence of at least two out of four cardinal symptoms for at least 12 weeks, in addition to objective evidence on physical examination or radiography.

C

18

Non–contrast-enhanced computed tomography is the imaging study of choice to confirm the diagnosis of chronic rhinosinusitis.

C

19, 20

Nasal saline irrigations improve sinonasal symptoms in patients with chronic rhinosinusitis.

A

2527

Intranasal corticosteroid sprays improve sinonasal symptoms in patients with chronic rhinosinusitis.

A

33, 35, 36

Short courses (up to three weeks) of oral corticosteroids, alone or as an adjunct to standard maintenance therapy, improve sinonasal symptoms in the short term in patients with chronic rhinosinusitis and polyps.

A

45, 46

Oral antibiotics, given for up to three weeks, may be considered as a treatment option for acute exacerbations of chronic rhinosinusitis.

C

31, 32


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The diagnosis of chronic rhinosinusitis is based on the presence of at least two out of four cardinal symptoms for at least 12 weeks, in addition to objective evidence on physical examination or radiography.

C

18

Non–contrast-enhanced computed tomography is the imaging study of choice to confirm the diagnosis of chronic rhinosinusitis.

C

19, 20

Nasal saline irrigations improve sinonasal symptoms in patients with chronic rhinosinusitis.

A

2527

Intranasal corticosteroid sprays improve sinonasal symptoms in patients with chronic rhinosinusitis.

A

33, 35, 36

Short courses (up to three weeks) of oral corticosteroids, alone or as an adjunct to standard maintenance therapy, improve sinonasal symptoms in the short term in patients with chronic rhinosinusitis and polyps.

A

45, 46

Oral antibiotics, given for up to three weeks, may be considered as a treatment option for acute exacerbations of chronic rhinosinusitis.

C

31, 32


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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BEST PRACTICES IN OTOLARYNGOLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not order more than one CT scan of the paranasal sinuses within 90 days to

The Author

AHMAD R. SEDAGHAT, MD, PhD, is an assistant professor in the Department of Otolaryngology at Harvard Medical School, Boston, Mass. He is also a rhinologist and endoscopic sinus and skull base surgeon at the Massachusetts Eye and Ear Infirmary in Boston.

Address correspondence to Ahmad R. Sedaghat, MD, PhD, Harvard Medical School, Massachusetts Eye and Ear Infirmary, 243 Charles St., Boston, MA 02114 (e-mail: ahmad_sedaghat@meei.harvard.edu). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

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