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Diseases

Chronic rhinosinusitis without nasal polyps

OVERVIEW

  • Highlights & Basics
  • Images

DIAGNOSIS

  • Diagnostic Approach
  • Risk Factors
  • History & Exam
  • Tests
  • Differential Diagnosis
  • Criteria
  • Screening

TREATMENT

  • Tx Approach
  • Tx Options
  • Emerging Tx
  • Prevention

FOLLOW-UP

  • Overview
  • Complications

REFERENCES

  • Citations
  • Guidelines
  • Credits

PATIENT RESOURCES

  • Patient Instructions

Highlights & Basics

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Key Highlights
  • Chronic rhinosinusitis is inflammation of the paranasal sinuses lasting more than 12 weeks.

  • Diagnosis is initially clinical. Nasal endoscopy may show inflammation, purulent discharge, edema, or frank polyps.

  • Initial medical treatment includes nasal saline irrigation and topical intranasal corticosteroids. Oral antibiotics, oral corticosteroids, antihistamines, and leukotriene receptor antagonists may also be considered.

  • Computed tomography is needed if initial medical treatment fails.

  • Functional endoscopic sinus surgery is very effective for patients unresponsive to medical treatment.

Quick Reference

  • History & Exam

    • Key Factors

      • Other Factors

        More information...
      • Diagnostics Tests

          More information...
        • Treatment Options

            More information...

          Definition

          Epidemiology

          Etiology

          Pathophysiology

          content by BMJ Group
          Last updated

          Images

          • Pre-op planning at a surgical navigation workstation

            Pre-op planning at a surgical navigation workstation

          • Image-guided endoscopic sinus surgery using an optical-based surgical navigation system

            Image-guided endoscopic sinus surgery using an optical-based surgical navigation system

          • Pre-op planning at a surgical navigation workstation

            Pre-op planning at a surgical navigation workstation

          • Image-guided endoscopic sinus surgery using an optical-based surgical navigation system

            Image-guided endoscopic sinus surgery using an optical-based surgical navigation system

          Citations

            Key Articles

            • Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015 Apr;152(2 Suppl):S1-S39.[Abstract][Full Text]

            • Peters AT, Spector S, Hsu J, et al. Diagnosis and management of rhinosinusitis: a practice parameter update. Ann Allergy Asthma Immunol. 2014 Oct;113(4):347-85.[Abstract]

            • Fokkens WJ, Lund VJ, Hopkins C, et al. European Position Paper on rhinosinusitis and nasal polyps 2020. Rhinology. 2020 Feb 20;58(suppl s29):1-464.[Abstract]

            Referenced Articles

            • 1. Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: establishing definitions for clinical research and patient care. Otolaryngol Head Neck Surg. 2004 Dec;131(6 suppl):S1-62.[Abstract][Full Text]

            • 2. Orlandi RR, Kingdom TT, Smith TL, et al. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol. 2021 Mar;11(3):213-739.[Abstract][Full Text]

            • 3. Anand VK. Epidemiology and economic impact of rhinosinusitis. Ann Otol Rhinol Laryngol Suppl. 2004 May;193:3-5.[Abstract]

            • 4. Benjamin MR, Stevens WW, Li N, et al. Clinical Characteristics of Patients with Chronic Rhinosinusitis without Nasal Polyps in an Academic Setting. J Allergy Clin Immunol Pract. 2019 Mar;7(3):1010-16.[Abstract][Full Text]

            • 5. Gliklich RE, Metson R. The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg. 1995 Jul;113(1):104-9.[Abstract]

            • 6. Leland EM, Vohra V, Seal SM, et al. environmental air pollution and chronic rhinosinusitis: a systematic review. Laryngoscope Investig Otolaryngol. 2022 Apr;7(2):349-60.[Abstract][Full Text]

            • 7. Drago L, Pignataro L, Torretta S. Microbiological aspects of acute and chronic pediatric rhinosinusitis. J Clin Med. 2019 Jan 28;8(2).[Abstract][Full Text]

            • 8. Doyle PW, Woodham JD. Evaluation of the microbiology of chronic ethmoid sinusitis. J Clin Microbiol. 1991 Nov;29(11):2396-400.[Abstract]

            • 9. Shapiro ED, Milmoe GJ, Wald ER, et al. Bacteriology of the maxillary sinuses in patients with cystic fibrosis. J Infect Dis. 1982 Nov;146(5):589-93.[Abstract]

            • 10. Sakakura Y, Majima Y, Harada T, et al. Nasal mucociliary transport of chronic sinusitis in children. Arch Otolaryngol Head Neck Surg. 1992 Nov;118(11):1234-7.[Abstract]

            • 11. Khan A, Vandeplas G, Huynh TMT, et al. The Global Allergy and Asthma European Network (GALEN rhinosinusitis cohort: a large European cross-sectional study of chronic rhinosinusitis patients with and without nasal polyps. Rhinology. 2019 Feb 1;57(1):32-42.[Abstract][Full Text]

            • 12. Wilson KF, McMains KC, Orlandi RR. The association between allergy and chronic rhinosinusitis with and without nasal polyps: an evidence-based review with recommendations. Int Forum Allergy Rhinol. 2014 Feb;4(2):93-103.[Abstract][Full Text]

            • 13. Chee L, Graham SM, Carothers DG, et al. Immune dysfunction in refractory sinusitis in a tertiary care setting. Laryngoscope. 2001 Feb;111(2):233-5.[Abstract]

            • 14. Makary CA, Luong AU, Azar A, et al. Evaluation and treatment of rhinosinusitis with primary antibody deficiency in adults: evidence-based review with recommendations. Int Forum Allergy Rhinol. 2023 Dec;13(12):2205-30.[Abstract][Full Text]

            • 15. Briggs RD, Wright ST, Cordes S, et al. Smoking in chronic rhinosinusitis: a predictor of poor long term outcome after endoscopic sinus surgery. Laryngoscope. 2004 Jan;114(1):126-8.[Abstract]

            • 16. London NR Jr, Tharakan A, Rule AM, et al. Air pollutant-mediated disruption of sinonasal epithelial cell barrier function is reversed by activation of the Nrf2 pathway. J Allergy Clin Immunol. 2016 Dec;138(6):1736-38.e4.[Abstract][Full Text]

            • 17. Ramanathan M Jr, London NR Jr, Tharakan A, et al. Airborne particulate matter induces nonallergic eosinophilic sinonasal inflammation in mice. Am J Respir Cell Mol Biol. 2017 Jul;57(1):59-65.[Abstract][Full Text]

            • 18. Zhao R, Guo Z, Dong W, et al. Effects of PM2.5 on mucus secretion and tissue remodeling in a rabbit model of chronic rhinosinusitis. Int Forum Allergy Rhinol. 2018 Nov;8(11):1349-55.[Abstract][Full Text]

            • 19. Phillips KM, Talat R, Caradonna DS, et al. Quality of life impairment due to chronic rhinosinusitis in asthmatics is mediated by asthma control. Rhinology. 2019 Dec 1;57(6):430-35.[Abstract][Full Text]

            • 20. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015 Apr;152(2 Suppl):S1-S39.[Abstract][Full Text]

            • 21. Peters AT, Spector S, Hsu J, et al. Diagnosis and management of rhinosinusitis: a practice parameter update. Ann Allergy Asthma Immunol. 2014 Oct;113(4):347-85.[Abstract]

            • 22. American College of Radiology. ACR appropriateness criteria: sinonasal disease. 2021 [internet publication]. [Full Text]

            • 23. American Academy of Otolaryngology - Head and Neck Surgery Foundation. Ten things physicians and patients should question. Choosing Wisely, an initiative of the ABIM Foundation. 2021 [internet publication].​[Full Text]

            • 24. Kuhn, JP. Imaging of the paranasal sinuses: current status. J Allergy Clin Immunol. 1986 Jan;77(1 Pt 1):6-8.[Abstract]

            • 25. Araujo E, Palombini BC, Cantarelli V, et al. Microbiology of middle meatus in chronic rhinosinusitis. Am J Rhinol. 2003 Jan-Feb;17(1):9-15.[Abstract]

            • 26. Dubin MG, Ebert CS, Coffey CS, et al. Concordance of middle meatal swab and maxillary sinus aspirate in acute and chronic sinusitis: a meta-analysis. Am J Rhinol. 2005 Sep-Oct;19(5):462-70.[Abstract]

            • 27. Desrosiers M, Evans GA, Keith PK, et al. Canadian clinical practice guidelines for acute and chronic rhinosinusitis. Allergy Asthma Clin Immunol. 2011 Feb 10;7(1):2.[Abstract][Full Text]

            • 28. Dykewicz MS, Wallace DV, Amrol DJ, et al. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol. 2020 Oct;146(4):721-767.[Abstract][Full Text]

            • 29. Fokkens WJ, Lund VJ, Hopkins C, et al. European Position Paper on rhinosinusitis and nasal polyps 2020. Rhinology. 2020 Feb 20;58(suppl s29):1-464.[Abstract]

            • 30. Mösges R, Heubach CP. What is the evidence for non-antibiotic drug therapy of rhinosinusitis? Laryngorhinootologie. 2011 Dec;90(12):740-6.[Abstract]

            • 31. Chong LY, Head K, Hopkins C, et al. Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis. Cochrane Database Syst Rev. 2016 Apr 26;(4):CD011996.[Abstract][Full Text]

            • 32. Chong LY, Head K, Hopkins C, et al. Different types of intranasal steroids for chronic rhinosinusitis. Cochrane Database Syst Rev. 2016 Apr 26;(4):CD011993.[Abstract][Full Text]

            • 33. Wang C, Lou H, Wang X, et al. Effect of budesonide transnasal nebulization in patients with eosinophilic chronic rhinosinusitis with nasal polyps. J Allergy Clin Immunol. 2015 Apr;135(4):922-29.[Abstract][Full Text]

            • 34. Rudmik L, Soler ZM. Medical therapies for adult chronic sinusitis: a systematic review. JAMA. 2015 Sep 1;314(9):926-39.[Abstract]

            • 35. Chong LY, Head K, Hopkins C, et al. Saline irrigation for chronic rhinosinusitis. Cochrane Database Syst Rev. 2016 Apr 26;(4):CD011995.[Abstract][Full Text]

            • 36. Soler ZM, Oyer SL, Kern RC, et al. Antimicrobials and chronic rhinosinusitis with or without polyposis in adults: an evidenced-based review with recommendations. Int Forum Allergy Rhinol. 2013 Jan;3(1):31-47.[Abstract]

            • 37. Head K, Chong LY, Piromchai P, et al. Systemic and topical antibiotics for chronic rhinosinusitis. Cochrane Database Syst Rev. 2016 Apr 26;(4):CD011994.[Abstract][Full Text]

            • 38. US Food and Drug Administration. Fluoroquinolone antibacterial drugs: drug safety communication - FDA advises restricting use for certain uncomplicated infections. May 2016 [internet publication].[Full Text]

            • 39. Steinke JW, Borish L. Leukotriene receptors in rhinitis and sinusitis. Curr Allergy Asthma Rep. 2004 May;4(3):217-23.[Abstract]

            • 40. US Food & Drug Administration. FDA requires Boxed Warning about serious mental health side effects for asthma and allergy drug montelukast (Singulair); advises restricting use for allergic rhinitis. 4 March 2020 [internet publication]. [Full Text]

            • 41. Sindwani R, Metson R. Image-guided frontal sinus surgery. Otolaryngol Clin North Am. 2005 Jun;38(3):461-71.[Abstract]

            • 42. Smith TL, Stewart MG, Orlandi RR, et al. Indications for image-guided sinus surgery: the current evidence. Am J Rhinol. 2007 Jan-Feb;21(1):80-3.[Abstract]

            • 43. Mehta U, Huber TC, Sindwani R. Patient expectations and recovery following endoscopic sinus surgery. Otolaryngol Head Neck Surg. 2006 Mar;134(3):483-7.[Abstract]

            • 44. Anne S, Mims JW, Tunkel DE, et al. Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations. Otolaryngol Head Neck Surg. 2021 Apr;164(2_suppl):S1-S42.[Abstract][Full Text]

            • 45. Chester AC, Antisdel JL, Sindwani R. Symptom-specific outcomes of endoscopic sinus surgery: a systematic review. Otolaryngol Head Neck Surg. 2009 May;140(5):633-9.[Abstract]

            • 46. Chester AC, Sindwani R, Smith TL, et al. Systematic review of change in bodily pain after sinus surgery. Otolaryngol Head Neck Surg. 2008 Dec;139(6):759-65.[Abstract]

            • 47. Chester AC, Sindwani R, Smith TL, et al. Fatigue improvement following endoscopic sinus surgery: a systematic review and meta-analysis. Laryngoscope. 2008 Apr;118(4):730-9.[Abstract]

            • 48. ​European Medicines Agency. ​Pseudoephedrine-containing medicinal products - referral. Mar 2024 [internet publication].[Full Text]

            • 49. Ebbens FA, Georgalas C, Luiten S, et al. The effect of topical amphotericin B on inflammatory markers in patients with chronic rhinosinusitis: a multicenter randomized controlled study. Laryngoscope. 2009 Feb;119(2):401-8.[Abstract]

            • 50. Lim M, Citardi MJ, Leong JL.Topical antimicrobials in the management of chronic rhinosinusitis: a systematic review. Am J Rhinol. 2008 Jul-Aug;22(4):381-9. [Abstract]

            • 51. National Institute for Health and Care Excellence. Balloon catheter dilation of paranasal sinus ostia for chronic sinusitis. September 2008 [internet publication].[Full Text]

            • 52. Taghi AS, Khalil SS, Mace AD, et al. Balloon sinuplasty: balloon-catheter dilation of paranasal sinus ostia for chronic rhinosinusitis. Expert Rev Med Devices. 2009 Jul;6(4):377-82.[Abstract]

            • 53. Batra PS, Ryan MW, Sindwani R, et al. Balloon catheter technology in rhinology: reviewing the evidence. Laryngoscope. 2011 Jan;121(1):226-32.[Abstract]

            • 54. Forwith KD, Chandra RK, Yun PT, et al. ADVANCE: a multisite trial of bioabsorbable steroid-eluting sinus implants. Laryngoscope. 2011 Nov;121(11):2473-80.[Abstract][Full Text]

            • 55. Han JK, Forwith KD, Smith TL, et al. RESOLVE: a randomized, controlled, blinded study of bioabsorbable steroid-eluting sinus implants for in-office treatment of recurrent sinonasal polyposis. Int Forum Allergy Rhinol. 2014 Nov;4(11):861-70.[Abstract][Full Text]

            • 56. Smith TL, Singh A, Luong A, et al. Randomized controlled trial of a bioabsorbable steroid-releasing implant in the frontal sinus opening. Laryngoscope. 2016 Dec;126(12):2659-64.[Abstract][Full Text]

            • 57. Dautremont JF, Mechor B, Rudmik L. The role of immediate postoperative systemic corticosteroids when utilizing a steroid-eluting spacer following sinus surgery. Otolaryngol Head Neck Surg. 2014 Apr;150(4):689-95.[Abstract][Full Text]

            • 58. Cervin A, Rimmer J, Wrobel A, et al. Long-acting implantable corticosteroid matrix for chronic rhinosinusitis: results of LANTERN Phase 2 randomized controlled study. Int Forum Allergy Rhinol. 2022 Feb;12(2):147-59.[Abstract][Full Text]

            • 59. American Academy of Otolaryngology-Head and Neck Surgery​. Position statement: drug-eluting sinus implants. Jan 2023 [internet publication].[Full Text]

            • 60. Sindwani R, Han JK, Soteres DF, et al. NAVIGATE I: randomized, placebo-controlled, double-blind trial of the exhalation delivery system with fluticasone for chronic rhinosinusitis with nasal polyps. Am J Rhinol Allergy. 2019 Jan;33(1):69-82.[Abstract][Full Text]

            • 61. Leopold DA, Elkayam D, Messina JC, et al. NAVIGATE II: Randomized, double-blind trial of the exhalation delivery system with fluticasone for nasal polyposis. J Allergy Clin Immunol. 2019 Jan;143(1):126-34.e5.[Abstract][Full Text]

            • 62. Palmer JN, Jacobson KW, Messina JC, et al. EXHANCE-12: 1-year study of the exhalation delivery system with fluticasone (EDS-FLU) in chronic rhinosinusitis. Int Forum Allergy Rhinol. 2018 Jun 1;8(8):869-76.[Abstract][Full Text]

            • 63. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope. 1970 Sep;80(9):1414-28.[Abstract]

            • 64. Parell GJ, Becker GD. Neurological consequences of scuba diving with chronic sinusitis. Laryngoscope. 2000 Aug;110(8):1358-60.[Abstract]

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