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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 (LTRAs) 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

          Citations

            Key Articles

            • Payne SC, McKenna M, Buckley J, et al. Clinical practice guideline: adult sinusitis update. Otolaryngol Head Neck Surg. 2025 Aug;173(suppl 1):S1-56.[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. Payne SC, McKenna M, Buckley J, et al. Clinical practice guideline: adult sinusitis update. Otolaryngol Head Neck Surg. 2025 Aug;173(suppl 1):S1-56.[Abstract][Full Text]

            • 2. Keating MK, Phillips JC, Phillips J. Chronic rhinosinusitis. Am Fam Physician. 2023 Oct;108(4):370-7.[Abstract][Full Text]

            • 3. 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]

            • 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. Rudmik L, Smith TL. Quality of life in patients with chronic rhinosinusitis. Curr Allergy Asthma Rep. 2011 Jun;11(3):247-52.[Abstract]

            • 6. DeConde AS, Soler ZM. Chronic rhinosinusitis: epidemiology and burden of disease. Am J Rhinol Allergy. 2016 Mar-Apr;30(2):134-9.[Abstract]

            • 7. ​Rădeanu DG, Bronescu V, Stan C, et al. Chronic rhinosinusitis: a multifaceted burden on patients and society--a systematic review. Surgeries. 2025 Jun;6(3):48.[Full Text]

            • 8. 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]

            • 9. 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]

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

            • 11. 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]

            • 12. 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]

            • 13. 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]

            • 14. 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]

            • 15. 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]

            • 16. Young J, Frenkiel S, Tewfik MA, et al. Long-term outcome analysis of endoscopic sinus surgery for chronic sinusitis. Am J Rhinol. 2007 Nov-Dec;21(6):743-7.[Abstract]

            • 17. Tröltzsch M. Epidemiology of odontogenic sinusitis. Otolaryngol Clin North Am. 2024 Dec;57(6):919-26.[Abstract]

            • 18. Karadeniz EB, Aliyeva C, Aydemir S, et al. Chronic rhinosinusitis in patients with primary immunodeficiency. Int Arch Allergy Immunol. 2023;184(3):302-10.[Abstract]

            • 19. Odat H, Alqudah M. Prevalence and pattern of humoral immunodeficiency in chronic refractory sinusitis. Eur Arch Otorhinolaryngol. 2016 Oct;273(10):3189-93.[Abstract]

            • 20. 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]

            • 21. 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]

            • 22. Gill AS, Meeks H, Curtin K, et al. Tobacco use increases the risk of chronic rhinosinusitis among patients undergoing endoscopic sinus surgery. Clin Otolaryngol. 2023 May;48(3):414-22.[Abstract][Full Text]

            • 23. Tan CJ, Leow BHW, Tan BKJ, et al. Association between smoking and chronic rhinosinusitis: a systematic review and meta-analysis. Laryngoscope. 2024 Jun;134(6):2513-24.[Abstract]

            • 24. Hutson K, Clark A, Hopkins C, et al. Evaluation of smoking as a modifying factor in chronic rhinosinusitis. JAMA Otolaryngol Head Neck Surg. 2021 Feb 1;147(2):159-65.[Abstract][Full Text]

            • 25. Jade KM, Scangas GA, Lee VS, et al. Impact of life-context factors on chronic rhinosinusitis 22-item sinonasal outcomes test: systematic review + meta-analysis. Otolaryngol Head Neck Surg. 2026 Jun 16.[Abstract][Full Text]

            • 26. 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]

            • 27. 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]

            • 28. 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]

            • 29. Shin JJ, Wilson M, McKenna M, et al. Clinical practice guideline: surgical management of chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2025 Jun;172 Suppl 2:S1-47.[Abstract][Full Text]

            • 30. 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]

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

            • 32. 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]

            • 33. 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]

            • 34. 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]

            • 35. 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]

            • 36. 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]

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

            • 38. 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]

            • 39. 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]

            • 40. 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]

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

            • 42. 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]

            • 43. 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]

            • 44. 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]

            • 45. Philpott C, Beard DJ, Saeedi E, et al. The clinical effectiveness of clarithromycin versus endoscopic sinus surgery for adults with chronic rhinosinusitis with and without nasal polyps (MACRO): a pragmatic, multicentre, three-arm, randomised, placebo-controlled phase 4 trial. Lancet. 2025 Aug 30;406(10506):926-39.[Abstract][Full Text]

            • 46. Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804.[Abstract][Full Text]

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

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

            • 49. 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]

            • 50. Toppila-Salmi S, Reitsma S, Hox V, et al. Comorbid chronic rhinosinusitis and asthma: shared risk factors and treatment implications-an EAACI Task Force Report. Allergy. 2026 Apr;81(4):1000-23.[Abstract][Full Text]

            • 51. Phillips KM, Hoehle L, Bergmark RW, et al. Reversal of smoking effects on chronic rhinosinusitis after smoking cessation. Otolaryngol Head Neck Surg. 2017 Oct;157(4):737-42.[Abstract]

            • 52. ​Academy of Medical Royal Colleges. Surgical intervention for chronic rhinosinusitis. Jan 2020 [internet publication].[Full Text]

            • 53. Beswick DM, Ramakrishnan VR. The utility of image guidance in endoscopic sinus surgery: a narrative review. JAMA Otolaryngol Head Neck Surg. 2020 Mar 1;146(3):286-90.[Abstract]

            • 54. Ramakrishnan VR, Orlandi RR, Citardi MJ, et al. The use of image-guided surgery in endoscopic sinus surgery: an evidence-based review with recommendations. Int Forum Allergy Rhinol. 2013 Mar;3(3):236-41.[Abstract]

            • 55. Lyu K, Tan B, Su Z, et al. The clinical outcome of image-guided system in endoscopic sinus surgery for chronic rhinosinusitis: a systematic review and meta-analysis. Laryngoscope Investig Otolaryngol. 2025 Apr;10(2):e70106.[Abstract][Full Text]

            • 56. 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]

            • 57. 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]

            • 58. 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]

            • 59. 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]

            • 60. 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):S1-42.[Abstract][Full Text]

            • 61. 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]

            • 62. 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]

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

            • 64. 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]

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

            • 66. 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]

            • 67. 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]

            • 68. 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]

            • 69. 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]

            • 70. 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]

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

            • 72. 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]

            • 73. 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]

            • 74. 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]

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

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

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