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Identification and Management of Chronic Rhinosinusitis

Identification and Management of Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) has an estimated prevalence of up to 5% of the population. By definition, CRS is a chronic inflammatory condition of the paranasal sinuses that causes chronic nasal symptoms. According to the American Academy of Otolaryngology-Head and Neck Surgery, diagnostic criteria for CRS include presence of at least 2 out of the 4 cardinal symptoms seen in CRS: (1) facial pain and/or pressure, (2) hyposmia or anosmia, (3) nasal obstruction, or (4) nasal drainage for at least 12 weeks.

In addition to the subjective symptoms noted above, objective evidence of CRS is required via either nasal endoscopy or radiology such as CT of the sinuses. Sinus plain films are no longer recommended for evaluation of CRS, due to poor accuracy. Sinus CT can be performed in the primary care setting in lieu of nasal endoscopy and, in most cases, may be able to definitively confirm or rule out CRS. Sinus CT scan can also be helpful for evaluating any anatomic defects or nasal polyposis.

Many patients with CRS also have asthma, and uncontrolled CRS can contribute to poor asthma control and increased emergency department visits or hospital admissions for asthma, as well as increased rates of oral corticosteroid use. Due to significant symptom burden, patients' quality of life can be decreased substantially, so prompt recognition and being familiar with proper management of CRS is prudent.

Thankfully, CRS is a very treatable disease. Goals of treatment in CRS include management of symptoms and improvement in quality of life. Pharmacotherapy or therapeutics for CRS include saline irrigation, corticosteroids, biologics, and endoscopic sinus surgery if needed. Intranasal saline irrigations and use of intranasal corticosteroid spray are considered first-line therapies. Intranasal saline irrigations with commercially available sinus rinse bottles or pots can be effective at reducing sinus symptoms as well as enhancing mucociliary clearance. Intranasal corticosteroid sprays have been shown to improve all sinonasal symptoms in all types of CRS. Topical corticosteroids have been utilized—off-label—with isotonic saline irrigations with improved benefit. Short courses of oral corticosteroids can improve severe symptoms in the short term. Oral antibiotics can be utilized for acute exacerbations and have been used longer-term by specialists to manage some types of CRS. Biologic agents, such as dupilumab, are also shown to substantially improve symptoms in CRS with nasal polyposis. Many other treatment modalities such as surfactants and topical antibiotics have been utilized for management of CRS in the specialty clinic. Endoscopic sinus surgery is an effective treatment of CRS when medical management fails and can significantly improve outcomes. However, patients will require routine maintenance therapy after sinus surgery as it is not curative.

Overall, the symptom burden in CRS can be substantial with significant reductions in quality of life as well as high healthcare costs and utilization. In patients who do not respond to initial therapy, prompt referral to an otolaryngologist (ENT) and/or consideration of other conditions should be the next step. Evaluation and control of other comorbid conditions, such as allergic rhinitis or asthma, should prompt referral to other specialists, such as an allergist, for proper management of these conditions.

References
  • Bachert C, et al. Efficacy and safety of dupilumab in patients with severe chronic rhinosinusitis with nasal polyps (LIBERTY NP SINUS-24 and LIBERTY NP SINUS-52): Results from two multicentre, randomised, double-blind, placebo-controlled, parallel-group phase 3 trials. Lancet. 2019;394:1638-1650.
  • Rosenfeld RM, et al. Clinical practice guideline (update): Adult sinusitis. Otolaryngol Head Neck Surg. 2015;152:S1-S39.
  • Sedaghat AR. Chronic rhinosinusitis. Am Fam Phys. 2017;96:500-506.

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Filed under: Allergy/Immunology

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