What is chronic rhinosinusitis?
Chronic rhinosinusitis (CRS) is a common chronic inflammatory condition affecting the paranasal sinuses and lining of the nasal cavity. It is characterized by persistent sinus inflammation and symptoms lasting 12 weeks or longer. The key symptoms of CRS include:
- Nasal obstruction, congestion, or blockage
- Facial pain or pressure
- Reduction or loss of smell
- Purulent nasal discharge
Other symptoms may include headache, fatigue, dental pain, cough, and ear pressure or fullness.
What causes chronic rhinosinusitis?
The exact causes of chronic rhinosinusitis are not fully understood. However, some key factors believed to contribute to the chronic inflammation include:
- Allergies – allergic rhinitis can trigger sinonasal inflammation
- Asthma – associated with increased CRS prevalence
- Environmental irritants – pollution, cigarette smoke
- Anatomic factors – deviated septum, nasal polyps, abnormal sinus drainage
- Immune dysfunction – impaired mucociliary clearance
- Microbial infection – bacterial, viral, or fungal
- Biofilms – microbes adhering to sinonasal mucosa
The chronic inflammation caused by these factors leads to edema, mucus retention, and further ciliary damage. This creates a vicious cycle making treatment difficult.
Prevalence of chronic rhinosinusitis
Chronic rhinosinusitis is a very common condition, affecting approximately 12% of the U.S. adult population. This equals over 30 million Americans.
Some key facts about the prevalence of CRS:
- Affects all age groups, most often adults in their 5th and 6th decades of life
- Women are affected slightly more often than men
- Certain occupations with greater exposures have increased prevalence (e.g. agricultural workers)
- Prevalence is increasing, likely due to increased recognition
- One of the most common chronic medical conditions requiring physician office visits
Due to the high prevalence, CRS also has a significant economic impact from direct healthcare costs and lost productivity.
Risk factors for chronic rhinosinusitis
Several factors can increase an individual’s risk of developing chronic rhinosinusitis:
- Allergic rhinitis – seasonal or perennial allergies, most common risk factor
- Asthma – associated with increased CRS prevalence
- Anatomic defects – deviated septum, nasal polyps, concha bullosa
- Immune deficiency – cystic fibrosis, primary ciliary dyskinesia, HIV/AIDS
- Prior surgery – sinus surgery can cause scarring
- Environmental irritants – cigarette smoke, air pollution
The more risk factors present, the higher an individual’s chance of having chronic rhinosinusitis. Proper treatment of conditions like allergies and asthma may help prevent CRS development.
Diagnosing chronic rhinosinusitis
Diagnosing chronic rhinosinusitis involves a complete history and physical exam, along with imaging studies to assess sinus anatomy.
Key elements of the diagnostic workup include:
- Symptom assessment – quality, severity, timing
- Nasal endoscopy – examines nasal cavity and sinus drainage
- CT scan – evaluates sinus anatomy and drainage pathways
- Allergy testing – identifies possible allergic triggers
- Cultures – check for bacterial, viral, or fungal infection
- Ciliary function testing – if primary ciliary dyskinesia suspected
These tests help identify causes and guide appropriate treatment options. The duration of symptoms also differentiates chronic vs acute rhinosinusitis.
Symptom criteria
The diagnosis of chronic rhinosinusitis requires meeting specific symptom criteria:
- 12+ weeks duration of 2+ symptoms:
- Mucopurulent drainage
- Nasal obstruction
- Facial pain, pressure, fullness
- Decreased sense of smell
- Inflammation documented on exam or imaging
Meeting these criteria confirms the diagnosis in the proper clinical context. Acute bacterial rhinosinusitis has a duration less than 4 weeks.
Chronic rhinosinusitis treatment options
Treatment for chronic rhinosinusitis focuses on controlling inflammation and possible infections. Typical therapies include:
- Nasal saline irrigation – rinses debris, hydrates tissues
- Intranasal corticosteroids – reduce inflammation
- Antibiotics – treat bacterial infections
- Antihistamines – control allergic symptoms
- Decongestants – relieve nasal congestion
- Surgery – opens blocked sinus drainage pathways
Treatment is usually most effective when employing multiple complementary therapies. Identifying and mitigating risk factors can also improve control of chronic inflammation.
Medical therapies
Medical management of CRS aims to control symptoms and restore sinus ventilation and drainage. Typical medical treatments include:
Saline irrigation – Flushing the nasal cavity with saltwater moisturizes tissues, removes allergens, thins mucus, and clears debris. This improves sinus ventilation.
Steroid nasal sprays – Topical intranasal corticosteroids are very effective at reducing sinus inflammation. Common options are fluticasone (Flonase) or mometasone (Nasonex).
Antibiotics – Bacterial infections may cause or worsen CRS. Culture-directed oral antibiotics treat these effectively when appropriate.
Antihistamines/decongestants – These help control allergies and relieve nasal congestion as adjuncts to other treatments.
Surgical treatment
For chronic rhinosinusitis unresponsive to medical therapy, sinus surgery may be recommended. The goals of surgery include:
– Draining mucus from blocked sinuses
– Removing sinus polyps and inflammatory tissue
– Widening narrow sinus drainage pathways
Common sinus surgery procedures for CRS include:
– Endoscopic sinus surgery -Less invasive procedure using an endoscope and small instruments to clear blockages and polyps. Most common surgery for CRS.
– Balloon sinus dilation – Small balloon is inserted and inflated to dilate obstructed sinus openings. Less tissue removal than traditional surgery.
– Functional endoscopic sinus surgery (FESS) – More extensive procedure removing tissue and bone to fully open all sinus drainage pathways.
Complications of chronic rhinosinusitis
Though not extremely common, chronic rhinosinusitis does have some possible complications to monitor for, including:
- Decreased sense of smell – inflammation and congestion impair olfaction
- Sinus infection spreading – intracranial, orbital, or bony infection
- Vision problems – infection reaches the eyes or optic nerves
- Asthma flares – upper/lower airway inflammation interacts
- Nasal polyps – chronic inflammatory masses in sinus cavities
Prompt treatment helps prevent most complications. Recurrent sinus infections, nasal polyps, and asthma issues are most common with poorly controlled CRS.
Prognosis and recurrence risk
With proper treatment and management of risk factors, many patients with chronic rhinosinusitis can achieve good symptom control and improvement in quality of life. However, CRS is considered a chronic condition with a relatively high likelihood of recurrence.
Some key facts about the prognosis for chronic rhinosinusitis:
- 50% will improve in weeks with medical treatment alone
- 20-30% have recurrent acute exacerbations of inflammation
- 20-30% have persistent symptoms despite some treatment
- CRS is associated with accumulating sinonasal mucosal damage
- Surgical interventions have 80-90% success rate short-term
- 50% risk of symptom recurrence 5-10 years after surgery
Close follow-up care and adherence to maintenance treatments can identify and treat recurrences early. This gives the best chance of preserving sinus function and quality of life.
Conclusion
Chronic rhinosinusitis is a very common source of sinus pressure, congestion, and facial pain. It results from persistent inflammation in the nasal and sinus cavities lasting 12 weeks or longer. Controlling allergy symptoms, irritants, and infections can successfully treat many cases. However, the chronic inflammatory damage makes recurrence fairly common. Surgery to open blocked sinus drainage combined with medical therapy provides the highest success rates. Understanding the causes, treatments, and prognosis for chronic rhinosinusitis allows for better management.