Chronic Rhinosinusitis

Introduction

Rhinosinusitis is a relatively common condition, characterised by inflammation of the mucosal linings of the nasal passage and paranasal sinuses.

This article will focus on chronic rhinosinusitis (CRS), which refers to symptoms lasting longer than 12 weeks. Its pathophysiology is complex, involving interactions between the dysfunctional nasal mucosa and environmental factors.

In this article, we shall look at the risk factors, clinical features and management of chronic rhinosinusitis.

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Figure 1 – Illustration demonstrating the features of rhinitis

Risk Factors

The main risk factors for chronic rhinosinusitis include asthma or atopy, aspirin sensitivity, ciliary impairment (e.g. cystic fibrosis or primary ciliary dyskinesia), smoking, and immunosuppression

Those with anatomical variations or mechanical obstruction, such as septal deviation, nasal polyps, or sinus hypoplasia, are also at increased risk of CRS.

Clinical Features

Symptoms of chronic rhinosinusitis* include nasal blockage (either obstruction or congestion), nasal discharge (either anterior or posterior discharge, including nasal drip), facial pain or pressure (usually unilateral over the maxillary or frontal sinus), and an altered sense of smell. Symptoms must be present for ≥12 weeks.

On examination, there may be tenderness or swelling in the maxillofacial area over the affected sinus. Rhinoscopy will reveal generalised mucosal swelling, mucopurulent (green/yellow) discharge, or nasal polyps (Fig. 2)

*Current guidelines state patients must have 2 or more of these symptoms for a diagnosis of CRS

Differential Diagnosis

The main differential diagnoses for chronic rhinosinusitis include:

• Recurrent acute rhinosinusitis – consider if there is resolution of symptoms between episodes
• Malignancy – consider in cases of unilateral nasal polyposis, the presence of bloodstained discharge, or eye signs
• Foreign bodies – more common in children, and typically presents with nasal obstruction and discoloured unilateral discharge

Investigations

To make a formal diagnosis of chronic rhinosinusitis, nasal endoscopy is required*. The presence of mucosal swelling, mucosal occlusion of middle meatus, or nasal polyps (most commonly seen around the middle meatus) are often seen in patients with CRS.

*CT imaging is only required if complications of CRS are suspected and in pre-operative planning

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Figure 2 – A nasal polyp, as observed on anterior rhinoscopy

Management

For mild disease, nasal saline douching and topical steroid spray should be trialled. Advice should be given to avoid any known triggers, smoking cessation (if relevant), and ensure good control of any associated conditions where possible (e.g. asthma.

Those with moderate to severe disease will long term treatment with topical steroids and referral for consideration for surgery. In addition, the advent of biologics has become increasingly relevant in the treatment of CRS.

Functional Endoscopic Sinus Surgery

The aim of Functional Endoscopic Sinus Surgery (FESS) is to remove any polyps that have formed and to open up the sinuses. This all can be done via an endoscope.

This will reduce obstruction, drain any collections of mucus, and allow topical treatments to reach all areas to prevent recurrence.

Complications of FESS include bleeding, infection, need for nasal packing, recurrence, orbital haematoma leading to visual loss, and injury to the anterior skull base leading to cerebrospinal fluid leak.

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Figure 3 – Schematic demonstrating principles of FESS

Complications

A mucocoele can develop in cases of CRS, were a collection of mucus in an epithelial-lined cavity forms, most commonly in the frontal sinus. Mucocoeles can erode bone and invade local structures such as the orbit and the brain.