Chronic rhinosinusitis is a disease of persistent sinonasal inflammation for which corticosteroid therapy provides patients with symptomatic relief and an improved quality of life. CRS is defined by symptomatology in conjunction with endoscopic and/or radiologic findings.
The true prevalence is estimated to be less than 5% when using guideline based diagnostic criteria.
CRS is diagnosed by the prescience of 2 or more of the following for 12 weeks or more:
nasal blockage/obstruction
nasal discharge
facial pain /pressure
hyposmia/ anosmia
Facial pain/ pressure
Cause : multi factorial with etiology in environmental , host immune behaviour, allergy , infective and genetic elements.
Systemic considerations include auto immune, cystic fibrosis and primary ciliary dyskinesia esp in children with immune deficiency.
QoL measures: The SNOT 22 – sinonasal outcome questionnaire is a multi language validated self administered CRS specific Questionnaire of 22 items rated from 0 to 5 (worst symptom). Total scores greater than 50 reflect a severe impact of CRS and a cut off score of 40 or more is incorporated into the criteria for biological therapy.
Imaging : Noncontrast CT of the paranasal sinuses is the primary imaging modality. sinus x-rays no longer have a primary role in sinonasal disease. Routine perioperative haematology and biochemistry are often performed to exclude undiagnosed thrombocytopenia, coagulopathy or undiagnosed abnormalities that may impact on general anaesthetist or surgery.
Red Flag Symptoms:
Epistaxis and blood stained secretions
Unilateral symptoms
Facial asymmetry
Frontal swelling
Neurologic signs
Signs of meningitis
Practise points for GP’s for managing chronic rhinosinusitis:
Allergy should be investigated and serum specific IgE or skin prick testing . Aswell as non contrast CT of the paranasal sinuses.
Biological therapy is available to assist with severe eosinophilia CRS refractory to medical and surgical treatment.(dupilumab and omalizumab).
Inhaled corticosteroids and nasal saline irrigation are appropriate first line treatment .
Facial pain in isolation is rarely of sinus origin and a headache or migraine disorder should be considered. Short courses of oral corticosteroids for 2/3 weeks can be used if nasal medication fails.
Paediatric CRS : Given the rarity of nasal polyps all children presenting with those should undergo investigation for Cystic Fibrosis. PCD needs a mucosal biopsy.
Adenoidectomy is typically the first surgical intervention and provides symptom resolution in 50 % of cases.
