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Patient education: Chronic rhinosinusitis (Beyond the Basics)

Patient education: Chronic rhinosinusitis (Beyond the Basics)
Literature review current through: Jan 2024.
This topic last updated: Oct 19, 2023.

CHRONIC RHINOSINUSITIS OVERVIEW — The sinuses are hollow air pockets in the bones of the face and head that probably exist to cushion the brain during trauma (figure 1). The sinuses are lined with a thin layer of tissue that normally makes a small amount of mucus to keep the sinuses healthy and lubricated and flush away germs.

Rhinosinusitis occurs when the lining of the sinuses gets infected or irritated, becomes swollen, and creates extra mucus. The swollen lining may also interfere with drainage of mucus.

People with rhinosinusitis have at least two of the following symptoms:

Nasal congestion

Mucus discharge from the nose or mucus that drips down the back of the throat

Facial pain, pressure, or "fullness"

A decreased sense of smell

Rhinosinusitis is considered chronic when it lasts least three months.

Chronic rhinosinusitis is different from the more common form of rhinosinusitis (called "acute rhinosinusitis" or just "sinusitis"), which is a temporary infection of the sinuses that often occurs following colds. A topic that discusses acute rhinosinusitis is available separately. (See "Patient education: Acute sinusitis (sinus infection) (Beyond the Basics)".)

Chronic rhinosinusitis is a more persistent problem, which requires a specific treatment approach. It is sometimes overlooked by both patients and health care providers because the symptoms are sometimes low grade and chronic. If you have been treated for rhinosinusitis with antibiotics or oral steroids multiple times within a single year or if you have two or more of the symptoms listed above much of the year, talk to your health care provider about whether you might have chronic rhinosinusitis.

Chronic rhinosinusitis cannot be cured in most cases, although treatment can significantly reduce symptoms and improve quality of life. The best approach to treatment involves identifying the factors that contribute to chronic rhinosinusitis in each specific person and correcting these factors to the degree possible. Most people are treated primarily with medications, although many also need surgery. Even after surgery, medications to control inflammation are usually needed indefinitely.

CHRONIC RHINOSINUSITIS CAUSES — Unlike acute rhinosinusitis, which is usually caused by infection, chronic rhinosinusitis often has more complicated and elusive causes. Infections can certainly contribute to or worsen chronic rhinosinusitis, but people with the chronic condition usually have longstanding inflammation that cannot be explained by infection alone. (See "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis".)

Health care providers divide chronic rhinosinusitis into three different categories, depending on the features that are present:

Chronic rhinosinusitis without nasal polyposis – Chronic rhinosinusitis without nasal polyposis is the most common type of rhinosinusitis. In this form of rhinosinusitis, the swelling and irritation of the sinus lining may be caused by different factors, such as allergies to things in the air, irritation from things in the air, and infections (figure 2). The factors are different in different people.

Chronic rhinosinusitis with nasal polyposis – Some people with chronic rhinosinusitis have abnormal growth of tissue inside their noses or sinuses called "nasal polyps." The polyps can become large and numerous enough to clog the sinuses and nasal passageway, causing symptoms such as congestion/nasal blockage and a decreased sense of smell (figure 3). Scientists do not fully understand why some people form nasal polyps. Treatment involves medications to shrink the polyps or surgery to remove them. Some people need both.

Chronic rhinosinusitis with fungal allergy ("allergic fungal rhinosinusitis") – Some people with chronic rhinosinusitis develop a strong inflammatory response to fungi (the plural of fungus) inside their sinuses. It is normal for air to contain small amounts of fungi (airborne spores), and most people can breathe in air containing fungal spores without problems. However, in some people, the allergy to fungi causes the sinus lining to make thick, dense mucus that fills the sinuses. To diagnose this type of chronic rhinosinusitis, a health care provider must find thick mucus in the sinuses, see fungi in the mucus under the microscope, and show (with allergy testing) that patients are allergic to fungi. (See "Allergic fungal rhinosinusitis".)

CHRONIC RHINOSINUSITIS RISK FACTORS — Several factors can increase your risk of chronic rhinosinusitis or worsen your symptoms once you have the disorder. These include:

Viral infections – Some people develop chronic rhinosinusitis after having repeated viral infections (such as the common cold). The repeated viral infections are thought to trigger inflammation in some patients with chronic rhinosinusitis, but the viral infections do not persist long term.

Allergies – Allergies are more common among people with chronic rhinosinusitis than they are among people in the general population. This is especially true of allergies that are present year-round, such as dust mites, animal dander, molds, and cockroaches. Allergies that are poorly controlled can worsen the symptoms of chronic rhinosinusitis. (See "Patient education: Allergic rhinitis (Beyond the Basics)".)

Exposure to tobacco smoke or airborne irritants – Exposure to cigarette smoke or certain environmental irritants can increase the risk of chronic rhinosinusitis.

Immune system disorders – Most people with chronic rhinosinusitis have normal immune systems. However, people with certain immune system problems are at an increased risk of chronic rhinosinusitis. They may also have recurrent problems with other infections, such as ear and lung infections (pneumonia). The most common immune problems associated with chronic rhinosinusitis are problems with antibody production or function.

In contrast, deviation of the septum (the piece of cartilage that divides the two halves of the nose) is not a common cause of chronic rhinosinusitis. The septum is not entirely straight in many people. Septum deviation may be present from birth or develop later in life as the result of injury to the nose. A deviated septum is a common cause of nasal blockage. It may cause one nostril or sometimes both nostrils to be blocked, but it is not a common cause of chronic rhinosinusitis.

CHRONIC RHINOSINUSITIS SYMPTOMS — As noted above, the symptoms of chronic rhinosinusitis must include two or more of the following:

Nasal congestion or blockage

Mucus discharge from the nose or mucus that drips down the back of the throat (postnasal drip)

Facial pain, pressure, or "fullness"

A decreased sense of smell

Young children may have other symptoms, including chronic cough and halitosis (bad breath). Many people with chronic rhinosinusitis also experience fatigue, although this symptom is not used to diagnose chronic rhinosinusitis, because there are many other causes of fatigue unrelated to sinus conditions. Still, fatigue is a prominent symptom in some patients with chronic rhinosinusitis, and it can be the most difficult symptom for some people to manage.

CHRONIC RHINOSINUSITIS DIAGNOSIS — Chronic rhinosinusitis is likely if a person has had two or more of the symptoms listed above for a period of at least three months. In addition, there should be evidence of sinus disease that can be seen on a sinus computed tomography (CT) scan or with a procedure called nasal endoscopy.

A sinus CT scan is a procedure that takes approximately 15 minutes and involves a series of radiographs of the head and face. The radiographs give a detailed picture of the sinus linings and any mucus, inflamed/thickened tissue, or polyps within the sinus spaces.

Nasal endoscopy is an office procedure in which a clinician uses a thin tube attached to a camera to see inside the nose and sinuses (figure 4). Endoscopy also allows the clinician to take a sample of mucus from inside the sinuses to examine under the microscope. Samples of mucus from the nose (which are easier to obtain) are not always representative of what is found in the sinuses.

CONDITIONS RELATED TO CHRONIC RHINOSINUSITIS — The linings of the nose and sinuses are similar to the linings of the lungs. Between 30 and 50 percent of people with chronic rhinosinusitis also have asthma. The people most likely to have asthma are those who have chronic rhinosinusitis and nasal polyps.

Some patients with chronic rhinosinusitis, nasal polyps, and asthma also have aspirin intolerance or aspirin sensitivity. Aspirin intolerance consists of a noticeable worsening in nasal or asthma symptoms, such as wheezing or trouble breathing, in the first few hours after taking aspirin, ibuprofen, naproxen sodium, or other nonsteroidal antiinflammatory drugs (NSAIDs).

Worsening of symptoms may involve sudden nasal congestion, pain and pressure in the sinuses, runny nose, red/watery eyes, wheezing, chest tightness, and cough. These reactions can be severe and even life threatening. In contrast, acetaminophen (brand name Tylenol) does not aggravate sinus and asthma symptoms in many patients with aspirin intolerance. If you think you may have aspirin intolerance, you should avoid aspirin and other similar medications (NSAIDs) and talk to your health care provider. (See "Aspirin-exacerbated respiratory disease".)

CHRONIC RHINOSINUSITIS TREATMENT — Unfortunately, chronic rhinosinusitis cannot be cured in most cases, but the symptoms can be managed so that they are not so burdensome. People with chronic rhinosinusitis usually need lifelong treatment to keep the symptoms under control. Several treatment options are available, but not all treatments are appropriate for all people. Different combinations of these treatments will be recommended depending on the type of chronic rhinosinusitis you have, the severity of your symptoms, and if other conditions are also causing symptoms (such as allergies or asthma).

Health care providers usually recommend starting with aggressive treatment to get symptoms and inflammation under control and then changing to a less aggressive approach over time. (See "Chronic rhinosinusitis without nasal polyposis: Management and prognosis" and "Chronic rhinosinusitis with nasal polyposis: Management and prognosis".)

Potential treatments for chronic rhinosinusitis include:

Lifestyle modifications — People with chronic rhinosinusitis who smoke cigarettes should stop. (See "Patient education: Quitting smoking (Beyond the Basics)".)

People who have environmental allergies as a contributing factor to their sinus problems may be able to change things in their home or work conditions to reduce exposure to the specific allergens that bother them. (See "Patient education: Trigger avoidance in allergic rhinitis (Beyond the Basics)".)

Daily nasal saline washing — Most people with chronic rhinosinusitis find that washing/irrigating their nasal passages daily with saline (salt water) helps reduce symptoms. Washing the nose before applying medications also clears away mucus and allows nasal medications to be absorbed better.

A variety of devices, including squeeze bottles, syringes, and Neti pots, may be used to perform nasal irrigation. Your doctor or pharmacist can recommend a nasal irrigation kit. These are available without a prescription. It is important to use distilled water for sinus irrigations to prevent transmission of infections from the water.

Antiinflammatory steroids — Because all forms of chronic rhinosinusitis involve some degree of inflammation (ie, irritation and swelling), most people with the condition need medications to reduce inflammation.

Glucocorticoids (commonly called "steroids") are very effective antiinflammatory drugs. They also decrease mucus production and help shrink any polyps that may be present. Steroids used for chronic rhinosinusitis are not the same as the steroids some athletes take illegally to build muscle.

Sprays and rinses — Your health care provider will probably ask you to try a steroid nasal spray initially, as sprays are easy to use. Sprays do not reach deep into the sinus cavities, but they reduce swelling in the nasal passages and open up the areas through which the sinuses drain (figure 5). Some are available over the counter in the United States (sample brand names: Flonase Allergy Relief, Rhinocort Allergy, Nasacort), while others require a prescription.

If the sprays are not working well enough, your health care provider may suggest other ways of getting the steroid further up into the nose. This can be done by adding a steroid solution to the saline nasal wash, switching to the exhalation delivery system (a kind of spray that is powered by a breath), or using nasal drops (not widely available in the United States). This way of delivering the medicine gets it closer to the sinus openings, where it is needed most.

It is important to try to use sprays and irrigations as consistently as possible as it may take some time for the nasal sprays and irrigations to improve symptoms. If you can get enough benefit from one of these methods, you can avoid taking steroid pills by mouth. Although effective, steroids taken by mouth expose the whole body to the drug and can cause side effects over time, such as problems with the eyes (cataracts and glaucoma) and thinning of the bones. These side effects are much less likely with sprays and rinses.

Steroid pills — In some cases, your health care provider will recommend taking steroid pills by mouth (orally). The most commonly used oral steroid is prednisone.

Oral steroids get into the circulation and deliver higher doses of drug compared with nasal sprays, rinses, or drops. This can result in better treatment of the inflammation and more dramatic improvement in symptoms. However, oral steroids suppress normal immune responses throughout the body and can cause side effects such as cataracts, glaucoma, and bone thinning, so health care providers use them only when necessary.

Antibiotics — Although chronic rhinosinusitis is often caused by inflammation rather than infection, sinus infections can develop and aggravate symptoms. As a result, some people need to take antibiotics. (See "Microbiology and antibiotic management of chronic rhinosinusitis".)

Leukotriene modifiers — Health care providers occasionally prescribe a group of medications called leukotriene modifiers to people with chronic rhinosinusitis who also have asthma. These medications include montelukast (brand name Singulair), zafirlukast (brand name Accolate), and zileuton (brand name Zyflo). These drugs work by reducing inflammation in a different way than glucocorticoids. These medications are not used for all types of chronic rhinosinusitis, and they appear to be most helpful for people with chronic rhinosinusitis with nasal polyposis who also have asthma.

Biologics for nasal polyposis — "Biologics" are medications that block a specific step in an inflammatory pathway. Biologics used for the treatment of chronic rhinosinusitis with nasal polyps include dupilumab (brand name Dupixent), omalizumab (brand name Xolair), and mepolizumab (brand name Nucala). These medications reduce the size of nasal polyps and improve the symptoms of chronic rhinosinusitis when used in conjunction with a steroid nasal spray or wash. They represent a significant advance in the treatment of nasal polyps, especially for patients with asthma and those who have had recurrence of nasal polyps despite sinus surgery.

Surgery — Although health care providers usually attempt to get the symptoms of chronic rhinosinusitis under control with medication first, some people need surgery to reopen the sinus drainage pathways and remove trapped mucus or polyps. Sinus surgery is usually performed through an endoscope, and no cuts are needed through the external skin (figure 4).

Situations in which surgery is helpful include the following:

When chronic rhinosinusitis symptoms do not improve enough with the medical treatments mentioned above and there is persistent sinus disease on sinus computed tomography (CT) scan, such as complete blockage of one or more sinuses.

When nasal polyps are present that do not shrink enough with medical treatment.

When the nasal septum, the thin wall between the nostrils, is pushed to one side, causing nasal blockage or poor sinus drainage.

As discussed above, surgery can be very useful in the treatment of chronic rhinosinusitis, although by itself, it is rarely enough to control symptoms long term. The factors that caused the sinus linings to become irritated and swollen and produce extra mucus in the first place must still be addressed. Therefore, most people require medications such as nasal steroid sprays or washes to control inflammation after sinus surgery.

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Sinusitis in adults (The Basics)
Patient education: Deviated septum (The Basics)
Patient education: Nasal polyps (The Basics)
Patient education: Chronic sinusitis (The Basics)
Patient education: How to rinse out your nose with salt water (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Acute sinusitis (sinus infection) (Beyond the Basics)
Patient education: Allergic rhinitis (Beyond the Basics)
Patient education: Quitting smoking (Beyond the Basics)
Patient education: Trigger avoidance in allergic rhinitis (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis
Chronic rhinosinusitis without nasal polyposis: Management and prognosis
Microbiology and antibiotic management of chronic rhinosinusitis
Orbital cellulitis
Septic dural sinus thrombosis
Aspirin-exacerbated respiratory disease
Allergic fungal rhinosinusitis
Chronic rhinosinusitis with nasal polyposis: Management and prognosis

The following organizations also provide reliable health information.

National Library of Medicine

National Institute of Allergy and Infectious Diseases (NIAID)

Allergy, Asthma, and Immunology Online

American Academy of Allergy, Asthma, and Immunology

[1,2]

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Daniel L Hamilos, MD, who contributed to earlier versions of this topic review.

Disclaimer: This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms. 2024© UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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