Optimizing Care for Chronic Rhinosinusitis Without Nasal Polyps: An Expert’s Approach

Key Takeaways

• Symptom persistence: CRSsNP is diagnosed when two or more of the following symptoms are present for more than 12 weeks: purulent rhinorrhea, nasal congestion, facial pressure, and smell dysfunction.
• Medical management first: Nasal corticosteroids and saline irrigations are the mainstays of treatment, with antibiotics reserved for bacterial exacerbations.
• Surgery as a supplement: Functional endoscopic sinus surgery (FESS) provides relief for refractory cases, but patients do require a component of post-operative medical therapy.

Chronic rhinosinusitis without nasal polyps (CRSsNP) is a common yet challenging condition seen in ENT and allergy clinics as well as in primary care clinics. While it may not present with the more obvious features of chronic rhinosinusitis with nasal polyps (CRSwNP), CRSsNP has a significant impact on patients’ quality of life. The key lies in recognizing the chronic nature of this disease and employing a tailored approach to diagnosis and management. In this commentary, I’ll share my approach to CRSsNP, focusing on diagnostic strategies and treatment modalities that can help us as specialists deliver optimal care to our patients.

Understanding Chronic Sinusitis: Why Duration Matters

One of the main diagnostic features of chronic rhinosinusitis is the persistence of symptoms. When a patient presents with purulent rhinorrhea, nasal congestion, facial pressure, and smell dysfunction that has persisted for more than 12 weeks, chronic rhinosinusitis should be very high on the differential. CRSsNP differs from recurrent acute sinusitis in that it is a chronic inflammatory condition of the sinonasal mucosal where symptoms fluctuate in severity but never fully resolve.

Accurate Diagnosis: The Role of Endoscopy and Imaging

Patients referred for suspected chronic rhinosinusitis require further diagnostic workup as objective inflammation of the paranasal sinuses is required to confirm the diagnosis and to distinguish CRSsNP from CRSwNP. CRSsNP is often characterized by a neutrophilic inflammatory response, as opposed to the eosinophilic-driven inflammation seen in CRSwNP.

Nasal endoscopy and CT imaging of the sinuses are essential to assess for sinonasal anatomy, extent of inflammation, and the presence of purulence or polyps. Proper diagnostic evaluation is key to avoid over-reliance on symptoms alone, which can sometimes blur the line between chronic rhinosinusitis and other causes of nasal obstruction or facial discomfort.

Long-term Management: Medical and Surgical Options

Once CRSsNP is diagnosed, it is important to emphasize that treatment is about managing a chronic disease rather than expecting a full cure. The goal is to reduce symptom severity and improve quality of life.

Medical Therapy

For most patients, medical management involves a combination of topical nasal corticosteroids and saline irrigations. Nasal corticosteroids help reduce inflammation in the sinuses, while saline irrigations flush out mucus, debris, and potential allergens. These are the cornerstones of long-term care and can significantly reduce symptoms when used regularly.

In cases where bacterial infection exacerbates the condition, culture-directed antibiotic therapy may be needed. However, it’s crucial to differentiate between bacterial infections and inflammatory flares, as unnecessary antibiotic use can contribute to resistance and patient frustration. Identifying true bacterial involvement, via in-office nasal endoscopy, helps guide appropriate antibiotic use.

When to Consider Surgery

For patients who do not respond adequately to medical management, or in cases where structural issues such as a deviated septum or obstructed sinus drainage pathways are present, surgical intervention has been proven to be highly effective. Functional endoscopic sinus surgery (FESS) aims to restore normal sinus drainage and improve access and therefore efficacy of medical therapies, like nasal corticosteroids.

While surgery can provide significant relief, it is not a cure on its own. Patients all require some form of ongoing medical therapy of variable duration to maintain the benefits of surgery. Setting realistic expectations about the role of surgery helps patients understand that while their symptoms can improve dramatically, optimal outcomes require both surgery and post-operative medical therapy.

Managing Expectations: Improving Quality of Life

Ongoing communication is critical. Patients should understand that treatments, including nasal sprays, saline irrigations, and possible surgical intervention, will help manage the disease but may not eliminate it entirely. Educating patients about the chronic nature of CRSsNP can improve adherence to long-term therapy, ensuring they stick with prescribed regimens and follow-up even when symptoms seem to improve.

Conclusion

CRSsNP presents unique diagnostic and management challenges for health care providers. By recognizing the chronic inflammatory nature of the disease, utilizing endoscopy and imaging to guide diagnosis, and implementing a combination of medical and surgical treatments, we can help our patients achieve significant symptom relief and improved quality of life.

Your Thoughts?

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To learn more about CRSsNP, join our live webinar on November 4, 2024, where I will discuss this topic in more detail.

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