Patient information: Chronic rhinosinusitis (Beyond the Basics)
- Daniel L Hamilos, MD
Daniel L Hamilos, MD
- Associate Professor of Medicine
- Harvard Medical School
- Massachusetts General Hospital
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, become swollen, and create extra mucus. The swollen lining may also interfere with drainage of mucus.
Chronic rhinosinusitis refers to a condition that lasts at least 12 weeks, despite being treated, and causes at least TWO of the following symptoms:
●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
Chronic rhinosinusitis is different from the more common form of rhinosinusitis (called acute rhinosinusitis), which is a temporary infection of the sinuses that often occurs following colds. 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 more low-grade and chronic.
If you have been treated for rhinosinusitis with antibiotics 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.
An article that discusses acute rhinosinusitis is available separately. (See "Patient information: Acute sinusitis (sinus infection) (Beyond the Basics)".)
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 long-standing 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 upon 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 growths inside their noses or sinuses called nasal polyps. The polyps can become large and numerous enough to clog the sinuses, causing symptoms (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 allergic 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:
●Allergies – Allergies are much 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 information: Allergic rhinitis (seasonal allergies) (Beyond the Basics)".)
●Exposure to tobacco smoke or airborne irritants – Exposure to cigarette smoke or certain environmental toxins, such as formaldehyde, 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 chest infections. The most common immune problem associated with chronic rhinosinusitis is antibody deficiency (hypogammaglobulinemia). However, there can be more subtle problems with immune defense that mainly affect just the nose, sinuses, and lungs. The type of immunity involved in this is called innate immunity. Innate immunity functions as an alarm system to activate other components of the immune system, such as white blood cells (granulocytes and lymphocytes).
●Viral infections – Some people develop chronic rhinosinusitis after having repeated viral infections (such as the common cold), although it is not clear that the infections actually cause the chronic rhinosinusitis.
●Deviated septum – The piece of cartilage that runs down the midline of the nose and separates the nostrils, called the septum, is not entirely straight in many people. This is a condition called a deviated septum. This 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:
●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
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 feature of 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 sinus endoscopy.
A sinus CT scan is a procedure that takes about 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 or polyps within the sinus spaces.
Sinus endoscopy is an office procedure in which a clinician uses a thin tube attached to a camera to see inside the 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 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. About one in five people with chronic rhinosinusitis also has 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 a condition called aspirin intolerance. The symptoms of aspirin intolerance consist of a noticeable worsening in nasal or chest symptoms in the first few hours after taking aspirin, ibuprofen, naproxen sodium, or other nonsteroidal anti-inflammatory drugs (NSAIDs).
Worsening of symptoms may involve sudden nasal congestion, pain and pressure in the sinuses, wheezing, chest tightness, and cough. These reactions can be severe and even life-threatening. In contrast, acetaminophen (Tylenol) usually does not aggravate sinus and asthma symptoms. If you think you may have aspirin intolerance, you should avoid aspirin and other similar medications and talk to your health care provider. (See "Aspirin-exacerbated respiratory disease".)
CHRONIC RHINOSINUSITIS TREATMENT
The linings of the nose and sinuses are similar to the linings of the lungs. About one in five people with chronic rhinosinusitis also has asthma. The people most likely to have asthma are those who have chronic rhinosinusitis and nasal polyposis.
Unfortunately, people with chronic rhinosinusitis usually need life-long treatment to keep the symptoms in check. Several treatment options are available for people with chronic rhinosinusitis, but not all treatments are appropriate for all people. Different combinations of these treatments will be recommended depending upon the type of chronic rhinosinusitis you have, the severity of your symptoms, and if other conditions are also at play (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: Management".)
Potential treatments for chronic rhinosinusitis include:
Lifestyle modifications — People with chronic rhinosinusitis who smoke cigarettes should stop. (See "Patient information: 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 information: Trigger avoidance in allergic rhinitis (Beyond the Basics)".)
Daily nasal saline washing — Most people with chronic rhinosinusitis find that washing their nasal passages daily with saline (salt water) helps reduce symptoms. Washing the nose before applying medications also clears away mucus and reduces its interference with medications. The table provides instructions on how to make your own saline and perform nasal washes (table 1).
Glucocorticoid nasal sprays, washes, and drops — 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 anti-inflammatory drugs. They also decrease mucus production and help shrink any polyps that may be present. Using glucocorticoids in the form of nasal sprays or drops has the advantage of putting the medicine right where it is needed and also of not treating the rest of the body where the drug is not needed.
Your health care provider will probably ask you to try a glucocorticoid 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. Some are available over-the-counter in the United States (sample brand names: Flonase Allergy Relief, Rhinocort Allergy), while others require a prescription.
If the sprays do not seem to be working well enough, your health care provider may suggest switching to nasal drops or adding a nasal glucocorticoid solution to the saline nasal wash. Nasal drops or washes help get the glucocorticoid solution higher up into the sinuses.
If drops are prescribed, you must put them into the nose while lying in specific positions. This allows the liquid to move into the different sinuses (figure 5). In the United States, steroids do not come in nasal drops, but a medication called budesonide (Pulmicort Respules) can be dissolved in saline and used as a nasal wash. Your health care provider will give you specific instructions on how to use these medications.
Glucocorticoid pills — In some cases, your health care provider will recommend taking glucocorticoids (steroids) by mouth (orally). The most commonly used oral glucocorticoid is prednisone.
Glucocorticoids taken orally 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, glucocorticoids taken by mouth suppress normal immune responses throughout the body and can cause side effects, 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. It is not unusual to need long courses of antibiotics, lasting several weeks, to fully treat a sinus infection in a person with chronic rhinosinusitis. (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. These medications include montelukast (Singulair), zafirlukast (Accolate), and zileuton (Zyflo). These treatments 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.
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 passages and remove trapped mucus or polyps (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 evidence of 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 sufficiently shrink with steroid treatment.
●When "allergic fungal rhinosinusitis" is suspected. Patients with allergic fungal rhinosinusitis usually have one or more sinuses that are completely blocked on sinus CT scan. Often these sinuses appear on the CT to be filled with thick, dense mucus that is difficult to remove in any other way except surgery. The surgery also allows for collection of samples of mucus, which are needed to confirm the diagnosis of allergic fungal rhinosinusitis. (See "Allergic fungal rhinosinusitis".)
●When there is severe deviation of the septum causing nasal blockage or difficulty with 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 be addressed. In addition, because it is often impossible to eliminate these factors completely, most people require medications to control inflammation over time.
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.
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 information: Sinusitis in adults (The Basics)
Patient information: Deviated septum (The Basics)
Patient information: Nasal polyps (The Basics)
Patient information: Chronic sinusitis (The Basics)
Patient information: Rinsing 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 information: Acute sinusitis (sinus infection) (Beyond the Basics)
Patient information: Allergic rhinitis (seasonal allergies) (Beyond the Basics)
Patient information: Quitting smoking (Beyond the Basics)
Patient information: 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: Management
Microbiology and antibiotic management of chronic rhinosinusitis
Septic dural sinus thrombosis
Aspirin-exacerbated respiratory disease
Allergic fungal rhinosinusitis
The following organizations also provide reliable health information.
- Fokkens W, Lund V, Bachert C, et al. EAACI position paper on rhinosinusitis and nasal polyps executive summary. Allergy 2005; 60:583.
- Scadding GK, Durham SR, Mirakian R, et al. BSACI guidelines for the management of rhinosinusitis and nasal polyposis. Clin Exp Allergy 2008; 38:260.
- Harvey R, Hannan SA, Badia L, Scadding G. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database Syst Rev 2007; :CD006394.
- Hamilos DL. Approach to the evaluation and medical management of chronic rhinosinusitis. Clin Allergy Immunol 2007; 20:299.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.