Initial management of chronic rhinosinusitis

Treatment for chronic rhinosinusitis can be started at presentation using the same therapies as for allergic rhinitis. Additional therapies include isotonic or hypertonic saline (sodium chloride solution) nasal irrigation.

If symptoms respond well to drug therapy, specialist referral is not usually needed.

If symptoms do not respond after at least 1 month of therapy, refer the patient to a specialist for further management. Assessment for possible allergic triggers via serum-specific immunoglobulin E (IgE) tests (‘RAST’ testing) and a computed tomography (CT) scan may help to guide the appropriate referral. A CT scan of a patient with chronic rhinosinusitis will show mucosal changes in the osteomeatal complex or sinuses. Sinus X-rays are rarely helpful and are not routinely recommended.

Further management depends on whether nasal polyps are identified on investigation or examination; see Chronic rhinosinusitis without nasal polyps and Chronic rhinosinusitis with nasal polyps. Polyps are grape-like structure that are pearly or greyish-yellow (a markedly different colour from the nasal mucosa); they may be easily visible inside the nasal cavity. About two-thirds of patients with chronic rhinosinusitis do not have polyps.

Chronic rhinosinusitis with or without nasal polyps can be caused by fungal conditions such as allergic fungal sinusitis and invasive fungal sinusitis. If a fungal aetiology is suspected, refer the patient to an ear, nose and throat surgeon. Topical or systemic antifungal therapy may be used by a specialist for invasive fungal disease. Surgical management may also be required.