1. Medical management of chronic
rhinosinusitis
Diagnosis ( investigations)
The European position paper on Rhinosinusitis & nasal polyps proposed the criteria for diagnosis of
chronic rhinosinusitis in adults as 12 or more weeks of persistent symptoms & sign with no complete
resolution.
Rhinosinusitis (including nasal polyps ) is defined as inflammation of the nose & the paranasal
sinuses characterized by two or more of the following symptoms:
Blockage/congestion;
Discharge : anterior /posterior (discoloured)
Facial pain /pressure;
Reduction or loss of smell;
Plus either :
Endoscopic signs of :
Polyps
Mucopurulent discharge from middle meatus;
Or oedema /mucosal obstruction primarily in the middle matus.
And/or :
CT changes:
Mucosal changes within osteomeatal complex and /or sinuses.
Predisposing factors & investigations
These includes allergic rhinitis , nonallergic rhinitis& immune deficiency.
Septal deviation ( Concha bullosa & Hellar cells are not responsible for CRS).
Systemic diseases , including Wegener’s granulomatosis, churg-strauss disease & sarcoidosis may
present with CRS. Therefore evidence of adhesion, contact bleeding, & crusting or aggressive
polyposis requiring oral steroids.
Consider underlying causes
Allergy (skin prick tests/RAST)

2. Immune deficiency (immunoglobulin/IgG subclasses)
Vasculitis ( Relevant investigations including full blood count, ESR, Eosinophil counts, ACE,
antinuclear antibody(ANA), antineutrophil cytoplasmic antibodies (ANCA) & nasal biopsy.)
Allergic fungal rhinosinusitis usually presents with nasal polyposis, tenacious allergic mucin
with intensely eosinophilic contain few fungal hypae on silver staining. CT scan shows evidence of
hyperdense regions due to chelation of metals.
Aspirin sensitivity (nasal lysine aspirin challenge)
Medical therapy
Medical therapy used in chronic rhinosinusitis include:
Allergen / irritant avoidance
Irritant can increase nasal symptoms , therefore avoidance of smoke,pollution, & occupational
irritants is uaually advised.
Allergen leads to mucosal inflammation & hypertrophy, possibly blocking osteomeatal complex.
Nasal douching
This reduces nasal symptoms & increase quality of life.
Corticosteroids
Systemic steroids (oral or intramuscular) can reduce the size of nasal polyp to a extent that is
comparable with surgery. Topical steroid reduce the recurrence of nasal polyps. 50% of post-surgical
patients unresponsive to topical steroid sprays respond to fluticasone propionate nasules.
Budesonide alone gave some symptom & airway improvement. A combination of dexamethasone &
tramazoline ( a decongestant) improves discharge, obstruction & facial pain with improvement in x-ray,
nasal airway resistance& mucociliary clearance.
There is no evidence to suggest that topical intranasal corticosteroid worsen nose & sinus infection.
Decongestants
In theory , these could be useful ,however there is no evidence to support this.
Antibiotic
Since the majority of exacerbations of chronic rhinosinusitis are probably viral rather bacterial. So
antibiotic used is not helpful. Common bacteria found in chronic rhinosinusitis include :
Haemophilus jnfluenzae
Streptococcus pneumonia
Staphylococcus aureus
Moraxella catarrhalis

3. Pseudomonas aeruginosa ( in cystic fibrosis)
Time- dependant killing antibiotic : post-antibiotic effect is minimum.so dosing time maintain
sharply.( β-lactum antibiotic, macrolides, clindamycine.)
Concentration –dependant killing antibiotic: prolonged post-antibiotic effect occurs even when
concentrations of are below MIC(aminoglycoside, quinolones, azalides,vancomycin).
Long-term prophylaxis of antibiotic
The observation that long –term erythromycin therapy(8weeks) reduces the mortality from diffuse
pan-bronchiolities(an intractable chronic respiratory infection of unknown aetiology) & improves
sinus symptoms in those patients with concomitant rhinosinusitis. Clarithromycin & roxithromycin
are also effective.
The improvement with long-term antibiotic appears to be better in those patients with a normal IgE
levels & is inversely proportional to the eosinophils count in bloods, smears& mucosa.
Long-term low dose antibiotic treatment(upto 12weeks) is associated with the development of
resistance & this therapy should be considered when others form of medical treatment failed.
Mechanism of Macrolide activity:
Anti-agent : decrease adhesion & virulence of the organisms.
On host: improvement of ciliary beat frequency, increase steroid receptors ,anti-inflammatory
effects( inhibits cytokine production, monocyte converted to macrophage,inhibit neutrophil
function).
Antifungals
Allergic fungal rhinosinusitis treated by surgical removal of all inspissated secretion plus medical
treatment with corticosteroid (topical & oral) together with oral antifungals.
Recently suggested that all nasal polyposis & chronic rhinosinusitis is of fungal aetiology. Oral
antifungal Itraconazole have been benifited.
Antileukotrienes
Approximately 50% of nasal polyps respond to some degree.Asthmatic symptoms also improved to
agreater degree than those of the nose.
Antihistamines
There is little evidence of the efficacy of antihistamines in chronic rhinosinusitis, presumably
because the majority have little or no effect on nasal blockage.
Aspirin
Aspirin sensitivity is usually associated with nasal polyposis & asthma. In patient with aspirin-sensitivity
asthma & nasal polyposis, following a response to aspirin there is a refactory period which

4. aspirin could again be taken without ill effects. This phenomenon has put to use by regular
administration of aspirin either orally or topically in the nose.(100mg daily have shown efficacy)
Immunotherapy
Immunoglobulin replacement therapy & bacterial vaccines.
Others therapy
Diet : many nasal polyposis patients note an exacerbation after drinking alcohol. Milk is regarded as
a mucus promoter. Certain patients adopt largely dairy –free diets with subjective benefit.
Diuretic :may reduce recurrency of polyps following polypectomy.
Nitric oxide doners : nitric oxide (NO) is manufactured in the paranasal sinus where bactericidal
levels reached. Arginine is the substrate. In CRS & nasal polyposis , Nitric oxide level is low, probably
secondary to ostiomeatal complex obstruction. Nitric oxide doners might be useful in improving
nasal mucociliary clearance.
Improve ostiomeatal complex drainage medically
Decongestants (brief use of topical formulation)
Nasal douching
Topical corticosteroids preferably drop formulation
Review at six weeks ; if no improvement CT scan to exclude sinister underlying disease.
Further medical therapy
Consider
Oral corticosteroids( few days) plus nonabsorbed drops(long term)for nasal polyposis.
Trail of antileukotrienes fors nasal polyposis
Antibiotics for infective rhinosinusitis & possibly nasal polyposis.
Aspirin ( topical or oral for nasal polyposis)
Specific therapy, for wegener’s granulomatosis: cyclophosphamide, azathiaprine and /or
cotrimoxazole.
Gammaglobulin replacement therapy for significant immune deficiency.
If no improvement after 3 to 6 months, consider surgical intervention.