What Is Chronic Rhinosinusitis?
Chronic rhinosinusitis (CRS) is an inflammatory disease of the nasal mucosa and paranasal sinuses lasting at least 12 continuous weeks. It is one of the most prevalent chronic diseases, affecting approximately 5-12% of the general population and generating a significant impact on quality of life.
CRS is classified into two main endotypes: CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP). This classification is clinically relevant because the inflammatory mechanisms, treatment, and prognosis differ substantially between the two groups.
CRS is not simply a prolonged infection. It is a complex chronic inflammatory disease that involves epithelial barrier dysfunction, dysbiosis of the nasal microbiome, and immune dysregulation. Bacterial persistence is a consequence, not the primary cause, of chronic inflammation.
Inflammatory Disease
CRS is fundamentally an inflammatory, not infectious, disease. Prolonged antibiotics are not the appropriate treatment in most cases.
Two Phenotypes
CRS without polyps (neutrophilic, Th1 inflammation) and CRS with polyps (eosinophilic, Th2 inflammation) require distinct therapeutic approaches.
High Prevalence
Affects 5-12% of the population. It is responsible for more antibiotic prescriptions than any other disease, often unnecessarily.
Pathophysiology
The current model of CRS recognizes epithelial barrier dysfunction as a central event. The normal nasal epithelium functions as a physical and immunologic barrier. In CRS, this barrier is compromised, allowing penetration of allergens, bacteria, and toxins that perpetuate inflammation.
In CRS without polyps, neutrophilic inflammation with a Th1/Th17 profile predominates. In CRS with polyps, eosinophilic inflammation with a Th2 profile, elevated local IgE, and IL-5 levels predominates. This Th2 profile is shared with asthma, explaining the frequent association between the two conditions.
Symptoms
The cardinal symptoms of CRS are nasal obstruction, anterior or posterior rhinorrhea, facial pain or pressure, and hyposmia or anosmia. The diagnosis requires at least two of these symptoms for more than 12 weeks.
Symptoms of Chronic Rhinosinusitis
- 01
Bilateral nasal obstruction
Persistent nasal congestion, frequently described as a sensation of pressure or fullness. Worse in CRSwNP.
- 02
Mucopurulent rhinorrhea
Thick, yellow, or greenish nasal discharge, different from the watery rhinorrhea of allergic rhinitis.
- 03
Postnasal drip
Sensation of secretion running down the throat, causing throat clearing, cough, and chronic pharyngeal discomfort.
- 04
Facial pain or pressure
Sensation of weight or pressure over the maxillary, frontal sinuses, or between the eyes. May worsen with bending the head.
- 05
Hyposmia or anosmia
Reduction or loss of smell — particularly prominent in CRSwNP, where eosinophilic inflammation affects the olfactory neuroepithelium.
- 06
Fatigue and malaise
Chronic tiredness, reduced concentration, and general sense of malaise. The impact on quality of life is comparable to heart failure.
Diagnosis
The diagnosis of CRS requires cardinal symptoms for more than 12 weeks associated with objective evidence of sinus inflammation by nasal endoscopy or computed tomography. Nasal endoscopy visualizes purulent secretion, mucosal edema, and nasal polyps.
Computed tomography of the paranasal sinuses is the standard imaging study. It demonstrates sinus opacification, mucosal thickening, and obstruction of the ostiomeatal complexes. Plain radiographs do not have sufficient sensitivity and are not recommended.
🏥Diagnostic Criteria for CRS (EPOS 2020)
- 1.Two or more cardinal symptoms present for more than 12 continuous weeks
- 2.One of the symptoms must be nasal obstruction or rhinorrhea (anterior or postnasal)
- 3.Objective evidence on nasal endoscopy: polyps, mucopurulent secretion, or mucosal edema
- 4.And/or evidence on CT: mucosal changes in the paranasal sinuses or ostiomeatal complex
DIAGNÓSTICO DIFERENCIAL
Diagnóstico Diferencial
Allergic Rhinitis
Watery rhinorrhea, sneezing, pruritus, no facial pain; positive allergen tests; normal sinus CT or with mild thickening
Nasal Polyps
Frequently associated with CRSwNP; progressive anosmia, gray-pale masses on nasal endoscopy
Granulomatosis with Polyangiitis (Wegener)
Nasal ulcerations, hemorrhagic crusts, septal perforation, systemic manifestations (lung, kidney); positive ANCA
Immunodeficiency
Recurrent infections since childhood, hypogammaglobulinemia; immunoglobulin measurement is necessary in refractory CRS
Cystic Fibrosis
CRS since childhood, bronchiectasis, pancreatic insufficiency; sweat test and CFTR genotyping
Granulomatosis with Polyangiitis (Wegener)
Granulomatosis with polyangiitis (GPA), formerly called Wegener's granulomatosis, is a small-vessel vasculitis that can affect the upper respiratory tract, lungs, and kidneys. The nasosinus manifestation may precede other manifestations by months or years, being clinically indistinguishable from common CRS in the early stages. Signs that increase suspicion include: hemorrhagic nasal crusts, mucosal ulcerations, recurrent epistaxis, and nasal septum perforation.
The "saddle nose" deformity (collapse of the nasal dorsum due to septal destruction) is a characteristic late manifestation. Measurement of ANCA (anti-neutrophil cytoplasmic antibodies) — especially c-ANCA/PR3 — is highly specific. Biopsy of the nasal mucosa may show granulomatous inflammation. The treatment is immunosuppressive and early diagnosis is essential to prevent irreversible organ damage.
Immunodeficiency and Refractory CRS
Primary immunodeficiencies should be investigated in patients with CRS refractory to optimized treatment, especially when there is a history of recurrent infections at other sites (otitis media, pneumonia) since childhood. Common variable immunodeficiency (CVID), Bruton agammaglobulinemia, and selective IgA deficiency are the most frequent in adults.
Screening includes measurement of serum immunoglobulins (IgG, IgA, IgM) and IgG subclasses, as well as evaluation of vaccine response. Hypogammaglobulinemia may manifest only with recurrent CRS in adult life. Treatment with intravenous immunoglobulin may be necessary in confirmed cases, always guided by an immunologist.
Cystic Fibrosis — Possible Diagnosis in Adults
Cystic fibrosis classically manifests in childhood with bronchiectasis, exocrine pancreatic insufficiency, and severe CRS. However, milder forms (attenuated genotype) may present in adult life with severe chronic CRS, mild bronchiectasis, and male infertility (congenital absence of the vas deferens) as predominant manifestations.
Suspicion should be raised in young adults with very severe, bilateral CRS that recurs after endoscopic surgery, especially with associated bronchiectasis. The sweat test (chloride above 60 mEq/L) and genotyping of CFTR gene mutations confirm the diagnosis. Treatment is multidisciplinary with a specialist physician, including CFTR modulators in selected forms.
Treatment
Treatment of CRS is stepwise, starting with maximum medical therapy before considering surgery. Topical nasal corticosteroid is the basis of treatment in both phenotypes. Saline nasal irrigation is an essential adjuvant.
Initial Medical Therapy
Topical nasal corticosteroid at high dose for at least 8-12 weeks. Saline irrigation with hypertonic saline (improves mucociliary clearance). Short-term antibiotic only for acute bacterial exacerbation.
Maximum Medical Therapy
Short oral corticosteroid (prednisone 7-14 days, especially in CRSwNP to reduce polyps). Low-dose macrolides for 12 weeks in CRSsNP (anti-inflammatory, not antibiotic, effect). Antileukotrienes as adjuvants.
Functional Endoscopic Sinus Surgery (FESS)
Indicated when there is failure of maximum medical therapy. Widens the natural sinus ostia, removes polyps, and restores sinus drainage and ventilation. Clinical improvement rate of 85-90%.
Biologics and Complementary Therapies
Dupilumab (anti-IL4/IL13) for refractory CRSwNP — approved and with proven efficacy in reducing polyps and improving smell. Acupuncture as an adjuvant for residual symptoms.
Acupuncture as Treatment
Acupuncture may be a useful complementary therapy in CRS, especially for the control of residual symptoms. Proposed mechanisms — still under investigation — include possible modulation of local inflammation, potential influence on mucociliary function, on the vascular tone of the nasal mucosa, and on facial pain.
Some studies suggest that acupuncture may help relieve nasal obstruction, facial pain, and quality of life in selected patients with CRS. Acupuncture does not replace pharmacologic or surgical treatment, but may be integrated as part of a multimodal approach coordinated by the physician.
A typical protocol involves 10-12 sessions over 6-8 weeks. Acupuncture is especially considered for patients who wish to reduce medication use or who have persistent symptoms after endoscopic surgery.
Prognosis
CRS is a chronic disease that requires continuous treatment in most patients. CRS without polyps has a better long-term prognosis, with control rates of 70-80% with adequate medical treatment. CRS with polyps tends to have a more recurrent course.
Functional endoscopic surgery offers significant improvement in 85-90% of patients, but is not curative — it requires postoperative maintenance with nasal corticosteroid and saline irrigation. The polyp recurrence rate after surgery is 40-60% at 5 years without maintenance treatment.
Biologics (dupilumab) represent a significant advance for refractory CRSwNP, with sustained reduction in polyp size, improvement in smell, and reduction in the need for revision surgery.
Myths and Facts
Myth vs. Fact
Chronic sinusitis is an infection that needs antibiotics
CRS is primarily an inflammatory, not infectious, disease. The base treatment is nasal corticosteroid, not antibiotics. Antibiotics are only indicated in acute bacterial exacerbations.
Surgery definitively cures chronic sinusitis
FESS widens the drainage pathways and removes polyps, but does not eliminate the underlying inflammation. Postoperative maintenance treatment with nasal corticosteroid and saline irrigation is necessary.
Plain sinus radiography diagnoses chronic sinusitis
Plain radiography has low sensitivity and specificity. Computed tomography is the appropriate imaging study. Nasal endoscopy provides essential complementary information.
Chronic sinusitis is caused by septal deviation
Septal deviation may contribute to obstruction of the ostiomeatal complex, but most people with septal deviation do not develop CRS. CRS involves immune dysfunction of the mucosa.
Greenish discharge always indicates bacterial infection
The color of nasal discharge correlates with the presence of neutrophil enzymes (peroxidase), not necessarily with bacterial infection. Colored discharge also occurs in noninfectious inflammation.
When to Seek Help
CRS should be evaluated by an otolaryngologist when symptoms persist for more than 12 weeks or do not respond to empirical treatment with nasal corticosteroid.
Frequently Asked Questions
CRS without polyps frequently achieves remission with adequate treatment — topical nasal corticosteroid, nasal irrigation, and, when indicated, endoscopic surgery. CRS with polyps is more challenging and tends to recur, but biologics such as dupilumab have revolutionized the treatment of severe cases. The goal is control, with long periods of remission.
It can be considered as a complement to conventional treatment. Medical acupuncture has been studied as an adjuvant approach for nasal obstruction, postnasal drip, and facial pain, with proposed mechanisms — still under investigation — involving possible local autonomic modulation and anti-inflammatory effects. It can be useful for patients with residual symptoms after conventional treatment, always as part of a plan coordinated by the physician.
Endoscopic nasosinus surgery (ESS) is indicated when there is failure of optimized medical treatment (nasal corticosteroid for at least 3 months, oral corticosteroid courses in polyposis), significant anatomic obstruction of the ostiomeatal complexes, or complications (mucocele, orbit, CNS). Surgery improves sinus drainage and ventilation, potentiating the efficacy of topical medications.
Generally no, at least not as long-term treatment. CRS is primarily an inflammatory disease. Antibiotics are indicated in acute infectious exacerbations. In selected cases with recurrent exacerbations, the physician may prescribe low-dose macrolides (anti-inflammatory effect). Indiscriminate use of antibiotics increases bacterial resistance.
Yes, it is the adjuvant intervention with the most evidence for CRS. Irrigation with isotonic or hypertonic saline solution (saline at 0.9% or 2-3%) removes bacteria, allergens, crusts, and secretions, reduces mucosal edema, and improves sinus drainage. Recommended 1-2 times per day with devices such as Neti pot or pressure bottles.
Acute sinusitis (ARS) lasts less than 4 weeks, generally after a cold, and is frequently viral (does not require antibiotic). CRS lasts more than 12 continuous weeks and is a chronic inflammatory disease that is mechanistically different. One of the most common errors is treating CRS with repeated antibiotic cycles — adequate treatment includes topical nasal corticosteroid as the base.
Small polyps may reduce with regular topical nasal corticosteroid and oral corticosteroid courses. Biologics such as dupilumab (anti-IL-4/IL-13) and mepolizumab have demonstrated significant polyp reduction in randomized studies, being an alternative to surgery in selected cases of severe CRSwNP. Large polyps generally require endoscopic surgery for adequate control.
In many cases yes, especially when the loss is due to mechanical obstruction by polyps or mucosal edema that subsides with treatment. Recovery may be gradual and slow (months). In CRSwNP, where there is damage to the olfactory neuroepithelium, recovery is less predictable. Oral corticosteroid may improve smell temporarily. Olfactory training (sniffing kit) may help in rehabilitation.
CRS more frequently causes facial pressure or pain than typical headache. Bilateral frontal headache, worse with bending the head, with purulent rhinorrhea and fever, may be sinus-related. However, "sinus headache" is frequently overdiagnosed — many headaches attributed to sinusitis are actually migraine or tension-type headache. The physician should distinguish between the two conditions.
For CRS, an initial cycle of 8-10 sessions (twice a week) is recommended, with reassessment of response. Acupuncture for nasal symptoms generally shows gradual effect over 4-6 weeks. Biweekly or monthly maintenance sessions help maintain control. The acupuncturist physician will individualize the plan according to severity and clinical response.
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