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What is chronic rhinosinusitis?
Swelling and inflammation of the lining of the sinuses and nose is called rhinosinusitis. Rhinosinusitis affects 5-10 percent of adults and is common in people who also have asthma or other allergic diseases. If symptoms go on for over 12 weeks, it is called chronic rhinosinusitis (CRS).
This condition has a big effect on how people interact with others and their overall quality of life. CRS is an expensive disease for both the person who has it and the community. It leads to missed work and high total health care costs because it mostly affects people of working age.
Types of rhinosinusitis
What kind of rhinosinusitis you have depends on how long you have symptoms:
- Acute rhinosinusitis follows a viral respiratory infection, lasts for about 4 weeks, and then goes away.
- Subacute rhinosinusitis lasts between 4 and 12 weeks before it goes away.
- A person with recurrent acute rhinosinusitis will have many episodes a year, with no symptoms at all in between.
- It is called chronic rhinosinusitis (CRS) if the symptoms last for 12 weeks or more.
Risk Factors for the Development of CRS:
To keep your sinuses healthy, you need an immune system, a clearing system that works well, and open drainage pathways. Problems can be caused by many things, such as smoking, genetics, and severe acid reflux (when acid from your stomach goes up into your throat and sometimes your sinuses). The risk of CRS can also be changed by things in the environment that can affect the types of bacteria, viruses, and fungi that normally live in the nose and sinuses. It is very important that people who have both asthma and CRS take care of their asthma as well.
People more likely to get CRS are middle-aged and older adults, women, people who smoke (currently or in the past), people who are very overweight, or those who drink a lot of alcohol.
The diagnosis of CRS
To diagnose chronic recurrent syndrome (CRS), doctors need to see if they have specific symptoms that have lasted for 12 weeks or more, and then sometimes also perform specific tests.
Symptoms of CRS
To be diagnosed with CRS, you must have at least two of the following symptoms for at least 12 weeks:
- blocked nose
- runny nose
- post-nasal drip (where fluid drips from the sinuses and down the back of the nose into the throat causing people to clear their throat or cough)
- not being able to smell or only being able to smell very strong smells
- pressure and pain in the face
Symptoms can also be broken down into four groups depending on where they are located:
- Nose – problems include nasal blocking with discharge and a reduced sense of smell
- Face – such as pain, pressure, or a headache
- Oropharyngeal (mouth and throat) symptoms – such as ear pain, bad breath, post-nasal drip, a persistent cough, and toothaches
- Systemic (whole-body) signs – such as feeling sick and tired, because of the chronic inflammation process.
Blockage or obstruction of the nose is the most common symptom of CRS. Postnasal drip is the next most common.
Warning Signs
People with facial pain or headaches (especially headaches on one side) and no other signs of sinusitis should see a doctor right away. These symptoms are called “red flags,” or symptoms they should talk to their doctor about right away because they don’t usually have CRS, but something else that needs to be investigated right away.
Other “Red Flags” include:
- Symptoms that get worse, on one side
- Blood coming out of the nose
- Eye symptoms
- Feeling numb or tingly in the face
- When the two sides of the face don’t look the same, called facial asymmetry
Tests for diagnosis
As well as symptoms, either an endoscopy (camera check) or a CT (or CAT) scan may provide some more information.
- During endoscopic (camera) procedures that look deeper inside the nose, abnormal tissue growths called nasal polyps may be seen.
- CT scans may show swollen sinuses, mucous membranes, polyps, and blocked drainage of the sinuses.
Managing CRS
Medications, nasal irrigation (rinsing with a saltwater solution that can be bought at a pharmacy), and, in the worst cases, surgery, are all used to treat CRS. New biologic therapies, such as monoclonal antibody (disease-fighter) therapy, offer options for patients who have not responded to other treatments.
The following medicines may be tried by your doctor:
- Nasal rinses with a salt-water solution that reaches the sinuses.
- Intranasal corticosteroid sprays (INCS), which are sprayed into the nose are used every day to help decrease swelling or inflammation. To work as they should they need to be sprayed into the nose in the right way. The INCS sprays only reach the nose and not the sinuses, unlike the nasal rinses.
- Oral corticosteroid drugs may help for a short time, but they can be problematic if used often and/or for a long time.
- Antibiotics to treat infection.
- Leukotriene antagonists can stop some of the proteins that cause inflammation.
- Aspirin desensitisation therapy can be an option for people who are allergic to anti-inflammatory drugs such as Nurofen, Brufen, Indocid and aspirin.
Surgery
If a person has tried several of the medicines their treating specialist has prescribed and they haven’t helped, they may refer the person to an ENT (Ear, Nose and Throat) surgeon for possible nose and sinus surgery. Nasal polyps can block the nose and sinuses and are often removed to improve nose and sinus drainage.
These are the goals of surgery:
- Improving breathing through the nose and drainage of the nose and sinuses so that medications and nasal rinses can work better.
- Removing polyps (abnormal growths), fungal or mucus build-up
- Keeping the lining of the nose and sinuses in a good condition
Nasal rinses are a permanent treatment for people who have sinus surgery.
Treatment options for chronic rhinosinusitis and nasal polyps
Modern medical treatments for CRS with/without nasal polyps have improved people’s health and their family, work, and social lives, but they only work if the people take the medications prescribed by their doctor in the way they are meant to be taken and do nasal rinses as advised. The most common way to treat CRS is with medicine, but surgery is also an option for some.
Treatment with monoclonal antibodies
Some people who have ongoing symptoms even though they follow specialist advice and have had surgery for nasal polyps can be reviewed by their specialist for possible treatment with monoclonal antibodies. An immune protein called a monoclonal antibody is made in a laboratory and is targeted to block the inflammatory molecules causing CRS.
Not everyone can be prescribed monoclonal antibody treatment by a specialist, but it does help some people whose conditions don’t get better even after the best medical and surgical care.
- There are strict guidelines that must be followed for prescribing monoclonal antibody treatment. It is a high-cost treatment and is best used in those who fulfil certain criteria.
- People are usually referred to a clinical immunology/allergy specialist, an ENT surgeon, or a respiratory specialist.
- The specialist will ask the patient about their CRS, and how it affects their life, and may do some tests before deciding which medical treatment is best for them.
Summary:
- CRS is a medical condition that needs to be treated by a doctor. For some people, surgery may also be a helpful option that improves symptoms.
- For people with CRS, management may include trying different medicines, treatments and/or surgery.
- There is no cure for CRS yet, but the treatments available can make life a lot better.
- When trying to manage CRS, it’s important to follow your doctor’s instructions.
- If the CRS is still not well managed after medical and surgical treatment, and is affecting your family, work and social life, monoclonal antibody treatment may be an option.