Definition and Epidemiology

Chronic rhinosinusitis (CRS) is a clinical syndrome characterized by persistent inflammation of the nasal and paranasal sinus mucosa with symptoms for longer than 12 weeks’ duration.¹ It is estimated that 16% of the population experiences CRS,^2,3 ranking it second in prevalence among all chronic conditions.³ CRS affects all major racial and ethnic groups,⁴ is more common in men,⁵ has a significant effect on quality of life,^6,7 and accounts for 11.5 million missed workdays with an estimated cost approaching $2449.00 per patient per year.⁸

CRS is classified into two main subtypes: CRS without nasal polyps (CRSsNPs) and CRS with nasal polyps (CRSwNPs).¹ This differentiation can be made only in a specialist’s office; for purposes of primary care, both are considered under the same category of CRS.⁹

Pathophysiology

Nasal congestion is primarily the result of vascular changes and chronic inflammation in the nasal mucosa induced by a combination of immunologic, infectious, and environmental factors.⁹ Predisposing and associated factors include dysfunctional cilia as seen in smokers and those with cystic fibrosis, allergy, asthma, aspirin sensitivity, genetic factors, and pregnancy.^1,9–11

Clinical Presentation

The clinical presentation of CRS includes nasal blockage, nasal discharge (anterior or posterior nasal drip), facial pain or pressure, and reduction in or loss of smell for 12 weeks or longer¹ and is distinguished from symptoms of acute onset and allergic rhinitis. See Table 88-1 for distinction in symptoms.

A detailed history is critical to the diagnosis. It is important to ask the patient about the onset and timing of symptoms, location of congestion on one side or both, and associated symptoms such as rhinorrhea, sneezing, eye symptoms, itchiness, change in smell, fever, purulent discharge, facial pressure, and snoring. Ask about triggers such as pollutants, allergens, and occupational chemicals. Ask the patient if there is a history of allergies, asthma, aspirin sensitivity, acute sinusitis, nasal trauma, nasal surgery, nasal polyps, or a family history of seasonal or environmental allergies. A detailed medication history and a history of smoking, exposure to passive smoke, and recreational drug use should also be elicited.⁹

Physical Examination

The patient is observed for any asymmetry or deformity of the nasal structure. The patient should be asked to press on each nostril individually and breathe in to test for obstruction. Inspect each nostril with an otoscope with a wide speculum. Apply gentle pressure to the tip of the nose with the examiner’s thumb to widen the nostrils, and then insert the lighted otoscope. The nasal mucous membranes are inspected for erythema, pallor, atrophy, edema, crusting, and discharge. The mucosa of the turbinates is often more erythematous in patients with chronic nasal congestion compared with the pale bluish hue or pallor seen in patients with allergic rhinitis. Any abnormalities, such as polyps, erosions, and septal deviations or perforations, should also be noted. Finally, the frontal and maxillary sinuses are palpated.¹¹

Diagnostics

Selection of laboratory studies depends on the differential diagnoses and any suspected disease process. Skin and in vitro tests for allergen-specific immunoglobulin E may be helpful in determining whether the symptoms are related to allergic or nonallergic disease. Plain x-ray studies and computed tomography (CT) are not recommended in primary care. The diagnosis of CRS is a diagnosis of exclusion in primary care, based on criteria and symptoms alone.^1,9