Chronic Rhinosinusitis Without Nasal Polyps

Chronic rhinosinusitis without nasal polyps is inflammation of the nose and paranasal sinuses lasting 12 weeks or more, with at least two symptoms (nasal obstruction, discharge, facial pain or pressure, reduced smell) and objective evidence of inflammation, but with no polyps on endoscopy. It is a heterogeneous condition and is often not driven by type 2 inflammation.

It is more common than the form with polyps, and affects about 5% to 12% of adults. It is associated with allergic rhinitis, asthma, smoking, anatomical obstruction, dental disease, immune deficiency and gastro oesophageal reflux.

Pathophysiology.

Poor mucociliary clearance, blockage of the ostia, biofilm formation, bacterial colonisation and neutrophilic inflammation maintain mucosal oedema and secretions. Allergic, anatomical and immune factors contribute.

Nasal blockage, thick discharge, postnasal drip, facial pressure or pain, reduced smell, cough, fatigue and halitosis. Symptoms persist with acute flares.

Red flags.

• Unilateral symptoms with bleeding or a mass.
• Orbital swelling, double vision or visual change.
• Severe headache, fever or neck stiffness.
• Frontal swelling.

Symptoms for 12 weeks or more, with endoscopy showing mucopus or mucosal oedema in the middle meatus, or CT showing mucosal thickening or opacification. CT is done to confirm the diagnosis before surgery, since symptoms alone are unreliable. Test for allergy, immune deficiency (immunoglobulins) and cystic fibrosis when recurrent or severe. Examine the teeth.

Differential diagnosis.

• Allergic rhinitis.
• Chronic rhinosinusitis with polyps.
• Odontogenic sinusitis.
• Migraine and other causes of facial pain.
• Fungal ball.
• Sinonasal tumour.

Give saline irrigation and topical corticosteroid for at least 8 to 12 weeks. Long term low dose macrolide helps patients with low IgE. Surgery (endoscopic sinus surgery) is for failure of medical treatment and CT-confirmed disease.

• Mometasone nasal spray 50 micrograms for each spray: 2 sprays into each nostril twice daily; long term; maximum 400 micrograms daily in each nostril; monitor for epistaxis and nasal irritation; use half the dose in children aged 3 to 11 years.
• Saline irrigation: 240 mL isotonic saline into each nostril once or twice daily; long term; monitor for ear fullness; use boiled or sterile water.
• Clarithromycin (low dose macrolide): 250 mg orally once daily for 12 weeks; maximum 500 mg daily; monitor QT interval, liver tests and drug interactions; avoid with QT-prolonging drugs and statins at high dose; halve the dose when creatinine clearance is under 30 mL/min.
• Co-amoxiclav (acute exacerbation with purulence): 625 mg orally three times daily for 7 to 10 days; maximum 1.5 g amoxicillin daily; monitor liver tests, diarrhoea and rash; give 625 mg twice daily when creatinine clearance is 10 to 30 mL/min.

Treat allergic rhinitis, stop smoking and treat dental disease.

Monitoring. Symptoms and endoscopy at 3 months; QT interval and liver tests during macrolide treatment.

Referral and escalation. ENT for failure after 12 weeks of treatment, or any red flag.

Special groups. Children need adenoid assessment and weight based dosing.