Key Facts

Rhinosinusitis is defined as inflammation of the nose and paranasal sinuses characterised by nasal obstruction, discharge, facial pain/pressure, and reduced sense of smell. It is one of the most common conditions seen in primary care.

Epidemiology

• Acute rhinosinusitis: extremely common; adults average 2-5 URTIs per year; 0.5-2% develop bacterial complication
• Chronic rhinosinusitis: prevalence 11% in UK adults
• Nasal polyps: affect 1-4% of the population; more common in males
• Significant socioeconomic burden: lost work days, healthcare costs

Aetiology

• Acute viral (most common): rhinovirus, influenza, parainfluenza, adenovirus
• Acute bacterial: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus
• Chronic: multifactorial — mucosal inflammation, impaired mucociliary clearance, bacterial biofilms, allergy, nasal polyps, anatomical factors (deviated septum, concha bullosa)
• Fungal: allergic fungal rhinosinusitis, fungal ball, invasive fungal sinusitis (immunocompromised)

Pathophysiology

• Viral infection causes mucosal oedema and inflammation at the ostiomeatal complex
• Obstruction of sinus ostia impairs ventilation and mucociliary drainage
• Retained mucus becomes secondarily infected with bacteria
• Chronic inflammation leads to mucosal remodelling, polyp formation, and biofilm development
• Aspirin-exacerbated respiratory disease (AERD/Samter's triad): nasal polyps + asthma + aspirin sensitivity

Acute Rhinosinusitis

• Nasal congestion and obstruction
• Purulent nasal discharge (anterior or posterior drip)
• Facial pain/pressure (worse on bending forward, unilateral or bilateral)
• Reduced or lost sense of smell (hyposmia/anosmia)
• Headache, malaise, fever
• Maxillary toothache

Chronic Rhinosinusitis

• Persistent nasal obstruction
• Ongoing nasal discharge (mucopurulent)
• Reduced sense of smell (often prominent)
• Facial pressure (less acute than acute sinusitis)
• Post-nasal drip
• Nasal polyps visible on examination (if present)

Red Flags

• Periorbital cellulitis/oedema (orbital complication)
• Frontal swelling (Pott's puffy tumour — frontal osteomyelitis)
• Severe headache, photophobia, neck stiffness (meningitis)
• Visual changes or proptosis (orbital abscess)
• Altered consciousness (intracranial abscess)
• Unilateral nasal mass with epistaxis in adults (malignancy)
• Blood-stained discharge (granulomatosis with polyangiitis, malignancy)

Bedside

• Anterior rhinoscopy: mucosal oedema, purulent discharge, polyps
• Nasal endoscopy (ENT): detailed examination of nasal cavity, middle meatus, and nasopharynx
• Temperature and observations

Bloods

• Not routinely required for acute rhinosinusitis
• FBC, CRP, ESR if complications suspected
• ANCA: if granulomatosis with polyangiitis suspected
• Total IgE, specific IgE: if allergic component

Imaging

• Not recommended for acute uncomplicated rhinosinusitis (NICE, EPOS)
• CT paranasal sinuses (non-contrast): gold standard for chronic rhinosinusitis assessment and pre-operative planning
  • Shows mucosal thickening, air-fluid levels, bony anatomy
  • Lund-Mackay scoring system for severity
• CT with contrast: if complications suspected (orbital, intracranial)
• MRI: if malignancy or intracranial extension suspected

Special Tests

• Nasal swab/culture: not routinely helpful (correlates poorly with sinus pathogens)
• Smell testing: olfactometry for chronic rhinosinusitis
• Allergy testing: if allergic rhinitis component

Non-pharmacological

• Steam inhalation: may provide symptom relief (no evidence of efficacy)
• Saline nasal irrigation: evidence of benefit in acute and chronic rhinosinusitis
• Adequate hydration
• Avoidance of triggers (allergens, irritants)

Pharmacological

• Acute rhinosinusitis:
  • Symptomatic relief: paracetamol/ibuprofen, saline nasal rinse
  • Intranasal decongestant: xylometazoline 0.1% spray BD for maximum 7 days (rebound congestion risk)
  • Antibiotics (NICE NG79 — only if clinically indicated):
    • Phenoxymethylpenicillin 500mg QDS for 5 days (first-line)
    • OR Amoxicillin 500mg TDS for 5 days
    • Alternative: doxycycline 200mg stat then 100mg OD for 5 days
    • Indicate: systemically very unwell, high fever, symptoms >10 days without improvement, immunocompromised, complications
• Chronic rhinosinusitis:
  • Intranasal corticosteroid: mometasone 200mcg (2 sprays) each nostril OD or fluticasone 200mcg each nostril OD — long-term
  • Saline irrigation: daily, large-volume (240ml)
  • Short course oral prednisolone: 25-30mg OD for 5-10 days for acute exacerbation or polyp reduction (before FESS)
  • Dupilumab (anti-IL4/13): for severe CRSwNP refractory to surgery and steroids (NICE TA851)

Surgical

• FESS (functional endoscopic sinus surgery): for chronic rhinosinusitis refractory to maximal medical therapy
  • Enlarges sinus ostia, removes polyps, improves drainage
  • Success rate 80-90% for symptom improvement
• Polypectomy: nasal polyp removal
• Balloon sinuplasty: minimally invasive alternative for selected cases
• Emergency surgery: drainage of orbital/intracranial abscess

Referral Criteria

• ENT referral: chronic rhinosinusitis >12 weeks not responding to medical therapy, recurrent acute sinusitis (≥4 episodes/year), nasal polyps, suspected complications
• Urgent/2-week wait: unilateral symptoms with epistaxis/obstruction in adults (exclude malignancy)
• Emergency: orbital complications, intracranial complications, facial swelling

• Acute viral rhinosinusitis: >90% resolve within 2-3 weeks without antibiotics
• Acute bacterial sinusitis: >70% resolve without antibiotics; antibiotics shorten duration by 1-2 days
• Chronic rhinosinusitis: chronic condition requiring long-term management; FESS provides significant improvement in 80-90%
• Nasal polyp recurrence after surgery: 20-40% at 5 years
• Complications of acute sinusitis (orbital, intracranial): <1% but potentially life-threatening
• Anosmia in chronic rhinosinusitis: may improve with topical steroids and surgery but often incompletely

EPOS 2020 Classification of Rhinosinusitis

Samter's Triad (AERD)

Complications of Acute Sinusitis