Sinonasal inflammation ≥12 weeks, subclassified by polyp status; managed with topical therapy and surgery.
Also known as: chronic sinusitis, CRS, chronic rhinosinusitis with polyps, CRSwNP, CRSsNP
Overview
Symptomatic inflammation of the nose and paranasal sinuses for ≥12 consecutive weeks, with objective evidence of inflammation on nasal endoscopy or CT imaging. Subclassified as CRS with nasal polyps (CRSwNP) or without (CRSsNP).
Epidemiology
Affects 5-12% of US adults. CRSwNP accounts for ~20-30% of cases and is associated with asthma (especially aspirin-exacerbated respiratory disease — Samter triad). Female-to-male ratio for CRSsNP slightly female-predominant; CRSwNP male-predominant.
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Question 1EENTMedium
A 42-year-old man presents with two years of progressive nasal congestion, decreased sense of smell, and persistent postnasal drip. He has a history of asthma and aspirin sensitivity. On anterior rhinoscopy, the provider visualizes pale, gray, glistening, grape-like translucent masses bilaterally in the middle meatus. The nasal mucosa is otherwise non-erythematous, and there is no purulent discharge. He has no fever or facial tenderness. Which of the following is the most likely diagnosis?
AInverted papilloma
BEsthesioneuroblastoma
CTurbinate hypertrophy
DConcha bullosa
ENasal polyps
Reveal answer & full explanation
Correct answer: E — Nasal polyps
AInverted papilloma
BEsthesioneuroblastoma
CTurbinate hypertrophy
DConcha bullosa
ENasal polyps✓
Why Nasal polyps is correct
The characteristic appearance — pale, gray, glistening, grape-like translucent masses bilaterally in the middle meatus — combined with chronic nasal obstruction and hyposmia is diagnostic of nasal polyps.
Polyps are benign edematous outpouchings of inflamed nasal/sinus mucosa and are strongly associated with chronic rhinosinusitis, asthma, and aspirin-exacerbated respiratory disease (Samter triad: asthma, aspirin sensitivity, nasal polyps) — all present in this patient.
Diagnosis is primarily clinical via anterior rhinoscopy or nasal endoscopy; CT is used to assess sinus involvement before surgery.
Why the others are wrong
Concha bullosa — is a pneumatized middle turbinate seen on imaging, not a visible translucent mass on rhinoscopy (confused-with bony variant).
Turbinate hypertrophy — enlarged (usually inferior) turbinates in allergic or vasomotor rhinitis can look pale and boggy, but they are sensate to probing and shrink with topical decongestant, whereas polyps are insensate, do not shrink, and appear as translucent grape-like masses in the middle meatus (confused-with allergic rhinitis).
Inverted papilloma — is typically unilateral, fleshy, and vascular with malignant potential, warranting biopsy and excision (confused-with neoplasm).
Esthesioneuroblastoma — a nasal mass with a diminished sense of smell suggests this tumor of the olfactory epithelium, but it is typically a unilateral, friable, vascular mass high in the nasal vault near the cribriform plate that often causes epistaxis, not bilateral pale, translucent, grape-like masses in the middle meatus in a patient with asthma and aspirin sensitivity (confused-with olfactory tumor)
Additional high-yield points
Unilateral polyps in adults warrant imaging and biopsy to exclude neoplasm.
Question 2EENTMedium
A 38-year-old woman with chronic rhinosinusitis presents with worsening nasal obstruction, anosmia, and postnasal drip over the past several months. Anterior rhinoscopy demonstrates bilateral pale, edematous polyps filling the middle meatus. She has had no prior treatment beyond saline irrigation. She has no signs of acute infection, no orbital symptoms, and no aspirin sensitivity. She is not pregnant. Which of the following is the most appropriate initial treatment?
ASubcutaneous dupilumab
BIntranasal corticosteroid spray
CEndoscopic sinus surgery
DOral antihistamine
EIntranasal oxymetazoline spray
Reveal answer & full explanation
Correct answer: B — Intranasal corticosteroid spray
ASubcutaneous dupilumab
BIntranasal corticosteroid spray✓
CEndoscopic sinus surgery
DOral antihistamine
EIntranasal oxymetazoline spray
Why Intranasal corticosteroid spray is correct
Nasal polyps are benign inflammatory outpouchings of nasal/sinus mucosa associated with chronic rhinosinusitis
First-line management for symptomatic nasal polyps is intranasal corticosteroids (e.g., mometasone or fluticasone), which reduce polyp size, improve nasal airflow, restore olfaction, and decrease recurrence after surgery
A short course of oral corticosteroids may be added for severe symptoms
Why the others are wrong
Endoscopic sinus surgery — reserved for patients with persistent symptoms or massive polyposis despite medical therapy; not appropriate as initial treatment
Intranasal oxymetazoline spray — a topical alpha-adrenergic decongestant that gives only transient relief of obstruction, does not shrink polyps or treat the underlying inflammation, and causes rebound congestion (rhinitis medicamentosa) when used for more than about 3 days
Oral antihistamine — nasal polyps are not primarily IgE-mediated, so oral antihistamines have limited benefit; they may be used adjunctively if concurrent allergic rhinitis is present but do not shrink polyps
Subcutaneous dupilumab — this anti-IL-4 receptor alpha biologic is FDA-approved for chronic rhinosinusitis with nasal polyps and does shrink polyps, but it is add-on maintenance therapy for disease inadequately controlled despite intranasal corticosteroids, usually after systemic corticosteroids or surgery, not initial treatment for a patient who has had only saline irrigation
Additional high-yield points
Patients with nasal polyps should be evaluated for underlying conditions such as cystic fibrosis (in children) and aspirin-exacerbated respiratory disease
Oral antibiotics are used for acute bacterial exacerbations with purulent discharge, not as routine therapy for uncomplicated chronic polyposis
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Persistent mucosal inflammation impairs mucociliary clearance and sinus drainage. CRSsNP shows neutrophilic Th1/Th17 infiltrate. CRSwNP demonstrates eosinophilic Th2-driven inflammation with elevated IL-4/IL-5/IL-13 — the target of newer biologics. Bacterial biofilms and fungal colonization may perpetuate disease.
Clinical presentation
Symptoms
≥2 of the following for ≥12 weeks: mucopurulent drainage, nasal obstruction, facial pain/pressure/fullness, decreased smell (anosmia/hyposmia is hallmark of CRSwNP)
Postnasal drip with chronic throat clearing or cough
Headache, ear fullness, dental discomfort
Fatigue, halitosis, reduced quality of life
Signs / physical exam
Nasal endoscopy: mucopurulent discharge from middle meatus, edema/erythema, or polyps (pale gray grape-like)
Polyps visible on anterior rhinoscopy in CRSwNP
Hyposmia on bedside smell testing
Cobblestoned posterior pharynx from postnasal drip
Possible facial tenderness on palpation
Classic findings
CRSwNP: anosmia + bilateral pale polyps + asthma history (consider Samter if ASA-sensitive). CRSsNP: facial pressure + mucopurulent discharge without polyps.
Differential diagnosis
Recurrent acute rhinosinusitis — ≥4 discrete episodes/year with full resolution between, total <12 weeks symptomatic; treat each episode and evaluate predisposing factors
Sinonasal malignancy — Unilateral persistent symptoms, epistaxis, facial numbness, mass on endoscopy; imaging and biopsy
Cystic fibrosis — Childhood-onset CRS, nasal polyps in pediatric patient → sweat chloride test
Primary ciliary dyskinesia — CRS + bronchiectasis + situs inversus (Kartagener); nasal nitric oxide low, biopsy of cilia
Diagnostic workup
Diagnostic criteria
AAO-HNSF 2025: symptoms ≥12 consecutive weeks consistent with CRS (≥2 of mucopurulent discharge, obstruction, facial pain/pressure, decreased smell) PLUS documented inflammation on anterior rhinoscopy or endoscopy (purulent mucus or polyps in middle meatus, mucosal edema) OR CT (paranasal sinus mucosal thickening or opacification).
Labs
Allergy testing (skin prick or specific IgE) if concurrent allergic rhinitis suspected
Sweat chloride and/or CF genetic testing in pediatric CRSwNP or chronic refractory CRS
Immunoglobulin levels (IgG/IgA/IgM) and vaccine response titers in recurrent infections
Total IgE, peripheral eosinophil count — biomarkers for biologic candidacy in CRSwNP
Short course of oral corticosteroids (prednisone 0.5-1 mg/kg × 5-10 days) for severe symptoms or polyp shrinkage
Targeted antibiotics — amoxicillin-clavulanate or doxycycline × 3 weeks — only during acute bacterial exacerbations
Second-line / adjunct
Functional endoscopic sinus surgery (FESS) — for failure of medical therapy, recurrent acute exacerbations, polyps, or complications
Aspirin desensitization for Samter triad — improves polyp control and reduces revision surgery
Biologics (add-on to intranasal steroid) for uncontrolled CRSwNP after failed medical and surgical therapy or when surgery is not an option (AAO-HNSF 2025) — dupilumab (anti-IL-4Rα), omalizumab (anti-IgE), mepolizumab (anti-IL-5), tezepelumab (anti-TSLP)
Long-term low-dose macrolide (azithromycin) — immunomodulatory; limited evidence in CRSsNP
Allergy immunotherapy if allergic component is dominant
Complications
Persistent QoL impairment, work/school disability
Acute bacterial exacerbations
Orbital and intracranial extension (mucocele, abscess) — less common than in acute disease but possible
Mucocele formation (especially frontal sinus)
Anosmia, dysosmia
Worsening asthma control
Sinonasal squamous cell carcinoma or inverted papilloma should be considered with unilateral persistent disease
AAO-HNSF 2025 — Payne SC et al. Clinical Practice Guideline: Adult Sinusitis Update. Otolaryngol Head Neck Surg 2025;173(Suppl 1):S1-S56
ICAR-RS 2021 — Orlandi RR et al. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis 2021. Int Forum Allergy Rhinol 2021;11(3):213-739
EPOS 2020 — Fokkens WJ et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2020. Rhinology 2020;58(S29):1-464
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