EENT · PANCE / PANRE

Chronic Rhinosinusitis (CRS)

Written & clinically reviewed by Ryan Busch, PA-C · Updated August 2026 · Report an error

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?
  • AConcha bullosa
  • BNasal foreign body
  • CInverted papilloma
  • DNasal polyps
Reveal answer & full explanation
Correct answer: D — Nasal polyps
  • AConcha bullosa
  • BNasal foreign body
  • CInverted papilloma
  • DNasal 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).
  • Nasal foreign body — presents acutely, usually in young children, with unilateral foul-smelling discharge, not bilateral painless polypoid masses (anchoring).
  • Inverted papilloma — is typically unilateral, fleshy, and vascular with malignant potential, warranting biopsy and excision (confused-with neoplasm).

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?
  • AIntranasal corticosteroid spray
  • BEndoscopic sinus surgery
  • COral antibiotics
  • DOral antihistamine
Reveal answer & full explanation
Correct answer: A — Intranasal corticosteroid spray
  • AIntranasal corticosteroid spray✓
  • BEndoscopic sinus surgery
  • COral antibiotics
  • DOral antihistamine

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
  • 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
  • Oral antibiotics — indicated for acute bacterial superinfection with purulent discharge and fever, not for uncomplicated chronic polyposis

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
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Risk factors

  • Allergic rhinitis, asthma
  • Aspirin/NSAID sensitivity (Samter triad: nasal polyps + asthma + aspirin sensitivity)
  • Cystic fibrosis, primary ciliary dyskinesia
  • Immunodeficiency (CVID, IgA deficiency, HIV)
  • Gastroesophageal reflux
  • Smoking, air pollutants
  • Anatomic obstruction (deviated septum, concha bullosa, polyps)
  • Dental disease (odontogenic CRS)

Pathophysiology

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
  • Allergic rhinitis — No CT mucosal disease; itching, sneezing, atopic history; intranasal steroid
  • Nonallergic rhinitis — Trigger-related symptoms without IgE sensitization or sinus inflammation
  • Allergic fungal rhinosinusitis — CRSwNP with thick allergic mucin containing fungal hyphae, hyperdense CT material, often unilateral expansion; surgery + topical steroids ± systemic
  • Granulomatosis with polyangiitis (GPA) — Saddle-nose deformity, ulcers, crusts, lung involvement; positive c-ANCA/PR3
  • Sarcoidosis — Strawberry-like nasal mucosa, multisystem involvement, elevated ACE, noncaseating granulomas
  • 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-HNS 2015: symptoms ≥12 consecutive weeks consistent with CRS (≥2 of mucopurulent discharge, obstruction, facial pain/pressure, decreased smell) PLUS documented inflammation on 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
  • ANCA, ACE if vasculitis or sarcoidosis suspected

Imaging

  • CT sinus without contrast — defines mucosal disease extent, anatomic variants, surgical planning. Lund-Mackay score quantifies severity
  • MRI if intracranial extension or sinonasal mass suspected
  • Nasal endoscopy (clinic) — direct visualization confirms inflammation; biopsy for masses or unilateral disease

Diagnostic algorithm

FeatureCRSsNPCRSwNP
Polyps on endoscopyAbsentPresent (bilateral typical)
AnosmiaLess commonHallmark feature
Asthma associationSometimesStrong (esp. AERD/Samter)
Inflammation typeNeutrophilic (Th1/Th17)Eosinophilic (Th2)
Response to topical steroidModerateOften robust
BiologicsNot indicatedDupilumab, omalizumab, mepolizumab for refractory
Surgery roleAdjunct when medical failsCommon; high recurrence without ongoing topical therapy
Phenotypic differences between CRS without and with nasal polyps.

Treatment

First-line

  • Saline nasal irrigation — high-volume, low-pressure with neti pot or squeeze bottle daily
  • Intranasal corticosteroid — fluticasone, mometasone, budesonide — daily long-term; consider budesonide nasal rinse for refractory CRSwNP
  • Treat comorbidities: allergic rhinitis (oral or intranasal antihistamine), asthma (controller), GERD
  • 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 for severe CRSwNP refractory to surgery and topical therapy — dupilumab (anti-IL-4Rα), omalizumab (anti-IgE), mepolizumab (anti-IL-5)
  • 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

PANCE pearls

  • Unilateral chronic sinusitis is a red flag — image and biopsy to exclude tumor, fungal disease, or odontogenic source.
  • CRSwNP with asthma + aspirin sensitivity = Samter triad (aspirin-exacerbated respiratory disease, AERD).
  • Anosmia points strongly toward polyposis — examine the nose carefully.
  • Avoid prolonged systemic antibiotics — topical therapy and surgery are more durable.
  • Pediatric polyposis demands CF workup — sweat chloride test.

References

  • AAO-HNS 2015 — Rosenfeld RM et al. Clinical Practice Guideline (Update): Adult Sinusitis. Otolaryngol Head Neck Surg 2015;152(2S):S1-S39
  • 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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Related EENT diagnoses

Acute Otitis Media (AOM)Otitis Externa (Swimmer's Ear)Sensorineural and Conductive Hearing LossCerumen ImpactionAllergic RhinitisAcute Bacterial Rhinosinusitis (ABRS)EpistaxisGroup A Streptococcal PharyngitisPeritonsillar Abscess (Quinsy)Bacterial ConjunctivitisViral ConjunctivitisAllergic ConjunctivitisHordeolum (Stye) and ChalazionBlepharitis

Differentials & related conditions

SarcoidosisCystic Fibrosis

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