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Chronic rhinosinusitis

What's new

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a new guideline for surgical management of chronic rhinosinusitis (CRS). Sinus surgery is recommended when the anticipated benefits outweigh nonoperative options, expected outcomes are clearly defined, and patients understand the need for long-term disease management following surgery. A predefined, uniform regimen or duration of medical therapy is not required before offering surgery. A preoperative fine-cut CT is recommended for surgical candidates; however, surgical planning should not rely solely on arbitrary thresholds for mucosal thickening, sinus opacification, or outflow obstruction. In cases involving polyps, osteitis, bony erosion, or fungal disease, surgery should aim for complete exposure of the sinus cavity and removal of diseased tissue rather than limited approaches such as balloon or manual ostial dilation. Postoperative evaluation with history and nasal endoscopy is recommended between 3 and 12 months after surgery. .

Background

Overview

Definition
CRS is defined as the evidence of inflammation in the sinonasal mucosa for > 12 weeks characterized by sinus pressure, nasal congestion, rhinorrhea, and decreased sense of smell.
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Pathophysiology
A complex interplay of host factors (defects in mechanical, innate, and adaptive components of immune system) and environmental factors (allergens, toxins, microbial agents) have been implicated in the development of CRS.
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Disease course
Clinical manifestations of persistent sinus pressure, nasal congestion, rhinorrhea, and a decreased sense of smell.
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Prognosis and risk of recurrence
CRS is not associated with increased mortality.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of chronic rhinosinusitis are prepared by our editorial team based on guidelines from the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2025,2018,2015), the American Academy of Allergy, Asthma & Immunology (AAAAI/ACAAI 2023), the American Academy of Family Physicians (AAFP 2023), the American College of Radiology (ACR 2022), the European ...
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Screening and diagnosis

Diagnostic criteria: as per AAFP 2023 guidelines, diagnose CRS in the presence of at least 2 of the following cardinal symptoms for ≥ 3 continuous months and objective criteria on nasal endoscopy or CT:
nasal blockage, obstruction, or congestion
anterior or posterior nasal drainage
facial pain or pressure
hyposmia.
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Diagnostic investigations

Nasal endoscopy: as per ICAR-RS 2016 guidelines, perform nasal endoscopy in conjunction with history and physical examination in the evaluation for CRS.
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  • Diagnostic imaging

  • Allergy and immune function testing

  • Nasal culture

  • Screening for comorbidities

Medical management

Nasal irrigation: as per AAFP 2023 guidelines, offer nasal saline irrigations as first-line therapy to improve sinonasal symptoms in patients with CRS.
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  • Intranasal corticosteroids

  • Oral corticosteroids

  • Leukotriene receptor antagonists

  • Antihistamines

  • Decongestants

  • Mucolytics

  • Biologic agents

  • Antibiotic therapy (short-term)

  • Antibiotic therapy (long-term)

  • Antibiotic therapy (topical)

  • Antifungal therapy

  • Other therapies

Therapeutic procedures

Balloon sinuplasty: as per AAO-HNSF 2018 guidelines, consider offering balloon dilation to improve short-term quality-of-life outcomes in patients with limited CRS without polyps. Consider performing balloon dilation as an adjunct to functional endoscopic sinus surgery in patients with chronic sinusitis without nasal polyps.
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Perioperative care

Preoperative assessment: as per AAO-HNSF 2025 guidelines, verify an existing diagnosis of CRS to ensure established diagnostic criteria (signs and symptoms) are met.
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  • Preoperative counseling

  • Preoperative medical therapy

  • Postoperative medical therapy

  • Postoperative follow-up

Surgical interventions

Endoscopic sinus surgery, indications: as per AAO-HNSF 2025 guidelines, offer sinus surgery in adult patients with CRS when the anticipated benefits surpass those of nonoperative management, there is clarity regarding expected outcomes, and patients understand the expectation for long-term disease management post-surgery.
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  • Endoscopic sinus surgery (technical considerations)

  • Endoscopic sinus surgery (corticosteroid-eluting stents)

Specific circumstances

Pediatric patients: as per EPOS2020 2020 guidelines, offer saline irrigations in pediatric patients with CRS.
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  • Patients with allergic fungal rhinosinusitis

  • Patients with aspirin-exacerbated respiratory disease (diagnosis)

  • Patients with aspirin-exacerbated respiratory disease (medical therapy)

  • Patients with aspirin-exacerbated respiratory disease (aspirin therapy after desensitization)

  • Patients with aspirin-exacerbated respiratory disease (endoscopic sinus surgery)

Follow-up and surveillance

Management of treatment failure: as per AAFP 2023 guidelines, consider referring patients not improving after a minimum of 3-4 weeks, preferably at least 8 weeks, of first-line medical management for surgical evaluation.
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