Chronic Rhinosinusitis without Nasal Polyps
Hopkins C, Surda P, Walker A, Wolf A, Speth M, Jacques T, et al. EPOS 4 patients. Rhinology. 2021 Suppl. 30: 1-57.
What are the sinuses?
The nasal cavity starts at the nostrils and travels backwards towards the throat. It is separated into left and right sides by a wall in the midline called the nasal septum. The sinuses are air-filled spaces within the bones of the face that connect into the nasal cavity on both sides.
There are four groups of sinuses on each side: maxillary, frontal, sphenoid and ethmoid. The maxillary sinuses are large single cavities that occupy most of the space behind the bone of the cheeks. The frontal sinuses are behind the eyebrows and forehead. The sphenoid sinuses are at the very back of the nasal cavity, in the central part of the skull. The ethmoid sinuses are slightly different to the other sinuses – they occupy the space between the eyes, and have many smaller cells separated by very thin bone, like a honeycomb. We don’t fully understand what role the sinuses evolved to do, and some people have missing or underdeveloped sinuses without developing any problems.
What do the sinuses do?
The sinuses are coated by a continuation of the same lining of the nasal cavity. In a healthy person, they continuously produce a small amount of mucus, which travels naturally out of the sinuses and into the nasal cavity, where it eventually passes backwards into the throat by the movement of tiny hairs. This mucus helps to moisten the air that you breathe, and to trap and deal with any viruses and bacteria. These functions of the sinuses are thought to help protect the lungs.
What causes my sinus disease?
In some disease, patients can develop long-lasting inflammation in the sinuses and nasal cavity. The most common of these conditions is chronic rhinosinusitis, where the lining of the entire nasal cavity and the sinuses becomes irritated and inflamed. Chronic rhinosinusitis is a disease with many causes. Understanding the background of disease is crucial so that we can offer a treatment that is likely to be effective.
Chronic rhinosinusitis without nasal polyps
Chronic rhinosinusitis (CRS) can be divided into categories. Some kinds of CRS cause the patient to develop nasal polyps, and some kinds do not. Nasal polyps are inflamed swellings that fill the sinuses and nasal cavity.
As the name suggests, chronic rhinosinusitis without nasal polyps refers to the condition where the sinuses are continuously inflamed but do not produce nasal polyps. The word “chronic” means that the condition affects patients in the long term (for at least 12 weeks, and often for years or decades) and does not have a “cure”. Luckily, it can usually be controlled with a combination of medical and surgical treatment.
How is it diagnosed?
Patients with chronic rhinosinusitis without nasal polyps (CRSsNP) typically experience some or all of the nasal symptoms as indicated in the table below.
In order to be diagnosed with CRSsNP, you have to be experiencing at least two of these symptoms over more than 12 weeks, and your symptoms must include blockage or discharge.
Abnormal coloured mucus draining from the sinuses
How will a doctor know if I have this condition?
In addition to the symptoms it causes, CRSsNP is also diagnosed by a doctor examining inside the nose. Examining the nose with an endoscope (a thin telescope that is usually attached to a camera) allows the doctor to determine whether you have nasal polyps. It also allows them to see evidence of an inflamed nasal lining, or abnormal coloured mucus draining from the sinuses (Figure above).
A doctor may also suggest organising a CT scan of sinuses – this is not essential for all patients, but it can be helpful if the diagnosis is in doubt or further treatment needs to be planned. In a patient without any sinus disease, the sinus spaces will appear black on a CT scan, as they are full of air. In a patient with CRSsNP, the sinuses may appear partially or completely full of mucus or swollen, inflamed sinus lining. This makes the sinus cavities appear grey rather than black on a CT scan. It is important to remember that having mucus or swelling visible on a CT scan does not mean that you have CRSsNP on its own: you must also be experiencing the characteristic symptoms.
ENT specialists may use specific medical questionnaires (known as “patient-reported outcome measures”) to assess the severity of CRS symptoms, and the impact of the disease on patients’ quality of life. The most common of these is the 22-question Sinonasal Outcome Test (SNOT-22), and visual analogue scales, where the patient is asked to rate the severity of each symptom on a scale from 1 to 10.
Blood tests are not essential for the diagnosis of CRSsNP. However, some patients may have blood tests for the diagnosis of possible allergy (skin prick tests are another method of doing this), or to investigate possible immune deficiency or autoimmune diseases. Some patients have a swab of nasal secretions taken, in order to determine which kinds of bacteria are present; however, it is not clear how these results should be used to guide treatment.
What causes CRSsNP
Our understanding of the different forms of chronic rhinosinusitis is improving constantly. However, we do not fully understand why some people develop CRSsNP and others do not. It is likely that each patient with CRSsNP will have a combination of several different factors, which come together to produce long-term inflammation inside the sinuses.
It is important to remember that CRSsNP is not simply an “infection that won’t go away” – the truth is that the relationship between bacteria and CRS is much more complex, as many bacteria and fungi live in our sinuses, both in patients with and without sinus problems.
Medical treatments for CRSsNP
Once a patient is diagnosed with CRSsNP, they should be started on a long-term medication regime. For most patients, this will consist of:
Saline (salt-water) nasal irrigation
Regular saline nasal irrigation is a helpful and effective treatment for most patients with chronic rhinosinusitis. It improves symptoms by improving the flow of mucus, and potentially by washing away irritants and allergens in the nose. However, on its own, it does not decrease the inflammation that causes CRSsNP. Adding other ingredients such as Xylitol and sodium hyaluronate may have a positive effect on some patients, but patients should discuss this with their doctor first.
Nasal steroid medication
Nasal steroid medication is the main treatment used for most patients with CRS. Steroids are medications that suppress inflammation, thereby reducing the patient’s symptoms of blockage and discharge. The medication is known as “topical”, meaning that it works by coming into direct contact with the inflamed lining of the nose and sinuses. Common steroids used include fluticasone, mometasone and budesonide. There is good-quality evidence that demonstrates that nasal steroids create a significant improvement in symptoms and quality of life in patients with CRS.
Some patients with CRSsNP do benefit from taking antibiotics, often for a longer period of time. However, we believe that this works by altering the immune system’s response to the bacteria rather than by simply killing the bacteria directly.
For further details on medical treatments, please refer to the appropriate leaflet
Surgical treatments for CRSsNP
Chronic rhinosinusitis is treated primarily with medical treatment (see above). The majority of patients will require long-term treatment with nasal steroid sprays/drops, saline irrigation and sometimes other medication. For some patients, this medication alone will be enough to control their symptoms. If a patient is already taking the maximum amount of medical treatment, but their symptoms are still affecting their quality of life, endoscopic sinus surgery (ESS) can be considered in order to give them better control of their disease. For further details, please read the patient leaflet titled “Surgery in CRS”.
A patient report of living with CRS without nasal polyps
“At first I was told that I just had a simple ‘sinus infection’, but this has lasted for years. My nose produces a lot of yellow mucus, almost all the time. Occasionally my husband can smell it, which is so embarrassing. Quite often I can smell a really unpleasant smell that nobody else can. It puts me off my food. I find it difficult to breathe through my nose, which has affected my sleep and my energy levels throughout the day. It can be difficult to remember to take my nasal drops and the saltwater irrigation; I just feel that I’m too young to be taking medication, even though they make me feel better.”
Frequently asked questions
How common is rhinosinusitis?
The prevalence of chronic rhinosinusitis (symptoms lasting more than 12 weeks) is around 5%-10% in the general population.
Are there any treatments I can get over the counter to help my sinus problems without having to see my doctor?
The availability of medications from pharmacies may depend on where you live, but your pharmacist is likely to be able to help and is a great place to start. Saline nasal irrigation can be easily purchased from pharmacies and online, and steroid nasal sprays (such as fluticasone and mometasone) are also available without prescription in some countries. Both of these medications significantly improve the symptoms of sinus problems when taken regularly; they can take a few weeks to start working fully.
It is important to remember that nasal decongestant sprays (e.g. xylometazoline or oxymetazoline) improve your nasal airway quickly, but are not suitable for long term use, and can make your symptoms worse.
Is CRS caused by allergies?
No, CRS is not usually caused by allergies. On the other hand, it can happen that patients with chronic rhinosinusitis also have allergies and the other way around. So, if you have chronic sinusitis and symptoms that raise the suspicion of allergy-like sneezing or itch, you can discuss an allergy test with your doctor.
Should I stop smoking?
Yes. Stopping smoking is the single most effective thing you can do to improve your overall health and the length of your life. In terms of sinus disease, we know that smoking worsens the symptoms of chronic rhinosinusitis, and that stopping helps us to control your symptoms.
I get terrible ‘sinus headaches’ but my ENT doctor has told me it is not coming from my sinuses? How can this be, as I feel the pressure in my forehead and between my eyes? Many patients seek help from ENT specialists with headaches that they feel are coming from their sinuses. However, if headache and facial pressure are your main symptoms, it is unlikely that the cause is sinus disease. This is especially true if you do not have symptoms of nasal blockage or discharge. Your ENT may have examined your nasal cavity and found no evidence of sinus disease.
Long-term “tension-type” headaches can frequently be felt in the forehead, between the eyes and across the cheeks. We refer to this as “midfacial segment pain”. When there is no evidence of sinus dis-ease, this should be treated using a similar medication as is used for other kinds of headache.
So, does CRS ever cause headaches?
CRS can cause headaches but it is often not the most characteristic symptom of this disease. It is important to realize that headaches without symptoms like runny nose, blockage etc. are very unlikely to be caused by CRS. Headaches associated with CRS are often described as a heaviness or fullness and/or dull sensation. They are first noticed at the same time that other symptoms of CRS started
and they usually fluctuate in severity along with other symptoms over time. They get better with successful treatment that improves other symptoms but may get worse with acute infections or when flying.
My doctor asked me to add xylitol to my sinus rinse - how does this work?
A number of different substances have been trialled as additives to saline rinse solutions, such as manuka honey, baby shampoo and xylitol. Of these, there is some evidence to support the use of xylitol, sodium hyaluronate and xyloglucan. It is thought that these likely improve the property of nasal mucus, and therefore help improve nasal function.
Please see also see the section on ‘Nasal rinses’ for more advice
My doctor told me my sinusitis has come from my tooth - how can infection spread from my tooth to my sinuses, and how should it be treated?
In some cases, inflammation and infection related to one of the upper molar (back) teeth can cause chronic rhinosinusitis on the same side. This occurs because the roots of the upper molar teeth are commonly within the floor of the maxillary sinus in your cheek. Patients usually experience congestion and an unpleasant-smelling discharge from one nostril. The affected tooth may be painful or not. This condition is known as odontogenic chronic rhinosinusitis. If you have sinusitis that is thought to originate from a tooth, the responsible tooth should be identified and treated by a dental professional. You may also benefit from treatment with antibiotics
and a steroid nasal medication, but the problem is unlikely to fully resolve unless the tooth is treated. If the responsible tooth cannot be identified, or the nasal symptoms continue after it has been treated, you may also benefit from having endoscopic sinus surgery to drain and widen the drainage pathway of the affected sinus.
I’m always tired – is it caused by my sinus issues?
If you suffer from chronic rhinosinusitis, this can give rise to symp- toms of tiredness, particularly if nasal blockage causes sleep distur- bance, but there are many other causes of fatigue.
What happens when I visit the ENT specialist? Do I have to have the camera and does endoscopy hurt?
If you visit the ENT specialist with symptoms of your nose like runny noses or blockage of your nose, he or she will most likely have a look inside of your nose with both a speculum and with a camera (endoscopy). With the endoscope, it is possible to look a little bit deeper inside your nose than with the speculum. Nasal polyps arise a bit deeper/higher up in your nose and often they will not be seen if the doctor only takes a superficial look in your nose without the endoscope.
In general, endoscopy does not hurt. In rare cases, if it causes dis- comfort because your nose is too swollen or because of anatomic variations, local anaesthesia can be used in your nose. Local anaesthesia can for example be applied by placing cotton wools with anaesthetic inside of your nose before the ENT specialist performs nasal endoscopy.