University of Cincinnati
Chronic Rhinosinusitis
What are sinuses?
Sinuses are air-filled spaces within your skull. The sinuses are lined with mucosa which secrete mucus. The lining of the mucosa has small hairs or “cilia” which beat the mucus to the natural opening of the sinus in order to drain the mucus out of the sinus and into the nose. Most people have four sinuses on each side for a total of eight sinuses. This includes the maxillary sinuses (cheek sinuses), the ethmoid sinuses (between your eyes), the frontal sinuses (along your forehead) and the sphenoid sinuses (behind your eyes). You are born with your maxillary and ethmoid sinuses, while your sphenoid and frontal sinuses develop as you age. Some people do not develop certain sinuses as their skull grows and this is a variant of normal and not cause for concern.
What is Chronic Rhinosinusitis?
Chronic rhinosinusitis (CRS) is a disease characterized by inflammation of the lining of the nose and sinuses. Patients are diagnosed with CRS when they experience sinus symptoms such as nasal obstruction, nasal discharge, post nasal drip, decreased sense of smell or facial pressure or pain for greater than 12 weeks AND a healthcare provider sees evidence of inflammation of the lining of their sinuses either on physical exam or imaging (such as a CT scan or MRI). Patients may often have reoccurring sinus infections and find their sinus symptoms do not completely go away between infections. Patients with CRS may also notice headaches, ear pain, pressure or popping, poor sleep quality, depressed mood or limitations in their daily activities secondary to their sinus symptoms.
What are nasal polyps?
Some patients with chronic rhinosinusitis have nasal polyps. Nasal polyps are non-cancerous and arise from inflammation of the lining of the nose and sinuses. The polyps can hang down like a bunch of grapes within the nose and cause symptoms such as nasal obstruction or loss of smell. Nasal polyps are associated with asthma, allergies, and certain diseases and immune disorders. Nasal polyps are not related to colon polyps and are not related to cancer in the nose.
What should I do if I suspect I have Chronic Rhinosinusitis?
If you are suffering from constant sinus symptoms such as nasal congestion, stuffiness, nasal obstruction, nasal discharge, post nasal drip, decreased sense of smell or facial pain that doesn’t go away, consider talking to your primary care doctor about going to see a doctor who specializes in sinus care (link to UC contact). A sinus doctor will listen to what symptoms you are having and for how long you have suffered from your symptoms and then may perform a nasal endoscopy. A nasal endoscopy involves placing a small camera in your nose to better evaluate the lining of your nose and sinuses. This nasal endoscopy is done while you are awake and does not cause pain. Your doctor may also order a CT scan to better evaluate the areas of the sinus they cannot see on nasal endoscopy.
How is Chronic Rhinosinusitis treated?
For a majority of patients, their disease can be successfully managed with medical therapy. This often involves some type of nasal steroid spray and salt water rinses of the nose. Some patients may need other medications added to their regimen for better control of their sinusitis. For a small percentage of patients, medical therapy may not be able to control their disease and they may benefit from sinus surgery. Sinus surgery will not cure their underlying inflammation but will help open the sinuses more to allow medication easier access to the sinus lining. Treating your chronic sinusitis with either medicine, surgery or both has been shown to improve your quality of life, sleep quality and productivity.
To understand how severe your sinus symptoms are, you can fill out the 22-item Sinonasal Outcomes Test (SNOT-22). Scores range from 0 (no symptoms) to 110 (maximal symptoms). Those with higher scores have more negative impact on their quality of life.
What is sinus surgery?
Sinus surgery, sometimes called functional endoscopic sinus surgery (FESS), is reserved for a small percentage of patients who need more than medical therapy to achieve optimal control over their sinus disease. All sinuses have a natural opening where mucus is drained from the sinus into the nose. In patients with sinusitis, the lining of the sinuses is inflamed and swollen and do not fully allow mucus to drain out of the natural. As a result, patients with chronic sinusitis often have trapped mucus in their sinuses which can lead to further inflammation and infection. Sinus surgery involves widening these natural openings to improve mucus clearance from the sinuses. The surgery is done with the aid of a small telescope placed inside the nose so the surgeon can delicately dissect the thin bone and mucosa within the nose and sinuses. No external excisions are required and there are no visible scars after sinus surgery. Most of the time, this is an outpatient procedure and you are allowed to go home on the day of surgery.
In addition to sinus surgery, some patients may also need a septoplasty (a procedure to straighten the septum – a structure which divides the inside of the nose into the left and right side) and/or an inferior turbinate reduction (a procedure which reduces the size of the inferior turbinates – bones which line the inside of the nose – in order to allow more air into the nose and sinuses). Depending on your symptoms and what the inside of your nose looks like, your surgeon may also recommend these procedures along with your sinus surgery.
What are other options for treatment?
In addition to the standard medical therapy of topical intranasal steroids and salt water rinses of the nose or sinus surgery, there are also other options to treat CRS. Based on your particular disease and unique needs and circumstances, other treatments may be right for you. Talk to your sinus doctor about what other treatments may fit your personalized needs.
If you have allergies, this could be making your sinus disease worse. Patients may need to treat their allergies with either medications or immunotherapy to improve their allergies. Immunotherapy is a process where patients are desensitized to the particular allergen they are allergic to with either allergy shots or allergy drops. When a patient’s allergies are well controlled, their sinus disease often improves.
If you have asthma, we know that treating your asthma can help improve your sinus disease. Likewise, treating your sinus disease can also improve your asthma.
Biologic medications are a class of medications that are new for the treatment of sinus disease. This class of medications has been used for many years to treat many other conditions such as asthma, eczema and rheumatoid arthritis. Dupixent (generic – dupilumab) was approved to treat chronic rhinosinusitis patients who have nasal polyps in July 2019. This medication has been shown to improve patients’ quality of life and cause a decrease in nasal polyp size. Dupixent is a medication that requires injection once a month which can be done by the patient in their home once they have learned how to do the injection at the doctor’s office.
Balloon sinuoplaty is another option for treating sinus disease. This can be done in the office and is a procedure where the natural opening of the sinus is slightly widened. This procedure can be helpful in certain conditions. Talk to your sinus doctor if balloon sinuoplasty is right for you.