What Is Chronic Rhinosinusitis?
Chronic rhinosinusitis, the medical term for chronic sinusitis, occurs when the spaces inside your nose and head remain inflamed for three months or longer. Your sinuses are normally filled with air, but when they become blocked and filled with fluid, germs can grow and cause infection. The condition affects the mucous membranes lining your nasal passages and sinuses, preventing proper drainage and creating an environment where inflammation persists.
The sinuses include four paired cavities: the maxillary sinuses in your cheekbones, frontal sinuses in your forehead, ethmoid sinuses between your eyes, and sphenoid sinuses deep behind your nose. When any of these become chronically inflamed, it disrupts the normal flow of mucus and air, leading to a cycle of inflammation that can be difficult to break without proper intervention.
Understanding Acute and Chronic Sinusitis
The key difference between acute and chronic sinusitis lies in duration and underlying causes.
Acute sinusitis typically develops suddenly, often following a cold or allergies, and resolves within four weeks with appropriate treatment. The symptoms are usually more severe but shorter-lived, and most cases respond well to antibiotics if caused by bacteria.
Chronic sinusitis, however, persists for 12 weeks or more and may have multiple contributing factors beyond simple infection. While acute sinusitis is often triggered by viral or bacterial infections, chronic cases frequently involve structural abnormalities, persistent allergies, immune system issues, or biofilm formation that makes treatment more complex.
Some people experience recurrent acute sinusitis – four or more episodes per year – which may eventually develop into chronic inflammation if underlying causes aren’t addressed.
Recognizing Chronic Sinusitis Symptoms
The hallmark chronic sinusitis symptoms include nasal congestion or blockage that makes breathing through your nose difficult, thick drainage from the nose or down the back of the throat, and a reduced sense of smell and taste. Many people experience facial pain, pressure, or fullness around their eyes, cheeks, nose, or forehead that may worsen when bending forward.
Additional symptoms often include ear pressure or fullness, aching in your upper jaw and teeth, a cough that may worsen at night, a sore throat, bad breath, and fatigue. Unlike acute sinusitis, where fever is common, chronic cases rarely cause fever unless there’s an acute flare-up or secondary infection. The persistent nature of these symptoms can lead to sleep disturbances, difficulty concentrating, and decreased productivity at work or school.
Common Causes and Risk Factors
Multiple factors can contribute to the development of chronic sinusitis.
Nasal polyps – soft, painless growths on the lining of nasal passages or sinuses – can block airflow and drainage.
A deviated nasal septum, where the wall between your nostrils is crooked, can restrict sinus passages and impair drainage.
Allergic rhinitis triggers inflammation that can block sinus openings, while respiratory tract infections can thicken and block sinus membranes.
Certain medical conditions significantly increase your risk. People with asthma often have chronic sinusitis, with studies showing a strong connection between the two conditions. Aspirin sensitivity can cause respiratory reactions and sinusitis. Immune system disorders and conditions that result in abnormal mucus secretion also contribute to chronic inflammation.
The Connection with Cystic Fibrosis
Cystic fibrosis, a genetic disorder affecting mucus production throughout the body, has a particularly strong association with chronic sinusitis. People with this condition produce abnormally thick, sticky mucus that blocks the sinus passages and creates an ideal environment for bacterial growth. Nearly all individuals with cystic fibrosis develop some degree of sinus disease, often beginning in childhood.
The thick mucus prevents normal sinus drainage, leading to persistent inflammation and infection. Treatment for sinus disease in patients with cystic fibrosis requires a comprehensive approach that addresses the underlying mucus abnormality through specialized therapies, aggressive infection management, and, sometimes, surgical intervention to improve drainage.
Understanding Fungal Sinusitis
Fungal sinusitis represents a less common but important cause of chronic sinus inflammation. While fungi are present in the environment and most people inhale fungal spores without problems, some individuals develop inflammatory or infectious responses. Allergic fungal sinusitis occurs when people with nasal polyps and allergies have an allergic reaction to airborne fungi, causing thick, sticky mucus and nasal polyps.
Invasive fungal sinusitis is a serious condition primarily affecting people with weakened immune systems, including those undergoing chemotherapy, organ transplant recipients, or individuals with uncontrolled diabetes. This aggressive infection can spread beyond the sinuses and requires urgent medical attention. Fungal ball sinusitis involves a clump of fungal material in the sinuses, typically requiring surgical removal.
Diagnosing Chronic Sinusitis
Diagnosing chronic sinusitis begins with a thorough medical history and physical examination. Your doctor will ask about your symptoms, their duration, and potential triggers. Examination of your nasal passages using a nasal endoscope – a thin, flexible tube with a light – allows direct visualization of your sinuses and can reveal inflammation, polyps, or structural abnormalities.
Imaging studies provide crucial information about sinus anatomy and disease extent. CT scans of the sinuses are the gold standard for evaluating chronic sinusitis, showing the degree of inflammation, blockages, and anatomical variations. MRI may be used when doctors suspect fungal infections or complications involving surrounding structures. Allergy testing helps identify specific allergens contributing to inflammation, while nasal and sinus cultures can identify bacterial or fungal infections requiring targeted treatment.
Treatment Options: From Conservative to Surgical
Treatment for chronic sinusitis typically begins with conservative medical management.
- Saline nasal irrigation helps flush out irritants and moisturize the nasal passages.
- Corticosteroid nasal sprays reduce inflammation, while oral or injectable corticosteroids may be prescribed for severe cases.
- Antibiotics are used to treat bacterial infections, though long-term use requires careful consideration to avoid resistance.
- Medications targeting underlying conditions play a crucial role. Antihistamines and allergy immunotherapy address allergic components, while biologic medications, such as dupilumab, have shown promising results in recent clinical trials for chronic sinusitis with nasal polyps. Antifungal treatments are necessary for fungal sinusitis.
The Role of Functional Endoscopic Sinus Surgery
When medical treatment fails to provide adequate relief after several months, functional endoscopic sinus surgery may be recommended. This minimally invasive procedure uses a thin endoscope inserted through the nostrils, avoiding external incisions. The surgeon removes blockages, polyps, or diseased tissue and enlarges sinus openings to improve drainage and airflow.
The surgery aims to restore normal sinus function while preserving healthy tissue. Recovery typically takes one to two weeks, though complete healing may take several months. Success rates are generally high, with most patients experiencing significant symptom improvement. However, surgery doesn’t cure the underlying tendency toward inflammation, so ongoing medical management is often necessary to prevent recurrence.
Evidence from Clinical Trials
Ongoing clinical trials continue to explore new treatments for chronic sinusitis. Researchers are investigating novel biologic therapies targeting specific inflammatory pathways, improved drug delivery systems that maintain medication in the sinuses longer, and innovative surgical techniques. Participating in clinical trials offers access to cutting-edge treatments while contributing to medical knowledge that may help future patients.
Living Well with Chronic Sinusitis
Managing chronic sinusitis requires patience and a comprehensive approach. Working closely with an otolaryngologist or allergist ensures proper diagnosis and treatment. Identifying and avoiding triggers, maintaining good nasal hygiene with regular saline rinses, managing allergies, staying hydrated, and using a humidifier can all help minimize symptoms. While chronic sinusitis can be frustrating, effective treatments are available, and most people achieve significant improvement with the right management strategy.
Conclusion
Effective chronic sinusitis treatment requires a multifaceted strategy tailored to individual needs, with medical therapy serving as the first line of defense for most patients. Studies comparing intranasal steroids versus placebo have consistently demonstrated the benefit of topical nasal steroids in reducing inflammation within the nasal cavity and improving nasal obstruction, while nasal saline irrigation helps clear purulent nasal discharge and maintain healthy sinus drainage. For patients with nasal polyposis, treatment approaches to treat nasal polyps often combine topical medications with systemic and topical antibiotics when infection is present. However, those with aspirin-exacerbated respiratory disease require specialized management protocols. Diagnostic procedures, such as nasal endoscopy, allow physicians to visualize the extent of inflammation and identify issues, such as recurrent sinusitis, that may require escalated intervention.
Recognizing the symptoms of chronic sinusitis early is crucial, as untreated chronic sinusitis can lead to severe symptoms and, in rare cases, serious complications, such as cavernous sinus thrombosis, that require immediate medical attention.
About the Author
Vincent Pisciotta
Dr. Pisciotta brings decades of ENT expertise, with advanced training at LSU and MD Anderson Cancer Center. He is recognized for his leadership and contributions to otolaryngology.
