How to Recognize Chronic Rhinosinusitis and How to Treat It

Rhinosinusitis refers to a state of inflammation of the nasal mucosa and paranasal sinuses, which may or may not be associated with the presence of nasal polyps.

“Rhinosinusitis,” emphasizes Dr. Aresi, “can broadly be classified into:

• Acute, when it resolves within 30 days and is usually a consequence of a cold;
• Chronic, if it lasts at least 12 weeks and has various causes.”

The typical symptoms of chronic rhinosinusitis are:

• Nasal breathing obstruction;
• Nasal discharge;
• Alteration of smell and taste;
• Facial pain and headache.

“The key and most disabling symptoms of chronic rhinosinusitis are, in summary, nasal breathing obstruction with nasal discharge and, above all, the loss of smell.

In the past, headache was always considered a diagnostic sign of sinusitis, but we now know that the correlation between headache and sinusitis is not always accurate,” explains the otolaryngologist.

The causes of rhinosinusitis can vary.

“The mechanisms underlying the onset of rhinosinusitis,” explains Dr. Aresi, “are multifactorial and include:

• Obstruction of the ostia (the ducts connecting the paranasal sinuses with the nose), caused by anatomical factors or repeated nasosinus inflammatory episodes that lead to swelling of the mucosa of the paranasal sinuses, resulting in narrowing of the ostia;
• Alteration of mucociliary transport: This can be a congenital condition (as in cystic fibrosis) or acquired (occurring in cases of recurrent bacterial or viral infections or in smokers). This transport deficit leads to the stagnation of nasal and sinus secretions, which promotes bacterial and/or viral superinfection;
• Alteration of the characteristics of nasal mucus: The slowing of mucociliary transport, stagnation of nasosinus secretions, and frequent inflammatory episodes lead to changes in the properties of the secretions, making them much more viscous."

Correctly identifying chronic rhinosinusitis is the first step to managing it adequately and effectively.

“It is always essential to perform a thorough specialist otolaryngological examination, focusing on understanding the type, extent, and duration of symptoms. The doctor-patient relationship and the empathy that should be established are crucial for collecting the patient's medical history,” emphasizes Dr. Aresi.

In addition to the examination, performing a nasal and laryngeal endoscopy with fiber optics has become indispensable. This is considered a second-level diagnostic tool and is typically prescribed by the otolaryngologist.

“With this minimally invasive and painless procedure, suitable even for children, it is possible to accurately assess the anatomy of the nasal cavities and larynx, and thus detect pathological conditions (mucosal or purulent secretions, nasal septum deviations, nasal polyps, etc.).

In particular cases, the otolaryngologist may also request radiological tests, such as a CT scan and/or MRI of the facial bones.”

Managing chronic rhinosinusitis requires a multidisciplinary approach involving specialists from various fields.

"Collaboration among ENT specialists, pulmonologists, allergists, dermatologists, rheumatologists, gastroenterologists, general practitioners, and pediatricians is essential," explains Dr. Aresi. "Chronic rhinosinusitis is often associated with coexisting conditions, such as bronchial asthma (in 20% of cases) and allergies."

To provide more targeted treatment, it is crucial to differentiate the various types of chronic rhinosinusitis based on their causes, paying special attention to whether nasal polyps are present.

Treatment can be broadly divided into:

• Medical therapy (local and systemic)
• Surgical therapy.

Medical Therapy (Local and Systemic)

"Local therapy involves nasal irrigation and topical nasal corticosteroids.

• Nasal irrigation helps remove:

  • Secretions, stimulating mucociliary clearance.
  • Allergens, which are inflammation mediators present in the nasal mucosa.

• Topical nasal corticosteroids aim to reduce symptoms such as:

  • Nasal obstruction.
  • Nasal discharge.
  • Mucosal swelling.

Systemic therapy, on the other hand, primarily involves the use of systemic corticosteroids.
"Systemic corticosteroids are combined with:

• Antibiotics for chronic rhinosinusitis.
• Antihistamines for allergic individuals," adds the specialist.

Surgical Therapy

When symptoms are debilitating, and medical treatment fails to produce significant improvement, surgical therapy is considered.

"Surgical therapy involves endoscopic sinus surgery, which today uses natural nasal pathways to:

• Correct congenital anatomical abnormalities, such as deviated nasal septum or turbinate hypertrophy.
• Restore the patency and functionality of the openings connecting the nasal passages to the paranasal sinuses, addressing the underlying causes of chronic rhinosinusitis."

The treatment of chronic rhinosinusitis with nasal polyps has recently undergone significant advancements with the introduction of new biological drugs.

“In recent years, it has been observed that most cases of chronic rhinosinusitis are associated with type 2 inflammation," explains Dr. Aresi. "This discovery has led to the development of new drugs, specifically monoclonal antibodies, which target type 2 inflammatory processes by inhibiting the production or migration of certain molecules."

These drugs are reserved for highly selected patients who meet specific criteria:

• Severe chronic rhinosinusitis with nasal polyps.
• A history of surgical interventions.
• Repeated systemic corticosteroid treatments.
• Often coexisting medical conditions.

“Only certain and well-defined clinical scenarios warrant biological therapy," concludes Dr. Aresi. "Careful patient selection is therefore crucial.”