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Management of CRSsNP
CRSsNP: Unraveling the Burden, Advancing Treatments, and Optimizing Care

Released: December 09, 2024

Expiration: December 08, 2025

Brent Senior
Brent Senior, MD
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Key Takeaways
  • Chronic rhinosinusitis (CRS) significantly affects a patient’s quality of life and productivity, with impacts on sleep quality, fatigue, and cognitive impairment.
  • CRS is classified into 2 categories—CRS without nasal polyps and CRS with nasal polyps—with distinct inflammatory profiles, symptoms, and comorbidities that require different management strategies.
  • The FDA-approved exhalation delivery system with fluticasone offers a new, nonsurgical treatment option for CRS and may be used first line or after failure of other agents.

CRS Diagnosis and Classification
Chronic rhinosinusitis (CRS) is defined as persistent sinonasal inflammation lasting more than 12 weeks, characterized by symptoms of nasal obstruction, facial pressure, or nasal discharge. According to the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) 2021 guidelines, diagnosis requires the presence of at least 2 cardinal symptoms and objective evidence of inflammation, such as endoscopic findings (edema, purulence, or nasal polyps) or radiologic changes. CRS is classified into 2 phenotypes, CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP), and can be distinguished based on clinical and pathophysiologic differences.

CRS Disease Burden 
CRS imposes a significant burden on patients, with effects extending far beyond nasal symptoms. The disease reduces health-related quality of life, as shown by quality-adjusted life year (QALY) scores. Patients with CRS report an average QALY score of 0.65, compared to 0.8 in the general population.

Patients with CRS experience impaired sleep quality and studies indicate that sleep disturbances in patients with CRS are more severe than those reported by patients with obstructive sleep apnea or narcolepsy. Fatigue is another prominent issue in CRS, with patients consistently reporting higher levels of fatigue compared to control groups. Cognitive and functional abilities are also notably compromised, further contributing to the disease burden and its impact on the patient’s quality of life.

The economic toll of CRS is substantial, with patients reporting an average of more than 25 days of absenteeism annually. These productivity losses result in an estimated $12.8 billion in costs on the US economy each year, highlighting the economic and social burden of CRS. 

Management of CRS
The ICAR-RS 2021 provides evidence-based guidance for CRSsNP management. I have also included recommendations based on my practice.

  1. Saline Irrigation: Saline irrigation is recommended as first-line treatment for CRSsNP due to its robust evidence of efficacy, safety, and tolerability and long history of use.
  2. Oral Antibiotics: Short courses of oral antibiotics have limited evidence of efficacy and are discouraged from first-line use. Extended courses are similarly discouraged due to poor evidence, except for macrolides, which may benefit specific patients. Prolonged macrolide therapy, such as azithromycin for 3 months or longer, shows evidence of reducing inflammation and improving symptoms in CRS.
  3. Oral Corticosteroids: Although oral corticosteroids seem like the right choice in CRS because it is an inflammatory disease, the evidence is actually quite limited. They may provide short-term symptom relief, but are not routinely recommended. 
  4. Intranasal Corticosteroid Sprays: These sprays are effective; they are recommended as first-line treatment and have a very high level of evidence. Although their benefit is more seen in CRSwNP, they also demonstrate symptom improvement in CRSsNP.
  5. Exhalation Delivery System With Fluticasone (EDS-FLU): This is a newer treatment introduced since the ICAR-RS 2021 guidelines and represents an exciting option for healthcare professionals. EDS-FLU is a fluticasone-dispensing device that is designed to deliver fluticasone directly into the nasal cavity and sinuses. This device works by having the patient exhale into a nozzle. When doing so, the patients soft palate closes, ensuring that the medication stays in the nasal cavity and does not flow into the back of the throat. It is different from currently used products on the market as it offers a different dosing regimen and delivery method.

Of note, EDS-FLU is the first nonsurgical treatment option that has been shown to improve symptoms as well as objective measures, such as sinus opacification, in patients with CRS with or without nasal polyps. It is the first and only FDA-approved medication for CRS without nasal polyps. The device can be used as first-line treatment for CRS or when symptoms persist despite OTC medications, potentially avoiding the need for surgical intervention.

When to Refer to an ENT 
Referral to an otolaryngologist should be strongly considered for patients with red flag symptoms such as unilateral or asymmetric symptoms, facial swelling, vision changes, one-sided bleeding, or nosebleeds. These signs warrant prompt otolaryngologic evaluation. In addition, patients with significant medical comorbidities, such as poorly controlled diabetes or immunosuppression should also be referred, as these conditions may complicate the management of CRSsNP. Patients with ongoing symptoms despite adequate trials should also be referred.

ENT Evaluation and Management 
During otolaryngologic evaluation, a comprehensive rhinologic history is obtained and sinonasal endoscopy is typically performed. Endoscopic cultures can be obtained to guide targeted therapy. Management decisions incorporate shared decision-making, considering the patient’s goals, ongoing symptoms, and quality of life impacts. If indicated, discussion of surgery can be appropriate as well.

Your Thoughts?  
In your clinical practice, what factors influence your decision to escalate care for patients with CRS or referrals to an otolaryngologist? Join the discussion by posting a comment below.

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In your clinical practice, how often do you refer patients with CRSsNP who fail over-the-counter therapies to an otolaryngologist?

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