- Sinonasal polyposis with nasal airway obstruction or suboptimal asthma control
- Chronic rhinosinusitis with persistent symptoms and objective evidence of disease by endoscopic and/or CT imaging that is refractory to maximal medical treatment
- Allergic fungal rhinosinusitis
- Recurrent acute rhinosinusitis (RARS)
- Unilateral paranasal sinus opacification, symptomatic or asymptomatic, consistent with chronic sinusitis, fungus ball, benign neoplasm (i.e, inverted papilloma), etc.
- Complications of sinusitis, including extension to adjacent structures (i.e. face, orbit, skull base)
- Complete anterior and posterior nasal examination (rhinoscopy after mucosal decongestion)
- Examination of nasopharynx
- Nasal endoscopy
- Dental, neurologic, ophthalmologic, and/or pulmonary evaluation may be required in cases of extrasinus involvement
Note: Imaging studies should be generally obtained after maximal medical therapy. Based on clinical
situation (i.e. concern for extrasinus complications or neoplasm), early or emergent imaging may be
required to confirm a diagnosis.
- Coronal CT scan (minimum 3 mm slice thickness, bone algorithm) is the preferred imaging study
- Navigation sinus CT in those cases for which surgical navigation is planned
- Sinus MRI with/without contrast for cases with skull base and orbital erosion (on CT imaging), possible neoplasm, AFRS and/or mucocele with orbit and skull base erosion.
- Endoscopically directed cultures in select cases
- Allergy testing (if symptoms are consistent with allergic rhinitis and non- or under-responsive to pharmacotherapy, eg, antihistamines, intranasal corticosteroids, etc.)
- Peripheral eosinophil count, total IgE level, or other laboratory studies may be required at the discretion of the physician.
- Immunodeficiency evaluation at the discretion of the physician.
Maximal Medical Therapy:
- Oral antibiotics of 2-4 weeks duration for patients with CRS (culture-directed if possible)
- Oral antibiotics with multiple 1-3 week courses for patients with RARS
- Systemic and/or topical steroids (at the discretion of the physician)
- Saline irrigations (optional)
- Topical and/or systemic decongestants (optional, if not contraindicated)
- Treatment of concomitant allergic rhinitis, including avoidance measures, pharmacotherapy, and/or immunotherapy (at the discretion of the physician)
- monitor for excessive bleeding; if present, notify surgeon
- monitor for excessive headache/pain; if present, notify surgeon
- monitor for blurry vision, double vision, eye swelling, etc.; if present, notify surgeon.
- monitor for mental status changes; if present, notify surgeon
- Endoscopy for debridement and assessment as clinically warranted2
- Monitor for CSF leak and vision changes
- Endoscopic-guided cultures for exacerbations
- Additional medical therapy, including but not limited to topical nasal steroids, saline irrigations, and topical antibiotics and/or steroids
- Coordination of care with other physicians, including PCP, allergist and pulmonologist as warranted
- Assess for the following:
- Improvement in symptoms ascribed to CRS
- Status of paranasal sinus mucosa
- Assess of complications, including CSF leak
- Status of concomitant asthma