Rhinology and Sinology
Core rules
Chronic rhinosinusitis (CRS) is nasal and sinus inflammation for at least 12 weeks with two or more symptoms (obstruction, discharge, facial pain/pressure, hyposmia) plus endoscopic or CT evidence. Phenotypes are CRS without nasal polyps and CRS with nasal polyps (CRSwNP); type 2 inflammation dominates CRSwNP, especially with asthma and aspirin-exacerbated respiratory disease. First-line therapy is saline irrigation plus intranasal corticosteroids; antibiotics are reserved for acute bacterial exacerbations. Oral steroids may shrink polyps briefly but carry systemic risks. Biologics such as dupilumab, omalizumab and mepolizumab are options for severe type 2 CRSwNP after surgery. Functional endoscopic sinus surgery opens the ostiomeatal complex and ethmoids; complications include CSF leak, orbital hematoma and synechiae. Allergic rhinitis follows ARIA principles: intranasal steroids plus second-generation antihistamines, with immunotherapy for refractory disease. Epistaxis anterior to Kiesselbach plexus is common; posterior bleeding arises from the sphenopalatine artery. First aid is pinching and leaning forward; visible vessels are cauterized, and refractory posterior bleeding needs packing or sphenopalatine artery ligation.
Worked example
A 45-year-old has bilateral polyps, asthma and aspirin sensitivity. Start saline and intranasal steroids, image with CT, and plan FESS if medical therapy fails. Aspirin desensitization is undertaken only with specialist allergy input because of bronchospasm risk.
Traps
Do not prescribe antibiotics for CRS without bacterial evidence. Avoid bilateral nasal packing in a patient with airway compromise. Not every nasal polyp is inflammatory: unilateral bleeding polyps need biopsy to exclude malignancy.