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Chronic rhinosinusitis and nasal polyps (CRSwNP)
Chronic rhinosinusitis is inflammation of the nose and sinuses for 12 weeks or more, diagnosed by symptoms together with an objective finding on endoscopy or CT; treatment starts with irrigation and an intranasal steroid, moves to endoscopic sinus surgery, and in type 2 disease with recurrent polyps to biological therapy.
Why it matters in the exam
Under EPOS 2020 the diagnosis requires two or more symptoms — nasal blockage or discharge (at least one of the two), facial pain or pressure, reduced smell — for 12 weeks or more, together with polyps or purulent discharge on endoscopy or mucosal changes on CT. The exam asks about the split by mechanism: type 2 (eosinophilic) disease is linked to asthma, polyps, loss of smell and recurrence after surgery, and it is the target of biologics.
Samter triad (AERD) is asthma, nasal polyps and sensitivity to aspirin and other NSAIDs. Nasal polyps in a child require cystic fibrosis to be excluded. A unilateral polyp in an adult is not an "ordinary polyp" — inverted papilloma or a malignant tumour must be excluded by biopsy and imaging. An antrochoanal polyp is a single polyp that leaves the maxillary sinus and reaches the nasopharynx, mainly in young patients.
Basic medical treatment: large-volume saline irrigation and a long-term intranasal steroid; short oral steroid courses are allowed up to twice a year. When medical treatment fails, functional endoscopic sinus surgery (FESS) is performed to open the drainage pathways and let topical drugs reach the mucosa. The commonest minor complication of FESS is synechiae (adhesions); the serious ones are orbital injury, CSF leak and internal carotid injury. Under EUFOREA, biologics (dupilumab, omalizumab, mepolizumab) suit bilateral polyps after surgery when 3 of 5 criteria are met: evidence of type 2 disease, need for systemic steroids twice a year or more, significant impairment of quality of life, loss of smell and comorbid asthma.
Key points
- Diagnosis: 2 symptoms, 12 weeks, and an objective finding.
- Basis: irrigation and intranasal steroid.
- Medical failure → FESS.
- Biologics for recurrent type 2 polyps.
- Unilateral → biopsy; child → cystic fibrosis.
Summary table
| Situation | Clue | Next step |
|---|---|---|
| CRS with polyps | Blockage and loss of smell, bilateral polyps | Irrigation, intranasal steroid, FESS |
| CRS without polyps | Discharge, facial pressure, thickened mucosa on CT | Irrigation, steroid, treat contributing factors |
| AERD (Samter) | Asthma, polyps, aspirin sensitivity | Surgery, biologic, aspirin desensitisation |
| Polyps in a child | Child with polyps or recurrent infections | Sweat test for cystic fibrosis |
| Unilateral polyp | In an adult, sometimes with bleeding | CT, MRI and biopsy |
| Recurrent type 2 disease | 3 of 5 criteria | Dupilumab, omalizumab or mepolizumab |
A free exam question
מה נכון לגבי טיפול באמצעות Leukotriene Inhibitors? (the question as examined, in Hebrew)
- א. Grade A of evidence ב- Chronic Rhinosinusitis with Nasal Polyps
- ב. Grade B of evidence ב- Chronic Rhinosinusitis with Nasal Polyps
- ג. Grade A of evidence ב- Chronic Rhinosinusitis without Nasal Polyps
- ד. Grade B of evidence ב- Chronic Rhinosinusitis without Nasal Polyps
In the full version for subscribers
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Sources
- EPOS 2020: European Position Paper on Rhinosinusitis and Nasal Polyps, 2020 — Chronic rhinosinusitis: definitions, management and biologics
- EUFOREA consensus on biologics for CRSwNP, 2023 update — Indications for biological treatment
- Cummings Otolaryngology: Head and Neck Surgery, 7th edition (2021) — Chronic rhinosinusitis and endoscopic sinus surgery
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.