Diagnostic Criteria for Chronic Rhinosinusitis

Core Symptom Requirements

The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) criteria require at least 2 of the following 4 cardinal symptoms persisting for ≥12 weeks: nasal blockage/obstruction/congestion, nasal discharge, facial pain/pressure/fullness, and decreased sense of smell/hyposmia/anosmia, with nasal blockage and nasal discharge being mandatory symptoms 1, 2, 3, 4
The American Academy of Otolaryngology recommends that symptoms alone are insufficient for diagnosis, and objective documentation of inflammation is required 1, 2, 3

The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) criteria require objective confirmation of inflammation through at least one of the following: nasal endoscopy, CT imaging, or other diagnostic methods 1, 2, 3
Nasal endoscopy is the preferred method for documenting inflammation, and it provides better visualization of the posterior nasal cavity, nasopharynx, and sinus drainage pathways 3
CT imaging is the gold standard for radiologic confirmation of CRS, and it is strongly recommended but not absolutely required for initial diagnosis 1, 2, 4

The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) criteria require symptoms to persist for ≥12 weeks, which distinguishes CRS from recurrent acute rhinosinusitis 1, 2, 3, 5

The American Academy of Otolaryngology recommends that CRS should not be diagnosed based on symptoms alone, as many conditions mimic CRS symptoms 2, 6
Anterior rhinoscopy is insufficient for diagnosis due to its low sensitivity and specificity, particularly in children <6 years old 5

The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) criteria recommend subclassifying CRS into three categories: CRS with nasal polyps, CRS without nasal polyps, and allergic fungal rhinosinusitis 1, 2, 4, 6

The American Academy of Otolaryngology recommends allergy testing in patients with recurrent or difficult-to-treat CRS, as up to 60% have significant allergic sensitivities to perennial allergens 3
Evaluation for underlying conditions such as immunodeficiency, ciliary dyskinesia, cystic fibrosis, anatomic abnormalities, and aspirin-exacerbated respiratory disease should be considered when CRS is refractory 2, 4

The American Academy of Otolaryngology recommends CT sinus imaging to rule out chronic rhinosinusitis (CRS) in patients with chronic symptoms, such as a 63-year-old female with chronic cough, postnasal drainage, nasal congestion, deviated septum, bilateral turbinate hypertrophy, and documented allergies who has failed multiple courses of antibiotics, systemic steroids, and budesonide nasal rinses 7
The European Position Paper on Rhinosinusitis (EPOS 2020) and the American Academy of Otolaryngology Clinical Practice Guideline support CT imaging after failure of appropriate medical treatment in patients with persistent symptoms 8, 7
The patient has completed 2-3 courses of antibiotics over the past year, received multiple courses of systemic steroids, and is currently on budesonide nasal rinses BID, but symptoms persist 7, 9, 10, 8
The Joint Task Force on Practice Parameters states that "CT and MRI may be useful to confirm diagnosis in patients with vague symptoms or if symptoms persist despite optimal medical treatment" 9, 10

The American Academy of Otolaryngology states that "CT of the paranasal sinuses should be obtained in diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis" 7
CT scan remains the gold standard for radiologic evaluation of CRS and is essential for confirming the diagnosis when symptoms alone are insufficient 8, 11
Symptoms alone have sensitivity of only 37-73% for CRS diagnosis, and up to 35% of patients with CRS have normal endoscopic findings, making imaging critical 11
CT provides objective documentation of inflammation, mucosal thickening, sinus ostial obstruction, and anatomical variants 7

The ACR Appropriateness Criteria for chronic cough specifically identifies upper airway cough syndrome (UACS)/CRS as a common cause and notes that "clinical evaluation of UACS is not sensitive and often not specific" 12, 11
Features of CRS may go unrecognized even by endoscopy in up to 35% of cases, and CT will help differentiate between anatomic obstruction requiring surgical intervention versus medical management 11, 7, 13
The patient has undergone bronchoscopy (normal), suggesting lower airway causes have been excluded and upper airway pathology is the likely source 12

The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) guidelines recommend starting intranasal corticosteroids immediately, as they are the most effective single agent for controlling both nasal congestion and improving sense of smell in CRS, with a regimen such as fluticasone propionate 2 sprays per nostril once daily for the first week, then 1-2 sprays per nostril once daily as needed 14, 15
Mometasone furoate 200 μg twice daily is equally effective and showed significant improvement in nasal obstruction, rhinorrhea, and sense of smell at 4 months in multiple trials, according to the Rhinology journal 14, 15

If CT confirms CRS with nasal polyps, the EPOS guidelines recommend continuing intranasal corticosteroids as first-line therapy, with consideration of short-term systemic corticosteroids if marked mucosal edema is present 14, 15, 16
For severe, recurrent CRS with nasal polyps, biologic therapy with dupilumab may be considered, which showed clinically significant improvements in SNOT-22 scores, smell scores, and nasal polyp scores at 4-6 months 17

The EPOS guidelines do not recommend adding montelukast to intranasal corticosteroids, as it was found to have no significant additional effect, unless patients cannot tolerate nasal corticosteroids 18, 16
Topical antifungals are not recommended, as multiple studies show no benefit for quality of life, symptoms, or disease signs in CRS patients 19