Management of Chronic Rhinosinusitis with Decreased Sense of Smell

Clinical Diagnosis

The American Academy of Otolaryngology-Head and Neck Surgery defines chronic rhinosinusitis (CRS) by symptoms lasting more than 12 weeks, including nasal congestion, decreased sense of smell, intermittent nasal discharge, and headaches 1, 2
Seasonal worsening during winter months suggests a possible allergic component, according to the Journal of Allergy and Clinical Immunology 3
A history of preceding upper respiratory infection is a common trigger for CRS, as noted by the Journal of Allergy and Clinical Immunology 4

The American Academy of Otolaryngology-Head and Neck Surgery recommends intranasal corticosteroids as primary treatment for CRS symptoms, which can effectively reduce nasal congestion, inflammation, and improve sense of smell 5, 6
Twice-daily dosing of intranasal corticosteroids is more effective than once-daily for symptom control, according to Rhinology 7
Saline nasal irrigation should be used concurrently with intranasal corticosteroids to clear mucus, reduce inflammation, and improve medication delivery, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 5, 8

Nasal endoscopy is essential for evaluating the presence of nasal polyps, purulent discharge, or anatomical abnormalities, and for distinguishing between CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP), according to the Mayo Clinic Proceedings 1, 4
A CT scan of sinuses may be considered if symptoms persist despite medical therapy, to clarify the extent of disease and provide objective documentation of inflammation, as recommended by the Journal of Allergy and Clinical Immunology 1, 4

A short course of oral corticosteroids may be considered if severe symptoms persist or nasal polyps are identified on endoscopy, particularly for improving sense of smell in CRS with nasal polyps, according to the Journal of Allergy and Clinical Immunology 3
Leukotriene modifiers, such as montelukast, may be considered as add-on therapy to intranasal corticosteroids to improve symptoms of headache and sense of smell, as noted by Rhinology 7, 6
Nasal decongestants may be used short-term (≤3 days) to help with severe congestion, but should be used cautiously to avoid rebound congestion, according to Rhinology 7

Decreased sense of smell is a cardinal symptom of CRS, particularly CRS with nasal polyps, and may improve with intranasal corticosteroids, but often requires longer treatment duration, as noted by the Mayo Clinic Proceedings 1, 3
Seasonal worsening suggests a possible allergic component that may benefit from antihistamines during exacerbations, according to the Journal of Allergy and Clinical Immunology 3, 4

Symptoms should be reassessed after 4 weeks of initial therapy, and if improvement occurs, intranasal corticosteroids should be continued as maintenance therapy, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 7, 5
If minimal or no improvement, nasal endoscopy and CT imaging should be considered to evaluate the extent of disease and provide objective documentation of inflammation, according to the Mayo Clinic Proceedings 1

Twice daily (2 times per day) is the most commonly studied and recommended frequency for normal saline irrigation in chronic rhinosinusitis, as recommended by the American Academy of Otolaryngology, with a moderate strength of evidence 9, 10
For acute symptoms or post-operative care, frequency can be increased to 3-4 times daily for better symptom control, according to the American Rhinologic Society, with a low strength of evidence 11
In clinical studies, normal saline nasal spray has been used 3-6 times daily for 2 weeks with a good safety profile, as reported by the European Rhinologic Society, with a high strength of evidence 12

High-volume, low-pressure delivery systems (like neti pots or squeeze bottles) provide better sinus penetration than nasal sprays, as stated by the American Academy of Allergy, Asthma, and Immunology, with a high strength of evidence 13
Normal saline (isotonic) is generally better tolerated than hypertonic saline, with fewer side effects such as nasal irritation, according to the American College of Allergy, Asthma, and Immunology, with a moderate strength of evidence 9, 14
Room temperature saline is as effective as warmed saline (40°C) for improving symptoms, as reported by the European Academy of Allergy and Clinical Immunology, with a low strength of evidence 15

For post-surgical patients (after FESS), normal saline can be used up to 4 times daily during the early recovery period, as recommended by the American Academy of Otolaryngology, with a moderate strength of evidence 11

Start with twice daily irrigation (morning and evening) for most cases of chronic sinusitis, as recommended by the American Academy of Otolaryngology, with a moderate strength of evidence 9, 10
If symptoms are severe or during acute exacerbations, increase to 3-4 times daily, according to the American Rhinologic Society, with a low strength of evidence 11