In brief
Chronic rhinosinusitis is an inflammatory disease of the nose and paranasal sinuses, with or without polyps. According to EPOS 2020, in adults it requires symptoms for at least 12 weeks and objective confirmation by endoscopy and/or CT; treatment ranges from medical therapy to FESS and biologic drugs.
Chronic rhinosinusitis (CRS) is an inflammatory disease of the nose and paranasal sinuses. It is not simply “sinusitis that lasts a long time”: diagnosis requires persistent symptoms and an objective assessment, because nasal blockage, discharge, facial pain and reduced sense of smell can have different causes. There are two main forms: chronic rhinosinusitis with nasal polyps (CRSwNP) and chronic rhinosinusitis without nasal polyps (CRSsNP, sine nasal polyps).
When is it chronic rhinosinusitis?
According to EPOS 2020, in adults symptoms must be present for at least 12 weeks. There must be at least two symptoms, at least one of which is nasal obstruction/congestion or anterior or posterior nasal discharge; facial pain or pressure and reduced or lost sense of smell may also be present. In specialist practice, the diagnosis is supported by objective findings on nasal endoscopy and/or CT of the paranasal sinuses.
What I consider in the assessment
| Parameter | Why it matters |
|---|---|
| Duration of symptoms | The 12-week threshold separates the chronic form from acute forms. |
| Nasal obstruction | Must be distinguished from a deviated septum, turbinate hypertrophy, rhinitis and other causes of a blocked nose. |
| Nasal/post-nasal discharge | Its site, appearance and side help to guide the assessment. |
| Sense of smell | Hyposmia and anosmia are common, especially in CRS with polyps. |
| Nasal endoscopy | Shows polyps, swelling, secretions and the anatomy of the nasal cavities. Findings are described with standardised scores: Lund-Kennedy and, for polyps, NPS (0–8). |
| CT of the paranasal sinuses | Documents the site and extent of disease when indicated and helps with surgical planning. Extent is measured with the Lund-Mackay score (0–24): on each side the maxillary sinus, anterior and posterior ethmoid, sphenoid and frontal sinus are scored (0 normal, 1 partial opacification, 2 complete), plus the ostiomeatal complex (0 or 2). |
| Nasal polyps | Distinguish CRS with polyps (CRSwNP) from CRS without polyps (CRSsNP). |
| SNOT-22 questionnaire | A validated questionnaire that measures the impact of the disease on quality of life and helps to follow its course over time. |
| Asthma and N-ERD | Important comorbidities, especially in forms with type 2 inflammation. |
| Eosinophils and other biomarkers | May help to characterise the inflammation in selected patients. |
| Previous surgery and systemic corticosteroids | Help to define the history, severity and control of the disease. |
Assess your symptoms: the SNOT-22 questionnaire
The SNOT-22 (Sino-Nasal Outcome Test) is a validated questionnaire with 22 items scored from 0 to 5, referring to the last two weeks. Repeated over time, it shows the effect of treatment. The online version on this site is the validated Italian version; at the consultation the questionnaire can be completed in English.
How to read the score: in chronic rhinosinusitis not controlled by medical treatment, with scores above 30 endoscopic surgery brings a noticeable improvement in more than 3 out of 4 patients, whereas below 20 the average benefit is small. Details and sources (in Italian).
If you have nasal polyps, you can enter your score in the tool below, which compares your data with the criteria for biologic drugs.
Self-check: could I be a candidate for a biologic drug?
A guidance tool for patients with nasal polyps. Enter the data you know (many can be found in your consultation and test reports). The calculation runs only in your browser: no data are saved or sent.
Criteria taken from the Italian Medicines Agency (AIFA) treatment plans for severe nasal polyps (NPS ≥ 5, SNOT-22 ≥ 50, age ≥ 18, failure of systemic steroids and/or surgery) and from the EPOS/EUFOREA 2023 recommendations (at least 3 of 5 criteria after surgery). The tool is for guidance only: assessing the indication, choosing the drug and prescribing it are the specialist’s responsibility. Reimbursement criteria in other countries may differ.
Chronic rhinosinusitis with and without nasal polyps: not the same disease
The distinction between CRSwNP (with nasal polyps) and CRSsNP (without polyps) is only the first level. Today the assessment also tends to consider phenotype, comorbidities and inflammatory mechanisms. In severe forms with polyps, asthma or N-ERD, type 2 inflammation may be particularly relevant.
Chronic rhinosinusitis and cystic fibrosis
In cystic fibrosis, the defect in the CFTR protein makes mucus thick not only in the bronchi but also in the nose and paranasal sinuses. Almost all patients show sinus changes on CT, and some develop nasal polyps, even in childhood. Reported symptoms are often mild compared with what endoscopy and CT show: this is why regular ENT assessment is useful even without obvious complaints.
The paranasal sinuses can act as a reservoir of bacteria such as Pseudomonas aeruginosa, which can reach the lower airways. Care of the nose is therefore part of the overall care of the disease, particularly in patients who are candidates for, or have already had, a lung transplant.
In children, nasal polyps are a warning sign that should prompt consideration of cystic fibrosis, to be checked with a sweat test and assessment at the reference centre.
The care pathway
- multidisciplinary assessment together with the cystic fibrosis centre (respiratory physician, paediatrician, respiratory physiotherapist and other specialists);
- nasal endoscopy, the SNOT-22 questionnaire, smell assessment and, when indicated, CT of the paranasal sinuses;
- medical treatment: high-volume nasal irrigation and nasal corticosteroids, with any additional topical treatments agreed with the centre;
- endoscopic surgery when obstruction or symptoms persist despite treatment, if sinus infections drive respiratory exacerbations, or ahead of lung transplantation;
- CFTR modulators: the most recent treatments have shown improvement in sinonasal symptoms, sense of smell and CT findings. ENT follow-up makes it possible to measure these effects and to assess whether and when surgery is still needed.
Dr Puya Dehgani-Mobaraki is part of the working group of the Umbria regional care pathway (PDTA) for cystic fibrosis and is responsible for the ENT part of the pathway at the Gubbio-Gualdo Tadino Hospital.
Treatment: a stepwise, personalised pathway
Treatment depends on the type of CRS, its severity, comorbidities and the response to previous treatments. Nasal irrigation and intranasal corticosteroids play a central role in many patients. Endoscopic sinus surgery (ESS/FESS) may be indicated when the disease remains inadequately controlled despite appropriate medical treatment. In severe uncontrolled nasal polyps, biologic drugs may also be indicated in selected patients.
Read more: nasal polyps and biologic drugs · FESS: before and after surgery (in Italian) · nasal irrigation (in Italian).
Scientific research and care pathway (PDTA)
Dr Puya Dehgani-Mobaraki is a co-author of the Italian Academy of Rhinology care pathway (PDTA) for type 2 chronic rhinosinusitis, published in 2023, which covers the diagnostic and therapeutic pathway, phenotyping, surgery and biologic therapies.
- Canevari FR, Giorli A, Monti G, Biagini C, Bagnasco D, Cavaliere C, Pipolo C, De Corso E, Gelardi M, Gramellini G, Ioppi A, La Mantia I, Malvezzi L, Bignami M, Dehgani-Mobaraki P, Seccia V, Maggiore G, Macchi A. Diagnostic therapeutic assistance pathway (PDTA) of type 2 chronic rhinosinusitis. Front Allergy 2023;4:1237131. doi:10.3389/falgy.2023.1237131. PubMed.
- Fokkens WJ, et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2020. Rhinology, 2020. DOI.
- Orlandi RR, et al. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis 2021. Int Forum Allergy Rhinol, 2021. PubMed.
- Kimple AJ et al. Cystic Fibrosis Foundation otolaryngology care multidisciplinary consensus recommendations. Int Forum Allergy Rhinol 2022. PubMed
- Efficacy of Elexacaftor-Tezacaftor-Ivacaftor on chronic rhinosinusitis in cystic fibrosis. 2024. PubMed
- Cystic fibrosis-related chronic rhinosinusitis: the key role of a comprehensive evaluation in the era of highly effective modulator therapy. 2024. PubMed
Author: Dr Puya Dehgani-Mobaraki, specialist in Otorhinolaryngology and Head and Neck Surgery. Last reviewed: September 2026. The information is for general education and does not replace an individual medical assessment.