Chronic Sinusitis Treatment: Medical Approach, FESS and Post-Operative Care

Chronic rhinosinusitis (CRS) is defined as inflammation of the paranasal sinuses lasting more than 12 weeks. Clinical criteria: at least two major symptoms — nasal obstruction, nasal discharge (anterior/posterior), facial pressure/pain, reduction in smell (hyposmia/anosmia). Supported by endoscopy or CT findings.

Two main clinical phenotypes: CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP). The polypoid form shows yellowish-grey mass-like soft tissue inside the nose. Histologically, the polyp form is dominated by eosinophilic inflammation.

Aetiology is multifactorial: anatomical narrowing (septal deviation, turbinate hypertrophy), allergy, immune dysfunction, biofilm, fungal aetiology, odontogenic source, environmental factors (smoking, air pollution). Rarely a single cause; multifactorial interaction is typical. Related service: our general ENT services.

Diagnosis begins with clinical history — symptom duration, frequency, prior treatments, allergy history, smoking, systemic conditions (asthma, cystic fibrosis, immunodeficiency). The aspirin sensitivity + nasal polyps + asthma triad ("Samter's triad" / NSAID-exacerbated respiratory disease) is characteristic.

Endoscopy: assessment of polyps, mucosa, septum, turbinates and sinus ostia. The Lund-Kennedy endoscopic score (0-12) quantifies disease severity.

CT (paranasal sinus CT): the gold standard for surgical planning. Visualises mucosal thickening, polyps, anatomical variants (concha bullosa, Onodi cell), bony pathology. The Lund-Mackay score (0-24) quantifies findings. MRI is usually not needed, but is performed for suspected orbital/intracranial complications.

Allergy testing (skin prick or specific IgE) and complete blood count (eosinophilia) help clarify aetiology. With anosmia, smell tests (Sniffin' Sticks) can be performed.

In CRS treatment the principle is "medical first". Adequate medical therapy for at least 3 months should be tried before surgery is considered. First-line drugs: intranasal corticosteroids (mometasone, fluticasone, budesonide). Locally acting with minimal systemic effect — safe for long-term use (3-6 months).

Saline irrigation (nasal lavage): isotonic (0.9%) or hypertonic (2-3%) saline used 1-2 times daily. Improves mucus clearance, reduces mucosal oedema, decreases allergen-irritant contact. Sinus rinse bottles or neti pots are used. The "low-tech, high-impact" part of treatment.

Antibiotics: in acute exacerbations (purulent discharge, increased facial pain, fever) 2-3 weeks of amoxicillin-clavulanate or doxycycline. Low-dose macrolide (clarithromycin, erythromycin) for 3-6 months can be used for anti-inflammatory effect in non-eosinophilic CRS.

Oral corticosteroids: a short (1-2 week) low-dose prednisolone course in polypoid CRS shrinks polyps and relieves symptoms. Long-term use is not recommended due to systemic effects. Biologics (dupilumab — anti-IL-4/13 antibody) are a newer option in severe polypoid CRS; used as alternative to or to prevent recurrence after surgery.

If medical therapy fails or chronic complications occur (mucocele, orbital cellulitis, fungal ball), surgery enters the picture. Functional Endoscopic Sinus Surgery (FESS) — developed in the 1980s by Stammberger and Messerklinger — is the modern gold standard.

The surgical philosophy: instead of removing all diseased tissue, open the natural drainage pathways of the sinuses (osteomeatal complex). Performed through the nose with an endoscope; no external incisions. Soft tissue resection is precise; anatomical planes are preserved. Maintaining bony orientation is critical for surgical success.

Which sinuses are opened varies: depending on disease, maxillary (ethmoid infundibulum + maxillary ostium), anterior ethmoid, posterior ethmoid, frontal, sphenoid. "Total ethmoidectomy + middle meatal antrostomy + frontal sinusotomy" is the broadest procedure.

Operative time 1-3 hours (depending on extent), general anaesthesia, hospital stay usually 1 day. Internal packing stays 1-3 days; once removed, the patient goes home. Healing takes 4-6 weeks. Step-by-step details: sinusitis (FESS) page.

Post-FESS care is half of surgical success. Inadequate post-op care results in recurrence (new polyps, adhesions, drainage obstruction). First week: after pack removal, isotonic saline irrigation 4-6 times/day, antibiotics 1-2 weeks if needed.

Endoscopic debridement: in clinic at 1, 3 and 6 weeks after surgery — gentle removal of crusts, fibrin adhesions and granulation tissue. Prevents adhesions and supports mucosal healing. Missing these visits substantially worsens surgical outcomes.

Long-term follow-up: intranasal corticosteroid continues at least 6-12 months. Saline irrigation is recommended for life (especially with polyps). Early intervention is essential for any sign of recurrence (obstruction, loss of smell). Avoid air pollution, smoke, allergen exposure.

In polypoid CRS, recurrence is high — 40-60% at 5 years. Biologics (dupilumab) are an additional option. New-generation drug-eluting stents (mometasone-releasing implants) can be placed in the sinus during surgery, providing local steroid and preventing adhesions.

FESS is a very safe surgery in experienced hands — complication rate 1-5%. Anatomical proximity (orbit, skull base, optic nerve, internal carotid) demands careful technique.

Minor complications (3-5%): bleeding (intra- or post-op), adhesions, transient hyposmia, frontal headache. Most resolve spontaneously or with simple intervention.

Major complications (0.1-0.5%): orbital haematoma (needs urgent decompression), CSF leak (cribriform plate injury — endoscopic repair), blindness (optic nerve injury, very rare), internal carotid injury (life-threatening — needs specialised expertise).

Hence surgeon selection matters — surgeons performing 100+ FESS/year have markedly lower complication rates than low-volume surgeons. Image-guided (navigation) systems improve safety in complex anatomy.

There is much CRS patients can do daily. Smoking cessation is essential — smoking impairs mucociliary clearance, sustains inflammation and reduces surgical success. Passive smoke is also harmful.

Saline irrigation should be part of the daily routine — like brushing teeth, made habit. Morning and evening, twice daily, is enough. Correct technique: deliver lavage into one nostril, allow it to exit the other or the mouth.

Allergy management: patients allergic to house dust mites, pollen or animal dander combine trigger avoidance + intranasal steroid + antihistamine. Allergen immunotherapy is effective in selected cases.

General health: humid environment (humidifier in winter-heated rooms), staying indoors on high-pollution days, regular exercise (immune support), good nutrition. These measures easily support sinus health. We share patient experiences on our Istanbul ENT services.