Chronic rhinosinusitis

Nasal polyps are benign, typically bilateral outgrowths of edematous nasal mucosa driven by chronic mucosal inflammation, most often arising with chronic rhinosinusitis, aspirin-exacerbated respiratory disease, or cystic fibrosis. Unilateral polyps or a mass that does not respond to treatment must be biopsied to exclude tumor.

Acute rhinosinusitis is inflammation of the nasal cavity and paranasal sinuses lasting up to 4 weeks, presenting with purulent nasal discharge plus nasal obstruction or facial pain/pressure/fullness. Most cases are viral and treated with acetaminophen/ibuprofen plus nasal saline irrigation alone; a minority are bacterial, identified by persistence beyond 10 days, a biphasic worsening course, or severe onset, and treated with amoxicillin-clavulanate 875/125 mg PO every 12 hours for 5 to 7 days.

Allergic rhinitis is an IgE-mediated inflammation of the nasal mucosa causing sneezing, rhinorrhea, congestion, and itch on allergen exposure, classified as seasonal or perennial. Diagnosis is clinical, supported by skin or specific IgE testing to identify allergens, and treatment is allergen avoidance with intranasal corticosteroids first-line, escalating to combination therapy and allergen immunotherapy.

Asthma is a chronic inflammatory airway disorder causing episodic, reversible airflow obstruction confirmed by spirometry or bronchial challenge testing. Management is a stepwise ladder led by inhaled glucocorticoids plus as-needed SABA or ICS-formoterol, escalating to biologics for severe type 2-high disease, with an oral glucocorticoid burst and frequent SABA for exacerbations.

Allergic (atopic) asthma is the most common asthma phenotype, an IgE-mediated eosinophilic airway inflammation triggered by aeroallergens, presenting with episodic wheeze, cough, and dyspnea in an atopic patient. Diagnosis combines demonstrated variable airflow obstruction with evidence of allergen sensitization, and treatment is inhaled corticosteroid-based controller therapy with allergen avoidance and, for severe disease, anti-IgE or anti-eosinophil biologics.

Cystic fibrosis is an autosomal recessive CFTR chloride-channel disorder causing thick secretions, bronchiectasis, and exocrine pancreatic insufficiency, diagnosed by elevated sweat chloride confirmed with CFTR genotyping and managed with CFTR modulators, airway clearance, and pancreatic enzyme replacement.

Acute invasive fungal rhinosinusitis is an angioinvasive infection of the sinonasal mucosa by Mucorales species or Aspergillus in immunocompromised or diabetic ketoacidosis patients that causes vascular thrombosis and tissue necrosis. It is a surgical and infectious disease emergency requiring same-day biopsy, emergent debridement, and high-dose liposomal amphotericin B, with mortality up to 60-80% even with therapy.

Septic thrombosis of the cavernous sinus from spreading facial, sinus, or orbital infection, marked by fever, proptosis, chemosis, and cranial nerve palsies that classically become bilateral. It is a neuro-ophthalmic emergency treated with immediate broad-spectrum IV antibiotics, source control, and consideration of anticoagulation.

Orbital cellulitis is infection of the fat and muscle posterior to the orbital septum, most often from spreading sinusitis, that causes proptosis, painful ophthalmoplegia, and vision loss and can progress to cavernous sinus thrombosis. It is a vision- and life-threatening emergency treated with admission, blood and tissue culture, orbital/sinus CT or MRI, and immediate empiric IV vancomycin plus ceftriaxone with ophthalmology and ear, nose, and throat (ENT) involvement.

Osteomyelitis is bone infection from hematogenous seeding or contiguous spread, most often from Staphylococcus aureus, presenting as subacute pain with or without a draining sinus tract and confirmed by bone biopsy culture. Empiric antibiotics are withheld until biopsy in a stable patient, and treatment combines source control with 4 to 6 weeks of culture-directed antibiotics, extended to 6 weeks or indefinite suppression for hardware-associated or chronic disease.