Chronic rhinosinusitis without nasal polyps

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Evidence last reviewed: 2 Jul 2026

Topic last updated: 31 Jul 2026

Chronic rhinosinusitis is inflammation of the paranasal sinuses lasting more than 12 weeks.

Diagnosis is initially clinical. Nasal endoscopy may show inflammation, purulent discharge, edema, or frank polyps.

Initial medical treatment includes nasal saline irrigation and topical intranasal corticosteroids. Oral antibiotics, oral corticosteroids, antihistamines, and leukotriene receptor antagonists (LTRAs) may also be considered.

Computed tomography is needed if initial medical treatment fails.

Functional endoscopic sinus surgery is very effective for patients unresponsive to medical treatment.

Definition

Chronic rhinosinusitis (commonly known as chronic sinusitis) is a persistent inflammatory condition affecting the nose and paranasal sinuses. It is diagnosed when at least two cardinal symptoms (mucopurulent nasal drainage, nasal blockage or obstruction, facial pain/pressure/fullness, and hyposmia) are present along with objective evidence of inflammation for a duration exceeding 12 weeks.[1][2]

Chronic rhinosinusitis can be classified into two groups, with and without (sine) polyps. This topic does not cover chronic rhinosinusitis in the presence of nasal polyps. See Nasal polyps.

History and exam

Key diagnostic factors

facial pain/pressure
nasal obstruction
nasal discharge/postnasal drip
purulence
headache

Full details

Other diagnostic factors

fatigue
cough
hyposmia/anosmia
fever
halitosis
dental pain
ear pain/pressure

Full details

Risk factors

ciliary dysfunction
allergic rhinitis
asthma/airway hyperreactivity
previous sinus surgery
dental disease
immunodeficiency
severe mid-septal deviations
concha bullosa deformity
paradoxically bent middle turbinates
foreign bodies
craniofacial anomalies
smoking
environmental pollution
sarcoidosis
granulomatosis with polyangiitis

Full details

Diagnostic tests

1st tests to order

anterior rhinoscopy
nasal endoscopy

Full details

Tests to consider

sinus CT
sinus MRI
nasal/sinus cultures
allergy testing

Full details

Treatment algorithm

ACUTE

chronic rhinosinusitis

ONGOING

continued symptoms despite medical therapy

Contributors

Authors

Raj Sindwani, MD, FACS, FRCS

Professor

Otolaryngology-Head and Neck Surgery

Neurological Surgery

Section of Rhinology and Endoscopic Skull Base Surgery

Head and Neck Surgery Department

Integrated Surgical Institute

Cleveland Clinic Foundation

Cleveland, OH

Disclosures

RS declares that he has no competing interests.

Christopher Roxbury, MD

Associate Professor

Otolaryngology-Head and Neck Surgery

Neurological Surgery

Section of Rhinology and Endoscopic Skull Base Surgery

Head and Neck Surgery Department

Integrated Surgical Institute

Cleveland Clinic Foundation

Cleveland, OH

Disclosures

CR declares that he has no competing interests.

Acknowledgements

Dr Raj Sindwani and Dr Christopher Roxbury would like to acknowledge Dr Jastin Antisdel, a previous contributor to this topic.

Peer reviewers

Ryland P. Byrd, Jr, MD

Professor

James H. Quillen College of Medicine

East Tennessee State University

Johnson City

Disclosures

RPB declares that he has no competing interests.

Thomas Sanford, MD

Assistant Professor of Otolaryngology - Head and Neck Surgery

St Louis University School of Medicine

St Louis

Disclosures

TS declares that he has no competing interests.

Ozgur Yigit, MD

Chief

ENT Department

Istanbul Training and Research Hospital

Istanbul

Turkey

Disclosures

OY declares that he has no competing interests.

Christos Georgalas, MD, PhD, DLO, FRCS (ORL-HNS)

Assistant Professor/Consultant

Academic Medical Center

Amsterdam

The Netherlands

Disclosures

CG declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Payne SC, McKenna M, Buckley J, et al. Clinical practice guideline: adult sinusitis update. Otolaryngol Head Neck Surg. 2025 Aug;173(suppl 1):S1-56.Full text Abstract

Peters AT, Spector S, Hsu J, et al. Diagnosis and management of rhinosinusitis: a practice parameter update. Ann Allergy Asthma Immunol. 2014 Oct;113(4):347-85. Abstract

Fokkens WJ, Lund VJ, Hopkins C, et al. European Position Paper on rhinosinusitis and nasal polyps 2020. Rhinology. 2020 Feb 20;58(suppl s29):1-464. Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Acute rhinosinusitis
- Allergic rhinitis
- Allergic fungal rhinosinusitis
More Differentials
Guidelines
- Clinical practice guideline: adult sinusitis update
- Clinical practice guideline: surgical management of chronic rhinosinusitis
More Guidelines
Patient information
Sinusitis
More Patient information
Videos
How to examine the nasal cavity
More videos
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Chronic rhinosinusitis without nasal polyps

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

chronic rhinosinusitis

continued symptoms despite medical therapy

Contributors

Authors

Raj Sindwani, MD, FACS, FRCS

Disclosures

Christopher Roxbury, MD

Disclosures

Acknowledgements

Peer reviewers

Ryland P. Byrd, Jr, MD

Disclosures

Thomas Sanford, MD

Disclosures

Ozgur Yigit, MD

Disclosures

Christos Georgalas, MD, PhD, DLO, FRCS (ORL-HNS)

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice