#chronicsinusitis

Australia has one of the most accessible and high-quality radiology ecosystems in the world. In NSW in particular, a competitive private imaging market has delivered rapid access, excellent technology, and broad geographic coverage. For patients, this is a clear strength.

For clinicians, however, it has introduced a growing problem:

fragmentation of imaging care and over-reliance on radiology reports

These two issues intersect in a way that directly affects how we diagnose and manage sinus disease.

The Core Principle: Look at the Scan

In rhinology, one principle remains fundamental:

Always review the images—not just the report

Radiology reports almost never conclude that the sinuses are “normal.” Instead, they frequently describe:

mucosal thickening partial opacification retention cysts “features of sinusitis”

For non-specialists—and for patients reading their own reports—this language implies disease. But in many cases, it does not reflect clinically meaningful pathology.

What Does “Normal” Actually Look Like?

We addressed this directly in our systematic review of sinus imaging in asymptomatic populations.

Across 16,966 individuals with no sinus symptoms, the findings were clear (1):

Mean Lund-Mackay score: 2.24 ~15% had a score ≥4 13% had mucous retention cysts 17.7% had mucosal thickening ≥2 mm

The implication is straightforward:

Incidental sinus findings are common—and often normal

This is a critical point for both clinicians and patients. CT imaging is highly sensitive, but it does not distinguish between physiological variation and disease.

Simple mucosal cysts are present in 13% of all patients and thickening of mucosa of 2-4mm is common in normal asymptomatic patients.

The Clinical Disconnect

Radiologists are doing exactly what they should—describing structural findings.

But sinus disease is not defined by imaging alone.

It requires:

symptoms (nasal obstruction, discharge, smell loss, etc.) objective findings (endoscopy ± imaging) clinical context

Without this, imaging findings risk being over-interpreted.

This leads to a familiar pattern:

patients labelled with “sinusitis” based on imaging antibiotics prescribed unnecessarily referrals driven by reports rather than symptoms persistent confusion when treatment fails

Why Reviewing the Images Matters

A written report cannot fully capture:

distribution of disease (localised vs diffuse) anatomical variation surgical relevance correlation with symptoms

When you review the scan yourself, you can distinguish between:

incidental change → common, non-contributory clinically relevant disease → requiring treatment

For example:

mild maxillary mucosal thickening in an asymptomatic patient → likely normal diffuse ethmoid disease with anosmia → clinically significant

This level of interpretation cannot be outsourced.

A New Problem: Fragmentation of Imaging Access

At the same time, accessing imaging has become more difficult.

Despite improved availability, we now face:

multiple radiology providers separate portals for each group different usernames, passwords, and 2FA systems locked accounts from failed logins difficulty accessing prior imaging across providers

The result is paradoxical:

More imaging—but less usable continuity

For surgeons, this affects:

comparison over time surgical planning confidence in decision-making

A Practical Solution: A Central Access Resource

To address this, I have created this page as a practical tool for ENT surgeons and referrers.

Instead of searching for individual radiology portals each time, you can:

select your state choose the radiology provider access the image portal directly

👉 Bookmark this page and use it as a central access point.

Radiology Image Access Finder

Select your state, then choose a radiology provider. The button will open the doctor / referrer image access portal.

Loading radiology access data...

State Select state NSW ACT QLD VIC SA NT TAS WA Radiology Group Select radiology group Open Doctor / Referrer Image Access Portal

This is a simple step—but one that can significantly reduce friction in daily clinical practice. Message me if there is update or correction required.

For Patients: Bring the Images

Patients should be encouraged to:

bring their imaging (USB or digital access) use consistent providers where possible understand that reports may not reflect disease

A report is helpful—but it is not definitive.

Listen to the Evidence

For a deeper discussion of incidental sinus findings and their clinical implications, you can listen to our podcast

OTO: Sinus Radiological Findings in General Asymptomatic Populations: A Systematic Review of Incidental Mucosal Changes

:

Conclusion

Modern rhinology requires more than access to imaging—it requires interpretation, context, and clinical judgement.

CT scans are sensitive—but not specific Reports describe findings—but do not define disease Access to imaging is improving—but continuity is worsening

The responsibility remains with the clinician.

If you don’t review the scan yourself, you risk treating the report—not the patient.

Reference 

Razi B, Perkovic A, Alvarado R, Stroud A, Ho J, Kalish LH, Campbell RG, Sacks R, Harvey RJ. Sinus radiological findings in general asymptomatic populations: a systematic review of incidental mucosal changes. Otolaryngol Head Neck Surg. 2022;167(1):16–24.

FAQ section

Why should ENT surgeons review sinus CT images themselves?

Because radiology reports describe findings, but ENT surgeons must decide whether those findings are clinically relevant.

Are minor sinus CT abnormalities common?

Yes. Studies show that mucosal thickening, retention cysts, and low Lund-Mackay scores are common even in people without sinus symptoms.

Does mucosal thickening mean sinusitis?

Not always. Mild mucosal thickening may be incidental and must be interpreted alongside symptoms and endoscopy.

Why are prior scans important?

Prior scans allow clinicians to compare changes over time, which is often essential for diagnosis and surgical planning.

Why is radiology access difficult in Australia?

Why “Chronic Sinusitis” and “Nasal Polyps” Are Misleading Terms

Understanding why modern rhinology is moving beyond these outdated disease labels

For decades, patients and doctors alike have used the term chronic sinusitis to describe persistent inflammation of the sinuses. It is one of the most commonly used diagnoses in ear, nose and throat (ENT) practice.

But there is a problem.

The term chronic sinusitis — or chronic rhinosinusitis (CRS) — is not actually a disease.

It is a description of inflammation, not an explanation of why that inflammation occurs.

In many ways, using the term “chronic sinusitis” today is like respiratory physicians describing asthma, COPD, bronchiectasis, and interstitial lung disease collectively as “chronic lungitis.”

No respiratory specialist would accept such a vague diagnosis. Yet in rhinology, we still routinely use a similarly imprecise term.

As our understanding of sinus disease improves, it is becoming increasingly clear that CRS is not one disease, but a group of very different conditions that share a common symptom — chronic inflammation of the sinus lining.

The Problem With the Term “Chronic Sinusitis”

The word sinusitis simply means inflammation of the sinuses.

But inflammation is a final pathway, not a diagnosis.

Inflammation can be caused by many different mechanisms:

allergy

immune dysregulation from the epithelial barrier

infection

genetic disease

mucociliary dysfunction

Grouping all of these under the same label risks oversimplifying the disease and potentially misdirecting treatment.

Nasal polyps are msimply the endpoint of chronic inflmmation and dont describe a specidfic disease condition

Historically, CRS was classified using a simple system:

CRS with nasal polyps

CRS without nasal polyps

While simple, this system ignores the biological diversity of sinus disease.

As research has advanced, it has become clear that these categories fail to reflect the underlying causes or mechanisms of inflammation.

Why “Nasal Polyps” Is Also a Misleading Diagnosis

The term nasal polyps is equally problematic.

A polyp is not a disease — it is a tissue response to chronic inflammation.

In other words, polyps are an endpoint of tissue remodeling, not the cause of the disease itself.

Many different conditions can produce tissue changes that look like nasal polyps.

Examples include:

Primary diffuse type-2 inflammatory CRS

Allergic fungal sinusitis (AFS)

Cystic fibrosis

Central compartment atopic disease (CCAD)

Respiratory epithelial adenomatoid hamartoma (REAH)

Antrochoanal polyps

These conditions have very different causes and treatments, yet they may all be described using the same label: “nasal polyps.”

Video:Polypoid degeneration of the sinus mucosa in cystic fibrosis. We understand that this condition wont respond to modern day biologics but then we dont discuss the ambiguity when treating non-CF CRS patients

This is why saying a patient “has nasal polyps” is often clinically incomplete.

It is similar to diagnosing someone with “a lung nodule” without explaining whether it is infection, inflammation, or cancer.

A Shift Toward Precision Medicine in Sinus Disease

Modern medicine is moving toward precision medicine — tailoring treatment based on the underlying mechanism of disease.

This approach has transformed the treatment of many inflammatory diseases, particularly asthma.

Asthma is no longer considered a single disease. Instead, it is divided into different endotypes, each driven by distinct inflammatory pathways.

The same shift is now occurring in rhinology.

Researchers and clinicians increasingly recognize that different forms of CRS require different treatments.

This is particularly important in the era of biologic therapies, including:

dupilumab

mepolizumab

tezepelumab

These medications target specific immune pathways and can cost tens of thousands of dollars per year.

Using them effectively requires accurate identification of the underlying disease mechanism.

The EPOS 2020 Classification of CRS

Recognising these challenges, the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS2020) proposed a more biologically meaningful classification of sinus disease.

Instead of focusing on the presence or absence of polyps, the new framework classifies primary CRS based on:

Anatomic distribution

Inflammatory endotype

This approach helps identify different clinical phenotypes that require different treatments.

Figure: Contemporary classification of primary chronic rhinosinusitis based on anatomical distribution and inflammatory endotype, adapted from EPOS2020 and Grayson et al. Step 1: Anatomical Distribution

Primary CRS may be divided into:

Localized disease

Examples include:

isolated frontal sinusitis

isolated sphenoid sinusitis

ostiomeatal complex disease

These conditions often behave more like mechanical or obstructive diseases.

Diffuse disease

Diffuse disease involves broader inflammation across the sinus system and is typically associated with systemic inflammatory pathways.

This category includes conditions such as:

eosinophilic CRS

central compartment atopic disease

allergic fungal sinusitis

Step 2: Inflammatory Endotype

The next layer of classification focuses on the dominant immune pathway.

Two major patterns are recognised:

Type-2 (Th2) inflammation

This pathway involves cytokines such as IL-4, IL-5, and IL-13 and is associated with:

eosinophilic inflammation

asthma

nasal polyps

corticosteroid responsiveness

Many modern biologic drugs target this pathway.

Non–Type-2 inflammation

These conditions involve different immune pathways and often behave differently clinically.

Examples include:

older onset disease

smokers

corticosteroid-resistant CRS

From Classification to Real Clinical Phenotypes

When anatomical distribution and inflammatory endotype are combined, a range of distinct CRS phenotypes emerges.

Examples include:

Central compartment atopic disease (CCAD)

Eosinophilic CRS (eCRS)

Allergic fungal sinusitis (AFS)

Non-eosinophilic CRS

Each has characteristic patterns of symptoms, imaging findings, and treatment responses.

CRS is not all the same and it dictates treatment

Understanding these phenotypes allows clinicians to move beyond a simple “one size fits all” approach to sinus disease.

Why This Matters for Patients

For patients, the terminology used to describe disease can directly influence treatment decisions.

Two people diagnosed with “chronic sinusitis” may actually have completely different diseases requiring different therapies.

For example:

A patient with localized sinus obstruction may benefit primarily from surgery.

A patient with type-2 inflammatory disease may benefit from:

corticosteroids

biologic therapy

long-term inflammatory control.

Without recognising these differences, treatment can become trial-and-error.

Rethinking the Language of Sinus Disease

Medicine evolves as knowledge grows.

Just as asthma has evolved from a single diagnosis into multiple inflammatory subtypes, sinus disease is undergoing a similar transformation.

The terms “chronic sinusitis” and “nasal polyps” remain useful as broad descriptions, but they should not be considered final diagnoses.

Instead, they are starting points.

Behind those labels lies a complex group of conditions with distinct causes, biology, and treatments.

Recognising these differences is essential if we are to move toward precision medicine in rhinology.

And perhaps one day, the term chronic sinusitis will seem just as outdated as calling every lung disease “chronic lungitis.”

References

Fokkens WJ, Lund VJ, Hopkins C, et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2020. Rhinology. 2020.

Grayson JW, Hopkins C, Mori E, Senior B, Harvey RJ. Contemporary classification of chronic rhinosinusitis beyond polyps vs no polyps. JAMA Otolaryngol Head Neck Surg. 2020.

Grayson JW, Cavada M, Harvey RJ. Clinically relevant phenotypes in chronic rhinosinusitis. J Otolaryngol Head Neck Surg. 2019.

Frequently Asked Questions About Chronic Sinusitis

What is chronic sinusitis (CRS)?

Chronic sinusitis, also called chronic rhinosinusitis, describes persistent inflammation of the sinus lining lasting more than 12 weeks. It is not a single disease but a group of conditions with different underlying causes.

Are nasal polyps a disease?

No. Nasal polyps are not a disease themselves. They are a tissue response to chronic inflammation and can occur in many different sinus conditions.

What causes chronic sinusitis?

Many different processes can cause chronic sinus inflammation including allergy, immune dysfunction, infection, microbial imbalance, genetic diseases such as cystic fibrosis, and type-2 inflammatory conditions.

Why is CRS classification important?

Different types of CRS respond to different treatments. Understanding the underlying inflammatory pathway helps doctors choose the most effective therapy, including surgery, steroids, or biologic medications.

What is type-2 inflammation in sinus disease?

Type-2 inflammation is an immune pathway involving cytokines such as IL-4, IL-5 and IL-13. It is commonly associated with eosinophilic CRS, asthma, and nasal polyps and is the target of modern biologic therapies.

What is the EPOS classification of CRS?

Are there any triggering factors for sinus headache ?

Do you often get headaches around the forehead, eyes, or nose and wonder why they keep coming back? 🤕 Many people don’t realize that common triggers like allergies, infections, weather changes, or blocked sinuses can lead to painful sinusitis headaches. Understanding the exact triggers is the first step to preventing them and finding lasting relief.

📖 Full medical explanation here: https://healthuseful.com/what-triggers-sinusitis-headaches/

ENT doctors use medications, suction cleaning, balloon sinuplasty & advanced FESS surgery to clear chronic sinus blockage safely.

Learn how your sinuses are treated 👃

Remission in Chronic Rhinosinusitis with Nasal Polyps (CRSwNP): Why “Feeling Better” Is No Longer Enough

For years, success in chronic rhinosinusitis with nasal polyps (CRSwNP) meant one thing: the patient feels better.

But in 2025, that is no longer our goal.

With the arrival of biologic therapies for nasal polyps—including dupilumab, mepolizumab, and benralizumab—the target has shifted. In other airway diseases, especially asthma, the conversation has moved beyond symptom improvement toward a more ambitious endpoint: remission. Severe asthma remission has been defined as a composite state (no exacerbations, no systemic corticosteroids, sustained symptom control, stable objective measures, over time).(1) Real-world studies show that remission is achievable in a meaningful subset of biologic-treated asthma patients.(2,3)

CRSwNP shares overlapping type 2 inflammatory biology with asthma and responds to targeted biologics.(4–7) So the obvious question is:

Should we aim for remission in nasal polyps too?

The answer is yes—but CRS is structurally different.

Why Sinus Surgery Changes the Remission Conversation

Unlike asthma, we can surgically modify the anatomy in CRSwNP.

Procedures such as complete sphenoethmoidectomy and extended surgery (e.g., Draf IIc/III) reshape the inflammatory environment, improve topical access, and reduce persistent diseased compartments.(8–10) Distribution studies demonstrate that extended frontal procedures can improve irrigation penetration compared with more limited frontal approaches.(9)

Recent evidence also shows that surgical completeness predicts disease trajectory and may influence response to subsequent biologic therapy. CT-based measures of completeness such as ACCESS (Amsterdam Classification of Completeness of Endoscopic Sinus Surgery) quantify how complete surgery is and have been linked to outcomes.(11) Similarly, the Completion of Surgery Index (CoSI) provides another structured approach to capturing adequacy of surgical extent.(12)

Our recent study—Extent of sinus surgery is associated with disease control in biologic treated type-2 dominant CRS—found that extended neo-sinuis surgery  was strongly associated with achieving disease control in biologic-treated patients.(13) Clincial remisison achieved in 60%+ of patients.

In other words: surgical completeness matters.

So remission in CRSwNP cannot be defined by symptoms alone.

CRSwNP Remission vs. Symptom Improvement

Traditionally, studies report:

Change in SNOT-22

Change in polyp score

Corticosteroid use

Avoidance of revision surgery

These are essential metrics and remain central in consensus guidance.(14,15) But they measure improvement, not a stable disease state.

A patient can be polyp-free yet still require repeated systemic corticosteroids. That is not remission.

That is partial control.

Partial control in nasal polyps

What Should Remission in Nasal Polyps Look Like?

A practical remission framework for CRSwNP should include multiple domains, similar to other inflammatory diseases:

Complete Clinical Remission (≥12 months)

Read the full guide by an ENT specialist 👇

👨‍⚕️ Dr Sagar Rajkuwar (MS-ENT) ENT Specialist | Nashik www.entspecialistinnashik.com

Yes! Gut imbalance, acid reflux, and food sensitivities can trigger inflammation, excess mucus, and chronic sinus congestion.

If you have bloating + sinus pressure together, your gut–sinus connection may be the reason.

👉 Learn how improving gut health can support long-term sinus relief.

👨‍⚕️ Dr Sagar Rajkuwar (MS-ENT) ENT Specialist | Nashik www.entspecialistinnashik.com