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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Symptoms >12 weeks: congestion, facial pain, rhinorrhoea, hyposmia
- CRS without polyps (CRSsNP) and CRS with polyps (CRSwNP)
- First-line: intranasal steroid + saline irrigation — minimum 3-month trial
- CT sinuses if medical treatment fails or before FESS
- FESS for refractory symptoms
- Samter's triad: polyps + asthma + NSAID sensitivity
Overview
Chronic rhinosinusitis is persistent sinus mucosal inflammation >12 weeks. CRSwNP is associated with asthma and aspirin-exacerbated respiratory disease (Samter's triad). Nasal polyps are benign, pedunculated, pale grey, insensate masses from the ethmoid sinuses.
Epidemiology
Affects ~11% of UK adults. More common >30 years. 25–30% have polyps. Risk factors: allergic rhinitis, asthma, smoking, immunodeficiency, CF, PCD.
Clinical Features
Symptoms
Persistent nasal congestion >12 weeks
Facial pain/pressure
Purulent discharge
Hyposmia/anosmia — especially CRSwNP
Unilateral polyp or progressive unilateral symptoms — exclude malignancy
Signs
Nasal polyps: pale, grey, insensate, pedunculated on rhinoscopy
Mucopurulent discharge in middle meatus
Investigations
First-line
Nasal endoscopyIdentifies polyps, mucopurulent drainage
Second-line
CT sinusesAfter failed medical therapy or before FESS
Specialist
Nasal biopsyIf unilateral polyp — exclude inverted papilloma/malignancy
Sweat testIf CF suspected (young patient with CRS + bronchiectasis)
Management
EPOS 2020 and NICE CKS1
Medical (3-month trial)
- Intranasal steroid (mometasone/fluticasone) daily
- Saline nasal irrigation
- Short oral prednisolone for severe CRSwNP with anosmia
2
If medical therapy fails
- ENT referral, CT sinuses
- Low-dose macrolide (clarithromycin 250 mg OD for 3 months) for CRSsNP
3
Surgery
- FESS: widen ostia, remove polyps, restore drainage
- Post-op: continued steroid + saline essential
4
Biologics for severe CRSwNP
- Dupilumab (anti-IL-4/13) or mepolizumab (anti-IL-5) — specialist only
Complications
- Anosmia: Profound in CRSwNP
- Asthma exacerbation
- Mucocoele
- Polyp recurrence: 40–60% after surgery
UKMLA Exam Tips
- 1Polyps: PALE, GREY, INSENSATE — distinguishes from turbinates (pink, sensate)
- 2Samter's triad: polyps + asthma + aspirin/NSAID sensitivity
- 3Unilateral polyp → biopsy. Bilateral = benign CRSwNP
- 4CT NOT first-line — only after failed medical therapy
- 5In children: nasal polyps suggest CF until proven otherwise
- 6Kartagener syndrome: situs inversus + bronchiectasis + CRS (PCD)
practicetest your knowledge on chronic sinusitisApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — ent and beyond.
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