ent.chronic-rhinosinusitis.core.v1PRODUCTION

ent.chronic-rhinosinusitis.core.v1

Chronic rhinosinusitis (CRSsNP vs CRSwNP, biologic-era ladder, EPOS 2020 / AAO-HNS 2015)

general_internal_medicinechronicsubacuteadultgeriatric

Hard-required inputs

0 / 10

Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame as a CHRONIC outpatient engine: 12-week symptom + objective evidence (endoscopy or CT) to confirm CRS, then phenotype-by-polyp (CRSwNP vs CRSsNP), then run the EPOS 2020 / AAO-HNS 2015 stepped ladder. Recognise AERD, AFRS, secondary causes (CF/PCD/GPA/sarcoid), and the RED-FLAG mimics (orbital, intracranial, invasive fungal). Acute invasive complications, surgical FESS, and invasive fungal disease are routed OUT, not authored here.

Inputs

Actions

Advance rule

Set

Advance when

chronic-CRS scope confirmed; orbital/intracranial/invasive-fungal mimics flagged for routing

Severity triggers (6)

6 need judgement

informationallife_threateningorbital_or_intracranial_extension
Proptosis / ophthalmoplegia / vision change (orbital extension), OR severe headache + meningismus + focal neuro (intracranial extension), OR Pott puffy tumour (frontal-bone osteomyelitis with subperiosteal abscess) — emergent complications of acute-on-chronic sinusitis (EPOS 2020 PMID 32077450)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateninginvasive_fungal_sinusitis_immunocompromised
Immunocompromised host (poorly controlled diabetes with DKA, prolonged neutropenia, recent transplant, advanced HIV) with sinus pain + black eschar / palatal ulcer / rapidly evolving sinus signs — INVASIVE FUNGAL SINUSITIS (mucormycosis, invasive Aspergillus) (EPOS 2020 PMID 32077450)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderateuncontrolled_type2_crswnp_biologic_eligible
CRSwNP meeting EPOS 2020 biologic eligibility: bilateral polyps + ≥3 of significant QoL (SNOT-22 high), smell loss, comorbid asthma, ≥2 OCS courses/year, prior FESS or surgical contraindication — type-2 endotype anchor (eos ≥250 or IgE elevated) (Fokkens PMID 32077450; Bachert PMID 31543428; Gevaert PMID 32524991; Han PMID 33872587)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderateaerd_samter_triad
Asthma + CRSwNP + NSAID/aspirin hypersensitivity (Samter triad / aspirin-exacerbated respiratory disease) — distinct disease-modifying pathway (EPOS 2020 PMID 32077450)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderaterefractory_to_maximal_medical_referral_for_FESS
Persistent CRS despite ≥4-8 weeks of adherent Step 1-3 therapy AND ≥1 short oral-CS course (CRSwNP > CRSsNP) — surgical evaluation indicated; CT-PNS Lund-Mackay maps surgical anatomy (EPOS 2020 PMID 32077450)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderaterecurrent_acute_sinusitis_4_per_year
≥4 episodes of distinct acute rhinosinusitis per year (recurrent acute, NOT chronic) — managed on this engine after the 4th event (EPOS 2020 PMID 32077450; AAO-HNS 2015)
Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RED_FLAGSoptionalDrives screening

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Recommended regimen

Chronic rhinosinusitis — phenotype-stepped medical ladder → FESS → biologic for uncontrolled type-2 CRSwNP

axis: crs_phenotype_stepped_medical_to_biologicstep 1 - Step 1 — Foundation (ALL CRS): high-volume saline irrigation + topical INCS

Selected step "Step 1 — Foundation (ALL CRS): high-volume saline irrigation + topical INCS" — Confirmed CRS (≥12 weeks symptoms + endoscopy or CT objective evidence) — both CRSwNP and CRSsNP; foundation that runs INDEFINITELY across all subsequent steps (EPOS 2020 Fokkens PMID 32077450; AAO-HNS 2015)

high_volume_saline_nasal_irrigation_240mL_BID
first line
mucociliary_clearance_irrigation
triggers: confirmed_crs_baseline_for_all_subtypes
EPOS 2020 (PMID 32077450) — daily high-volume saline irrigation reduces symptoms and is the indispensable mechanical foundation; superior to low-volume sprays for CRS; safety is excellent
mometasone furoate (intranasal)
first line
intranasal_corticosteroid
2 sprays each nostril (200 mcg total) once daily — or BID in moderate-severe disease • intranasal • once-daily to BID (max: 400 mcg/day total)
triggers: confirmed_crs_baseline_for_all_subtypes
EPOS 2020 (PMID 32077450) — topical INCS is the central pharmacologic foundation for both CRSsNP and CRSwNP; mometasone or fluticasone are the canonical agents. Counsel correct technique: head-tilt forward, contralateral hand, aim laterally to avoid the septum (lowers epistaxis risk)
rxcui 108118
fluticasone propionate (intranasal)
first line
intranasal_corticosteroid
2 sprays each nostril (200 mcg total) once daily • intranasal • once daily (max: 400 mcg/day total)
triggers: confirmed_crs_baseline, mometasone_intolerance_or_preference
EPOS 2020 (PMID 32077450) — interchangeable with mometasone as foundational INCS; minimal systemic absorption
rxcui 41126

outpatient playbook — drug actions (4)

1. saline irrigation 240 mL BID (foundation, all CRS)
240 mL BID • intranasal_irrigation • BID
trigger: Confirmed CRS — both subtypes
EPOS 2020 foundation, indefinite
2. mometasone furoate intranasal 200 mcg once-daily or BID (foundation, all CRS)
rxcui 108118
200 mcg once-daily to BID • intranasal • once-daily to BID
trigger: Confirmed CRS — both subtypes
EPOS 2020 PMID 32077450 — central pharmacologic foundation; correct-technique counselling
3. budesonide off-label irrigation 1 mg in 240 mL BID for CRSwNP step-up
rxcui 19831
1 mg in 240 mL • intranasal_irrigation • BID
trigger: CRSwNP refractory to Step 1 after 4-8 weeks of adherent use
EPOS 2020 PMID 32077450 — off-label adjunct, better mucosal penetration
4. prednisone 30-40 mg/day × 5-10 days for acute exacerbation
rxcui 8640
0.5 mg/kg/day, typical 30-40 mg • PO • once daily × 5-10 days
trigger: Acute CRS exacerbation; track courses/year
EPOS 2020 — short course only; ≥2/year = uncontrolled = biologic-eligible

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Nasal obstruction / nasal discharge persisting ≥12 weeks (± facial pain/pressure, hyposmia/anosmia) — the dominant CRS entry per EPOS 2020 (Fokkens Rhinology PMID 32077450) and AAO-HNS Adult Sinusitis CPG 2015; Persistent hyposmia / anosmia ± nasal obstruction — strongly skewed toward CRSwNP / type-2 phenotype, biologic-eligibility entry (Gevaert JACI 2020 PMID 32524991; Bachert Lancet 2019 PMID 31543428); Incidental finding of paranasal-sinus mucosal disease / polyposis on CT or MRI in a symptomatic patient — endoscopy + symptom-screen to confirm CRS (EPOS 2020 PMID 32077450).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Chronic rhinosinusitis (CRSsNP vs CRSwNP, biologic-era ladder, EPOS 2020 / AAO-HNS 2015)** (ent.chronic-rhinosinusitis.core.v1).
Phenotype framing: Terminal differential: PRIMARY-CRS CRSsNP (predominantly non-type-2/mixed) vs PRIMARY-CRS CRSwNP (predominantly type-2 eosinophilic) vs AERD (CRSwNP + asthma + NSAID-intolerance pivot) vs AFRS (allergic fungal — eosinophilic mucin + fungal hyphae + heterogeneous CT + type-I-hypersensitivity pivot) vs ODONTOGENIC sinusitis (unilateral maxillary + dental source pivot) vs SECONDARY-CRS (CF/PCD/GPA/sarcoid/IgG4 — systemic-feature pivot, reframe and route out) vs invasive fungal sinusitis (immunocompromised + necrosis pivot — emergency, route out). The choice of pathway flows from this branch.
Scope: Frame as a CHRONIC outpatient engine: 12-week symptom + objective evidence (endoscopy or CT) to confirm CRS, then phenotype-by-polyp (CRSwNP vs CRSsNP), then run the EPOS 2020 / AAO-HNS 2015 stepped ladder. Recognise AERD, AFRS, secondary causes (CF/PCD/GPA/sarcoid), and the RED-FLAG mimics (orbital, intracranial, invasive fungal). Acute invasive complications, surgical FESS, and invasive fungal disease are routed OUT, not authored here.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Chronic rhinosinusitis — phenotype-stepped medical ladder → FESS → biologic for uncontrolled type-2 CRSwNP** — step "Step 1 — Foundation (ALL CRS): high-volume saline irrigation + topical INCS".
1. high_volume_saline_nasal_irrigation_240mL_BID (mucociliary_clearance_irrigation, first line) — EPOS 2020 (PMID 32077450) — daily high-volume saline irrigation reduces symptoms and is the indispensable mechanical foundation; superior to low-volume sprays for CRS; safety is excellent
2. mometasone furoate (intranasal) 2 sprays each nostril (200 mcg total) once daily — or BID in moderate-severe disease intranasal once-daily to BID (intranasal_corticosteroid, first line) — EPOS 2020 (PMID 32077450) — topical INCS is the central pharmacologic foundation for both CRSsNP and CRSwNP; mometasone or fluticasone are the canonical agents. Counsel correct technique: head-tilt forward, contralateral hand, aim laterally to avoid the septum (lowers epistaxis risk)
3. fluticasone propionate (intranasal) 2 sprays each nostril (200 mcg total) once daily intranasal once daily (intranasal_corticosteroid, first line) — EPOS 2020 (PMID 32077450) — interchangeable with mometasone as foundational INCS; minimal systemic absorption

Setting playbook (outpatient) — Diagnose CRS against EPOS 2020 / AAO-HNS 2015 criteria, phenotype CRSwNP vs CRSsNP via endoscopy, run the stepped medical → surgical → biologic ladder, and establish longitudinal rhinology + allergy / asthma co-management
4. saline irrigation 240 mL BID (foundation, all CRS) 240 mL BID intranasal_irrigation BID — Confirmed CRS — both subtypes (EPOS 2020 foundation, indefinite)
5. mometasone furoate intranasal 200 mcg once-daily or BID (foundation, all CRS) 200 mcg once-daily to BID intranasal once-daily to BID — Confirmed CRS — both subtypes (EPOS 2020 PMID 32077450 — central pharmacologic foundation; correct-technique counselling)
6. budesonide off-label irrigation 1 mg in 240 mL BID for CRSwNP step-up 1 mg in 240 mL intranasal_irrigation BID — CRSwNP refractory to Step 1 after 4-8 weeks of adherent use (EPOS 2020 PMID 32077450 — off-label adjunct, better mucosal penetration)
7. prednisone 30-40 mg/day × 5-10 days for acute exacerbation 0.5 mg/kg/day, typical 30-40 mg PO once daily × 5-10 days — Acute CRS exacerbation; track courses/year (EPOS 2020 — short course only; ≥2/year = uncontrolled = biologic-eligible)

Non-pharmacologic actions:
- Saline-irrigation technique demonstration at first visit (head-tilt, contralateral hand)
- INCS-spray technique demonstration (head-tilt forward, aim laterally)
- Smoking-cessation counselling at every visit
- Asthma co-management (united-airways) and allergy / immunotherapy referral when atopic
- FESS referral for refractory disease or anatomic indications (route OUT)
- Biologic eligibility worksheet (EPOS 2020 criteria) when CRSwNP uncontrolled despite Steps 1-3 ± surgery
- Aspirin-desensitisation referral when AERD confirmed (specialist centre)

AVOID / contraindication checks:
- Do not anchor on CRS when orbital or intracranial extension present (recognise red flags, route OUT emergently — EPOS 2020)
- Invasive fungal sinusitis in immunocompromised is NOT CRS (black eschar / rapid progression / DM or neutropenic / transplant — emergent debridement + amphotericin, route OUT)
- Short course OCS ≥2 per year defines uncontrolled disease not a sustainable strategy (EPOS 2020 — escalate to surgery or biologic, do not normalise chronic OCS)
- Long term systemic corticosteroid maintenance not recommended for CRSwNP (HPA suppression, glucose, BP, bone, mood — use INCS + budesonide irrigation + biologic instead)
- Azithromycin macrolide QT and ototoxicity screen (long course low dose is OPTION for non type 2 CRSsNP only; baseline ECG; counsel)
- Biologic NOT first line must follow adequate medical and usually surgical therapy (EPOS 2020 biologic eligibility criteria; payer / shared decision)
- Dupilumab conjunctivitis and transient eosinophilia counsel (clinically usually mild; eosinophilia rarely requires therapy)
- Omalizumab anaphylaxis rare but mandates first dose observation (per label)
- Aspirin desensitisation only in experienced centres (anaphylaxis / severe bronchospasm risk; never DIY)
- INCS correct technique counselling required (head tilt forward, contralateral hand, aim laterally — wrong technique drives epistaxis + non response)

Monitoring

Regimen monitoring:
- SNOT-22 at each visit drives step up or step down (EPOS 2020 PMID 32077450)
- nasal endoscopy lund kennedy at each visit
- smell quantification UPSIT or sniffin sticks baseline and followup
- oral corticosteroid courses per year tracked explicitly (≥2 per year = uncontrolled; biologic-eligibility metric)
- asthma control ACT and exacerbation rate if comorbid (united-airways)
- biologic response at 6 months NPS SNOT22 smell OCS use asthma control (non-responders reassess endotype / switch)
- long-term INCS minimal systemic effect but monitor IOP cataract in high dose users

Setting (outpatient) monitoring:
- SNOT-22 + Lund-Kennedy endoscopy + smell at each visit (3-6-monthly stable, more frequent post-biologic / post-surgery)
- Track oral-corticosteroid courses per year explicitly (the biologic-eligibility metric)
- Asthma control (ACT, exacerbations) if comorbid
- Biologic response at 6 months (NPS, SNOT-22, smell, OCS-use, asthma control)

Follow-up plan: Longitudinal chronic-disease arc: every 3-6 months stable, 4-6 weeks after biologic start / surgery, urgent if uncontrolled flare. Allergy testing + immunotherapy decision for atopic / AFRS. Asthma co-management (CRSwNP and asthma are united-airways; treat in parallel). Smoking cessation. Patient education on irrigation technique + INCS technique (head-tilt, contralateral hand) — adherence is the dominant determinant of medical-ladder success. Pregnancy planning conversation (biologic timing).
- Close-out criterion: structured longitudinal plan + allergy / asthma co-management + adherence-coaching documented

Monitoring phase: Track at every 3-6-month review: SNOT-22 trend, Lund-Kennedy endoscopy score, smell (UPSIT/Sniffin-Sticks), oral-corticosteroid usage in past year (key uncontrolled-disease metric), asthma control if comorbid (ACT, exacerbations). On biologics: response at 6 months by SNOT-22 + NPS + smell + asthma control + oral-CS use — non-responders (no improvement in ≥3 domains) should be reassessed for endotype / switch / continued surgery. Long-term INCS systemic absorption is minimal but monitor IOP and cataract risk in long-term high-dose users.

Disposition

Current setting: outpatient — Diagnose CRS against EPOS 2020 / AAO-HNS 2015 criteria, phenotype CRSwNP vs CRSsNP via endoscopy, run the stepped medical → surgical → biologic ladder, and establish longitudinal rhinology + allergy / asthma co-management

Disposition criteria:
- Stable CRS on phenotype-appropriate ladder → continued outpatient longitudinal management
- Red-flag complication → emergent admit / route OUT by engine_id

Escalation triggers (move to higher acuity):
- Orbital signs (proptosis, vision change, ophthalmoplegia) → emergent IV abx + ENT/ophth, route OUT
- Intracranial signs (severe headache, meningismus, focal neuro, Pott puffy tumour) → emergent neurosurg, route OUT
- Immunocompromise + sinus invasion + black eschar / palatal ulcer → INVASIVE FUNGAL SINUSITIS, emergent surgical debridement + amphotericin, route OUT
- Severe uncontrolled asthma flare in AERD → asthma pathway
- Refractory disease despite maximal medical therapy + 1 prior FESS → biologic ladder

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Proptosis / ophthalmoplegia / vision change (orbital extension), OR severe headache + meningismus + focal neuro (intracranial extension), OR Pott puffy tumour (frontal-bone osteomyelitis with subperiosteal abscess) — emergent complications of acute-on-chronic sinusitis (EPOS 2020 PMID 32077450)
- [LIFE_THREATENING] Immunocompromised host (poorly controlled diabetes with DKA, prolonged neutropenia, recent transplant, advanced HIV) with sinus pain + black eschar / palatal ulcer / rapidly evolving sinus signs — INVASIVE FUNGAL SINUSITIS (mucormycosis, invasive Aspergillus) (EPOS 2020 PMID 32077450)
- [MODERATE] CRSwNP meeting EPOS 2020 biologic eligibility: bilateral polyps + ≥3 of significant QoL (SNOT-22 high), smell loss, comorbid asthma, ≥2 OCS courses/year, prior FESS or surgical contraindication — type-2 endotype anchor (eos ≥250 or IgE elevated) (Fokkens PMID 32077450; Bachert PMID 31543428; Gevaert PMID 32524991; Han PMID 33872587)

Citations

- EPOS 2020 — European Position Paper on Rhinosinusitis and Nasal Polyps (Fokkens et al, Rhinology 2020 PMID 32077450) — the global authority; AAO-HNS Adult Sinusitis CPG 2015 update remains the US algorithm floor. Biologic-era anchors: LIBERTY-NP SINUS-24/52 dupilumab (Bachert Lancet 2019 PMID 31543428), POLYP 1/2 omalizumab (Gevaert JACI 2020 PMID 32524991), SYNAPSE mepolizumab (Han Lancet Respir Med 2021 PMID 33872587). All PMIDs live-PubMed-verified 2026-05-26. [PMID:32077450](https://pubmed.ncbi.nlm.nih.gov/32077450/)
- Cited evidence (PMID 31543428) [PMID:31543428](https://pubmed.ncbi.nlm.nih.gov/31543428/)
- Cited evidence (PMID 32524991) [PMID:32524991](https://pubmed.ncbi.nlm.nih.gov/32524991/)
- Cited evidence (PMID 33872587) [PMID:33872587](https://pubmed.ncbi.nlm.nih.gov/33872587/)

Last reconciled with current guidelines: 2026-05-26.

References

EPOS 2020 — European Position Paper on Rhinosinusitis and Nasal Polyps (Fokkens et al, Rhinology 2020 PMID 32077450) — the global authority; AAO-HNS Adult Sinusitis CPG 2015 update remains the US algorithm floor. Biologic-era anchors: LIBERTY-NP SINUS-24/52 dupilumab (Bachert Lancet 2019 PMID 31543428), POLYP 1/2 omalizumab (Gevaert JACI 2020 PMID 32524991), SYNAPSE mepolizumab (Han Lancet Respir Med 2021 PMID 33872587). All PMIDs live-PubMed-verified 2026-05-26. — PMID:32077450
Cited evidence (PMID 31543428) — PMID:31543428
Cited evidence (PMID 32524991) — PMID:32524991
Cited evidence (PMID 33872587) — PMID:33872587

Clinical Commander