“I’ve got the sinus,” is a common patient complaint, but teasing out details is key to distinguishing chronic sinusitis from a constellation of other sinonasal conditions, said Amrita Ray, DO, MPH, an otolaryngologist at Henry Ford Health in Detroit, in a presentation at American College of Physicians Internal Medicine (ACP-IM) 2026 Meeting in San Francisco.

Ray presented a case of a patient whose symptoms appear several times a year and last for about a week, usually in conjunction with weather changes. Symptoms include nasal congestion, pus, and facial pressure, and improvement occurs with antibiotics and steroids.

The patient may have chronic rhinosinusitis, allergic rhinitis, chronic rhinosinusitis, a cold, or even a migraine, Ray said.

“The same cold that resolves in 5 days for one patient becomes a 3-week sinus infection for another, the difference is compounded triggers,” she said.

Preexisting factors that can influence the trajectory of disease fall into two categories. Intrinsic issues include septal deviation, a narrow ostiomeatal complex, or underlying immunodeficiencies or atopic disease. External triggers may include various allergens and environmental pollutants, such as smoke and household mold.

What Else Is It?

A diagnosis of chronic rhinosinusitis requires 12 weeks of at least two symptoms including nasal congestion, postnasal drip, facial pain, and reduced sense of smell. Objective findings must also be shown on a scope or CT scan, Ray said.

Properly diagnosing or ruling out chronic rhinosinusitis is essential for guiding the appropriate use of antibiotics, Ray said. Conditions that are strictly nasal in origin, in which sinus symptoms are secondary, do not necessarily need antibiotic treatment, she said.

But chronic rhinosinusitis shares overlapping symptoms with many diseases, making parsing out the driving force difficult, Ray said.

The starting point for doing so is a thorough history. Clinicians should ask patients about potential known irritants or triggers, prior allergy symptoms and testing or immunotherapy.

A thorough history also informs antibiotics decisions, with particular attention to comorbid conditions such as allergy and asthma. When treating chronic rhinosinusitis, antibiotics should be used selectively, said Alexander Duffy, MD, division chief of Rhinology & Anterior Skull Base Surgery at Temple University Hospital in Philadelphia, who was not at the presentation but weighed in on sinusitis management in primary care.

“For any sinus-related symptoms, the maximal benefit actually comes from symptomatic relief, and prescribing nasal saline rinses followed by intranasal corticosteroids, up to twice daily, can help even acute-phase symptoms,” Duffy said.

Several specific diagnoses warrant special consideration, Ray said. Gastroesophageal reflux can present with chronic throat clearing, a sore throat, and postnasal drip, she said. Frequent nasal symptoms — particularly those accompanied by sensitivity to light or sound — may indicate migraines. A neurology evaluation can help identify atypical facial pain patterns, which often mimic sinusitis on the surface.

Recent dental work, tooth root infections or impactions, teeth grinding, or complaints of foul smell or taste may signal odontogenic sinusitis, a dentally-driven cause of nasal complaints frequently overlooked, she said. If a patient notes additional complaints such as kidney or joint issues, consider an underlying vasculitis workup and referral to a rheumatologist, Ray said.

For suspected cases of chronic sinusitis, treatment should include nasal saline irrigations and nasal sprays such as topical antihistamines. These treatments can help during acute symptom flare ups, as well as reduce sinonasal inflammation and trigger burden.

Patients with chronic rhinosinusitis who continue to experience severe infections that negatively affect quality of life may benefit from surgery and should be referred, Ray said. The goal of surgery is not only to restore ventilation and drain pathways, but also to allow for mechanical clearance with saline alongside topical medical delivery, she said.

“Surgery won’t prevent you from getting sick but should help reduce the frequency and severity of those illnesses,” she said.

But patients should also “understand that ongoing medical therapy is still required postoperatively, and some individuals, particularly those with nasal polyps or aspirin-exacerbated respiratory disease, may require revision surgery,” Duffy said.

Patients with unilateral symptoms such as rhinorrhea and nasal polyps, and orbital signs such as proptosis, should receive prompt referrals to ear, nose, and throat specialists, Ray said.

Benefits of Biologics

Biologics represent a new chapter for patients who have chronic rhinosinusitis with nasal polyps, particularly those with asthma, Ray said. Current options include dupilumab, omalizumab, and mepolizumab. Biologic approval for patients may require documentation of the condition, failure on topical nasal steroids, and polyp recurrence despite surgery.

Randomized controlled trials have also shown benefits of biologics for chronic sinusitis. But these drugs are most often reserved for either nonsurgical candidates with comorbidities or patients who have failed an endoscopic sinus surgery and postoperative medical treatment, Duffy said.

For some patients, “surgery opens the door; biologics help keep it open,” Ray said.

Ray disclosed having no relevant financial conflicts of interest. Duffy disclosed having no relevant financial conflicts of interest.