"Cold" Lasting 5 Months - What It Really Is and How to Manage It

Step 1: Reframe the Diagnosis

Step 2: Initial Workup

• Clinical history + examination - duration, quality of symptoms, triggers, associated asthma, aspirin sensitivity
• Nasal endoscopy - look for polyps, mucosal oedema, mucopus in middle meatus
• Skin prick testing or specific IgE - rule in/out allergic component
• CT sinuses - if medical treatment fails (not first-line imaging)
• Consider: FBC, IgG/A/M levels if recurrent infections suspected (immune deficiency workup)

Step 3: Medical Management

First-Line (All Patients)

• Fluticasone propionate, mometasone, budesonide sprays
• Strong Cochrane evidence: improves symptom scores (SMD -0.46, P<0.00001) and reduces polyp size (SMD -0.73, P<0.00001)
• Safe long-term - second-generation agents have very low systemic bioavailability
• Delivery technique matters: head tilted forward, aim spray laterally toward the eye
• Must use consistently for at least 4-8 weeks before assessing response
• Scott-Brown's Otorhinolaryngology, Vol 1, p.1109

• Large-volume (e.g. NeilMed bottle or neti pot) isotonic or hypertonic saline
• Cochrane evidence supports benefit both alone and as an adjunct to INCS
• Improves mucociliary clearance, removes mucus, crusts, and inflammatory mediators
• Large volume > simple sprays for mucus management
• Generally well tolerated; recommended for all CRS patients
• Scott-Brown's Otorhinolaryngology, Vol 1, p.1110

Second-Line (Based on Phenotype)

• Prednisolone 0.5 mg/kg/day for 5-7 days
• Used in CRS with nasal polyps (CRSwNP) for rapid symptom control or pre-operatively
• Not for long-term use due to systemic side effects

• Low-dose macrolides (e.g. clarithromycin 250 mg daily, erythromycin 250 mg BD) for 12-24 weeks
• Work via anti-inflammatory mechanism, NOT antimicrobial
• Best evidence in CRS without polyps (CRSsNP) + normal IgE (non-eosinophilic type)
• Caution with increasing macrolide resistance and GI side effects
• Scott-Brown's Otorhinolaryngology, Vol 1, p.1110

• Indicated if allergic rhinitis is a driver (perennial or seasonal)
• Oral non-sedating (cetirizine, loratadine, fexofenadine) or intranasal (azelastine)
• Combined INCS + antihistamine sprays (e.g. Dymista = fluticasone + azelastine) have additive benefit

• Adjunct in CRSwNP with concomitant asthma or allergic rhinitis
• Mixed evidence for CRS alone; more benefit in patients with nasal allergy
• Scott-Brown's Otorhinolaryngology, Vol 1, p.1110

For Refractory / Severe Cases

• Dupilumab (anti-IL-4Rα): now approved for CRSwNP with eosinophilic disease - a 2024 systematic review (PMID 39149992) comparing dupilumab vs sinus surgery found comparable efficacy in polyp reduction
• Omalizumab (anti-IgE): significant reduction in symptom scores and polyp size in PCRCTs
• Mepolizumab (anti-IL-5): significant effect on polyp size
• Reserved for patients who fail maximal medical therapy and/or post-sinus surgery recurrence
• Scott-Brown's Otorhinolaryngology, Vol 1, p.1110-1111

• For Samter's triad (nasal polyps + asthma + aspirin sensitivity)
• Incrementally increasing aspirin doses to achieve tolerance, maintained long-term
• Reduces polyp recurrence rates

Step 4: When to Refer for Surgery

• Symptoms persist after maximal medical therapy (INCS + saline + appropriate adjuncts for 8-12 weeks minimum)
• CT confirms significant sinus disease (Lund-Mackay score)
• Nasal polyps causing significant obstruction
• Suspected focal abnormality (foreign body, fungal ball, odontogenic source)
• Complications of sinusitis (orbital, intracranial)

Step 5: Red Flags - Do Not Miss

• Unilateral symptoms (raises concern for neoplasm)
• Epistaxis + nasal obstruction (nasopharyngeal carcinoma)
• Orbital symptoms (proptosis, diplopia, periorbital swelling)
• Neurological signs
• Crusting with blood-stained discharge (vasculitis, e.g. GPA/Wegener's)
• Systemic symptoms (weight loss, fever)

Summary Management Pathway

5 months nasal symptoms
        ↓
Exclude red flags → urgent ENT
        ↓
History + nasal endoscopy + allergy testing
        ↓
CRS confirmed (±polyps) / Allergic Rhinitis
        ↓
1st line: INCS (4-8 weeks) + saline irrigation
        ↓
Allergic component? → Add antihistamine ± montelukast
        ↓
Non-eosinophilic CRS? → Consider macrolide 12-24 weeks
        ↓
Polyps / severe disease? → Oral steroid short course
        ↓
Failed maximal medical therapy?
        ↓
ENT referral → CT sinuses → FESS ± biologic therapy