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BackTable / ENT / Article
Chronic Rhinosinusitis & ‘Brain Fog’: How to Treat Cognitive Dysfunction in CRS
Audrey Qian • Updated Jul 22, 2025 • 69 hits
Chronic Rhinosinusitis (CRS) is traditionally characterized by nasal congestion, runny nose, facial pressure, and reduced sense of smell and taste. However, many patients also report cognitive difficulties, commonly described as ‘brain fog,’ that extend beyond the scope of sinonasal complaints. Emerging evidence indicates that nearly half of CRS patients may experience some degree of cognitive dysfunction – difficulty concentrating, slow thinking, and poor mental clarity. These deficits may be present even in patients with nasal obstruction only.
Recognizing and addressing cognitive dysfunction can not only improve overall quality of life but also guide more individualized treatment strategies. Dr. Aria Jafari, otolaryngologist and Assistant Professor at University of Washington, explains cognitive screening practices in clinics and the importance of a more holistic and patient-centered treatment strategy for CRS.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Cognitive dysfunction, or “brain fog,” affects approximately 50% of patients with CRS, with higher-order attention deficits identified through both subjective cognitive assessments like the NIH Neuro-QOL Short Form and objective measures like the Stroop test.
• Cognitive dysfunction can inform CRS treatment planning. Improvement with anti-inflammatory therapies may support earlier consideration of surgical or biological treatment, while persistent cognitive symptoms may prompt neurology referral or consideration of adjunctive therapies.
• Emerging diagnostic tools, including eye movement tracking and functional neuroimaging, show promise in objectively evaluating CRS-related cognitive changes and may complement current self-reported quality-of-life tests like the SNOT-22.
• Recognizing CRS as a systemic, “whole-life” disease rather than one limited to nasal symptoms can enhance patient-centered care by acknowledging cognitive dysfunction as a valid and actionable aspect of disease burden.
Table of Contents
(1) Incorporating Cognitive Screening into Chronic Rhinosinusitis Evaluation
(2) How Cognitive Dysfunction Guides Chronic Rhinosinusitis Management
(3) Chronic Rhinosinusitis as a Whole-Life Disease: Cognitive Assessments & Adjunctive Therapies
Incorporating Cognitive Screening into Chronic Rhinosinusitis Evaluation
Cognitive dysfunction, colloquially referred to as “brain fog,” is reported in approximately 50% of CRS patients seen in clinic, according to data from a study utilizing the NIH Neuro-QOL Short Form. This screening tool, which is a self-administered Likert-scale tool that assesses perceived cognitive challenges, such as slow thinking, difficulty in concentrating, and trouble with mental arithmetics; has been integrated into sinus clinics for informative cognitive assessment. Interestingly, cognitive dysfunction is not exclusive to patients with polypoid disease or significant inflammation – about 10% of patients with nasal obstruction alone also report symptoms of brain fog.
Objective neuropsychological testing, such as the Stroop test, further elucidates the nature of cognitive dysfunction in CRS. Patients tend to perform adequately on basic tasks but struggle with interference-based tests requiring higher-order executive function. Medical treatment for CRS has been associated with improvements in the Stoop test performance, supporting a potential reversibility of cognitive dysfunction.
[Dr. Aria Jafari]
I think it's important to know that not every patient with sinusitis has brain fog. [chuckles] That's one thing that I think we should just discuss off the bat. We did a study and about 50% of patients that come through our clinic who have a diagnosis of chronic rhinosinusitis end up having some form of at least mild cognitive dysfunction when they were administered a test. It's called the Neuro-QOL NIH Short Form 8-question Test. It's like a screening test. It has population norms and I was surprised to see half the patients actually were below the population norm for cognition. About one in six actually had severe cognitive dysfunction, which was one and a half standard deviations from the mean. That's a pretty impactful, pretty big number.
[Dr. Ashley Agan]
Is that test asking them, how well do you feel like you can do these tasks? Is it actually like giving them a test and making them think? You know what I mean? [laughs] Are there right and wrong answers on that test?
[Dr. Aria Jafari]
Yes. There's so many tests that test cognition. We incorporated this into our intake in our sinus clinic through a virtual format. We found that it wasn't something that needed to be administered by a research coordinator or anything like that. It's a Likert scale. It's one to five. It asks questions like, tell us how often this occurs. One of the questions is like, "My thinking is slowed. It seems like my brain is not working as well as usual. I have trouble concentrating. I have trouble adding and subtracting numbers in my head." Those are some of the questions that we ask. Yes, there's a lot of different tests that we administer.
We've done different types of tests, more like objective tests as well instead of subjective tests, where the patient reports it and more things that we're able to measure more objectively as well. This was just surprising to see the sheer number of patients who have trouble with this daily functioning. Then I also asked the question like, what about patients who just have nasal obstruction, their nose is blocked? Maybe they're seeking care. How do they do on this test? There's a decent amount of patients who also have a report cognitive dysfunction. About 10% of patients with obstructive pathology alone also have some sort of cognitive dysfunction. Overall, it's just much higher in these sinonasal patients than the average population.
[Dr. Gopi Shah]
Before we moved past, talking about tests, you had sent us an example of the Stroop test. Basically- or I'll let you describe what this, what this test is.
[Dr. Aria Jafari]
Yes. Yes, we were just talking about neuropsychiatric testing. Among the battery of neuropsychiatric tests, one of the oldest tests that neuropsychologists administer to patients is something called the Stroop test. It tests interference so if you have a distractor in your environment, how much are you able to focus on the task at hand and to execute the task at hand while you're distracted by something else.
[Dr. Ashley Agan]
Basically, the Stroop test is every day in my house.
[Dr. Aria Jafari]
Yes. What's interesting is the sinus patients actually do overall okay on basic tasks. I think that's also important to know. We're not-- These patients aren't having a significant amount of reaction time issues or a more of like the simple types of tasks. They're actually having issues with a little bit more of like the higher level tasks which require more attention or more brain function. Stroop tests that. Folks at MUSC administered this test to their patients and they wanted to see the impact of medical therapy on cognitive dysfunction in chronic rhinosinusitis.
They found that the reaction test, the Stroop reaction test, which is basically a series of words that are in colors, there'll be like a red word, it'll say red, but it'll be in red color and then there'll be like a green word and it'll be in green and then they'll administer that and then they'll administer the same words, but the colors will be switched in the words. It'll be listed as green, but it'll be red and they'll ask the patient to say the color and not the word. They found that patients with chronic sinusitis actually struggled with that because it's hard for them to get past the fact that the word green is actually in red color. That actually was interestingly also something that improved with medical treatments.
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How Cognitive Dysfunction Guides Chronic Rhinosinusitis Management
Given the commonality of CRS patients experiencing brain fog, cognitive dysfunction is emerging as an informative factor in treatment planning for CRS. If brain fog improves with medical therapy such as steroids, it may suggest that inflammation is a likely etiology, supporting the moving forward of definitive treatment, including surgery or biologics. If cognitive dysfunction is severe, providers may opt to escalate medical therapy sooner, which includes oral steroid bursts, budesonide nasal irrigations, and earlier consideration of surgery.
However, when sinonasal inflammation is well-controlled but cognitive symptoms remain, clinicians should also consider referral to neurology for further evaluation or screening for other systemic conditions affecting cognition. Dr. Jafari explains that some patients pursue or benefit from complimentary treatments, such as naturopathy, acupuncture, or acetyl-L-carnitine, highlighting that treatment plans should go beyond objective findings to consider the patient’s personal experience with symptom burden.
[Dr. Gopi Shah]
As we think about taking care of these patients, treatment, whether it be medical, surgical, combination, biologics, all the things in our tool belt, do we expect patients to have, I assume you probably do like pre and post and you're following their cognitive function. What are you seeing in that regards? Is it usually, you had mentioned, fluctuating symptoms earlier? If we can get things under control, can we promise patients that they can be brain fog-free? [laughs]
[Dr. Aria Jafari]
Yes, I think I always like to see how patients respond to medical treatment and if their symptoms are going to respond to steroids or intranasal steroids or oral steroids, I tend to think that maybe good control over the condition overall through surgical treatment or biologic treatment or whatever we're offering them, will also have a similar benefit if it's truly related to underlying inflammation. We have that conversation together. I think that, yes, if they have strong benefit from the anti-inflammatory treatment, then the patient will have-- It's more likely that treating them with surgery or medical treatment in general will improve their cognitive functioning.
I think that this all plays into this X factor that I think about in sinus patients where we have the diagnosis, working at a teaching hospital and we have residents and fellows, often they'll see my patients in the clinic, they'll go in and get a history and do an exam and they'll come back and I'll always ask, what do you want to do? How do we want to treat this patient?
We always have a guess when we go in, but sometimes when we go in, based on what the patient tells us, that treatment plan completely changes, right? They're like, there's polyps coming out the nose, but they're not bothered by it at all. Okay, we're going to do something completely different. A lot of this is guided by the patient, how much it's affecting them, how much this condition is shaping their everyday life.
I will say, in general, if cognitive dysfunction is part of their symptomatology in a significant way it often pushes me to escalate medical therapy sooner and if needed, offer surgery to regain better control over their disease.
[Dr. Gopi Shah]
Does that mean you're more likely to do budesonide rinses or oral steroid burst versus like if you're going to, when you say offer medical therapy sooner?
[Dr. Aria Jafari]
Yes, exactly. Exactly right. I'm much more likely to offer a steroid burst and budesonide irrigations and maybe even convert or offer surgery sooner maybe than another patient that's not so bothered by that.
[Dr. Gopi Shah]
You'll have patients who get better with their sinonasal, the classic sinus symptoms, and the brain fog. Then you'll have patients that maybe they don't respond with the sinus or the brain fog symptoms. What do you do with the patients that the sinonasal symptoms get better, their polyps are better, but they still have this brain fog? Do you get patients like that? For us, seeing objectives, pus, swelling, pulse, we're like, okay, I have something to-- The brain fog, I think, I guess maybe because--
[Dr. Aria Jafari]
It's harder to see. Yes.
[Dr. Gopi Shah]
Yes.
[Dr. Aria Jafari]
Absolutely. Yes, I think those are the patients that we start thinking about something else going on, honestly. Those are the neurology patients where we'll collaborate with the neurologist to get their symptoms under better control or better understand or characterize their symptoms. I think the sinusitis can really cloud the brain fog symptoms in those patients. Often, they're much better, but they may not be where they want to be in terms of their cognitive symptoms. We'll have to collaborate with the neurologist to get a better sense of what's going on.
Interestingly, practicing in Seattle, I see a lot of patients who often seek like complimentary care through like naturopathy or acupuncture. I've actually learned about a lot of adjunctive treatments that treat brain fog, like acetyl-L-carnitine, which has actually reasonable evidence to support cognition. Acupuncture, I think there was a recent Nature paper that showed that it may help autonomic nervous system function and potentially help this patient group. It's like all hands-on deck effort if they're in that small group of patients who are still looking for more benefit.
Chronic Rhinosinusitis as a Whole-Life Disease: Cognitive Assessments & Adjunctive Therapies
Despite the use of some cognitive assessments in the clinic, there are still limitations of subjective self-report tools like SNOT-22 – objective assessments are also needed. For example, eye movement tracking offers a promising, non-invasive indication of brain circuitry integrity and attentional deficits in CRS patients. Functional neuroimaging could also be beneficial for evaluating neural network alterations associated with sinonasal inflammation.
According to Dr. Jafari, clinicians seeing CRS as a whole-life disease may help patients feel heard. It can also guide CRS treatment planning that may explore adjunctive therapies, such as cognitive behavioral therapy, antidepressants, or acetyl-L-carnitine, alongside traditional sinus management to improve overall patient quality of life.
[Dr. Aria Jafari]
I think one of the main things that is holding us back right now is that a lot of our measures are subjective. We're asking patients to fill out a questionnaire. If someone is feeling miserable, they may fill out a questionnaire a certain way. Our SNOT-22 scores tend to track with our cognitive testing scores, especially when they're administered to the patient to self-report their condition. I think I'd like to see more objective data, more objective research, shifting away from cognitive testing and questionnaire-based assessments, but maybe more towards what we've been doing recently, which is eye movement testing, which is a low cost and a non-invasive way to assess integrity of brain circuitry.
Our eyes and our brain are super tightly connected and our attention is actually often very well measured by where we look. We've used it in our research recently where we showed that CRS patients who have significant sinus inflammation compared to controls, they have deficits in terms of eye movements and attention. We used different paradigms to assess that within that patient population. I think more studies like that, I think that was like a CRS patient population versus control. I think it'd be really interesting to look at the CRS patients, treat them, whether it's surgery or medical treatment, and then retest those same patients using eye tracking and eye movement assessments.
I think functional neuroimaging can be super helpful in this space as well. I'd love to collaborate with experts in functional neuroimaging. It's really exciting, but it's also really expensive. If anyone's interested in listening, reach out, we're happy to collaborate. It's tough because neuroscience and this type of work, we can't just go in and like sample their brain or, even doing CSF sampling is super invasive. We do have to find these surrogate tests to better understand what's going on.
[Dr. Aria Jafari]
I think there's also some other interesting, super cool ideas that have come out in the literature, I think, what do we do about this. I think folks who are listening may be like, "Okay, great. I have a patient with CRS. They have cognitive dysfunction. Maybe I'll do some prednisone or, if they don't get better, what other options do I have?" I wonder if approaching this, approaching the neurocognitive component to CRS in a different way, in addition to our classic sinus treatments, could offer additional quality of life benefits, things like cognitive behavioral therapy or antidepressants or herbal supplements, I mentioned acetyl-L-carnitine. It'd be cool to see if those patients do better after surgery because we're specifically addressing that dimension of their experience.
[Dr. Aria Jafari]
I think it just is important to recognize that inflammation doesn't just stuff up your nose. It like rewires your brain. I think the more we understand how the brain and inflammation is connected to each other, I think the more we'll understand that this condition actually is a whole-body condition and a whole-life disease. I think that that's something that I hope that folks who are listening in will appreciate. I think we already appreciate that when we talk to these patients, but recognizing it as a real thing and telling patients that this is something that is a component of the condition and making sure they're heard can be really powerful.
Podcast Contributors
Cite This Podcast
BackTable, LLC (Producer). (2025, June 2). Ep. 225 – Sinusitis & Cognitive Impairment: Exploring the Inflammatory Pathway [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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