Review articleThe office management of recalcitrant rhinosinusitis
Section snippets
Infectious disease
The concept of the ostiomeatal complex (OMC) is almost mandatory in a discussion of the pathophysiology of CRS. The OMC includes the middle meatus, ethmoid infundibulum, and hiatus semilunaris. The natural drainage of the anterior ethmoid, maxillary, and frontal sinus is through the OMC. An important initiating event of CRS is chronic mucosal obstruction at the natural ostia of the sinus that results in impeded mucociliary clearance, bacterial overgrowth, and release of chronic inflammatory
Allergy and inflammation
The pendulum has recently swung from the belief that bacteria may be the pathogenic cause of CRS to a growing acceptance that, in certain patients, IgE and non-IgE inflammatory-based mechanisms may lead to the development of CRS. Nasal allergic mechanisms driven initially by IgE and mast/basophil cell degranulation may be a significant cofactor in many patients with chronic sinusitis. Delayed responses involving eosinophils and Th2 helper T cells have been shown to be prevalent in the nasal
Diagnostic work-up and treatment of patients with CRS
Functional endoscopic sinus surgery has been shown to be an effective adjunctive therapy in patients who meet the definition of CRS [1], [15], [16]. Despite recent medical and surgical advances in treatment of CRS, certain patients will persist with disease or will have a rapid recurrence of symptoms. Many patients presenting to the otolaryngologist's office with recalcitrant sinusitis have already had the standard therapies for sinusitis, many of which are used in treating acute
Infectious causes
The armamentarium of antimicrobial agents has steadily grown since the introduction of penicillin in the 1940s. The increasing number of antimicrobial classes has allowed more effective treatments of CRS. In parallel with the development of more antibiotics has been the observance of a greater number of antimicrobial-resistant bacteria. This phenomenon has been observed in community-acquired pneumonia as well as in the CRS patient. Common bacteria isolated from patients with CRS are
Inflammatory causes
The involvement of bacterial infection in CRS is well accepted and provides the basis for the most prevalent approaches to treating this condition. Other inflammatory processes, however, may be involved in priming the sinus mucosa for bacterial infection or may themselves be the inciting event. A recent interest in the involvement of IgE-mediated inflammatory responses in CRS has resulted in the application of novel therapies in the treatment of CRS.
Allergic symptoms should be explored in all
Genetic mechanisms
The involvement of local and systemic humoral immunity is important in a host defense against viral and bacterial upper respiratory infections. Both congenital and acquired forms of immunodeficiency may predispose a patient to CRS. The immune competence of the patient with a history of multiple sinus surgeries or poor response to culture-directed antibiotic therapy should be assessed. Evaluation may include quantitative immunoglobulin levels and response to polysaccharide-coated immunizations
Summary
The patient referred to the otolaryngologist for the treatment of CRS has received many therapies for the condition. Newer therapies available focus on the anti-inflammatory therapies and local application of antimicrobial and antifungal agents to the sinus cavities. Much clinical work remains to be done to prove the efficacy of currently available treatments. The recent advances in the understanding of allergic and immune mechanisms may allow eventual intervention at the level of cytokines and
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