When Surgery, Antibiotics, and Steroids Fail to Resolve Chronic Rhinosinusitis

This article examines the modalities in the treatment of chronic rhinosinusitis (CRS). A correct diagnosis is the first requirement in the successful management of CRS. CRS-directed therapy might fail if the actual cause of symptoms is nonsinogenic. Nasal endoscopy and sinus computed tomography are the primary modalities used in the diagnosis of sinusitis. Allergy and gastroesophageal reflux, may not directly cause sinusitis, but they frequently mimic the symptoms of sinusitis. Therapy can include avoidance of allergens and desensitization in the former and antireflux therapy in the latter. Underlying systemic causes of refractory sinusitis include immunodeficiency and systemic granulomatous and eosinophilic syndromes. Correct diagnosis is essential to directed therapy. Patients with aspirin exacerbated respiratory disease may benefit from aspirin desensitization. Optimization of mucociliary clearance can be augmented with nasal lavage and mucolytics. Additional nonsteroidal anti inflammatory modalities include use of the leukotriene modulators, montelukast and zileuton. Patients with elevated IgE may benefit from omalizumab (anti-IgE); however, cost constraints restrict use to those patients who have severe asthma. This article also includes management strategies beyond the usual antibiotics, steroids, and sinus surgery. Once immunodeficiency and confounding local mimics of sinusitis are addressed, additional interventions should be tried separately initially to assess the individual patient's response to therapy.