Refractory chronic rhinosinusitis: pathophysiology and management of chronic rhinosinusitis persisting after endoscopic sinus surgery

Abstract

Refractory chronic rhinosinusitis (RCRS) is defined as persistence of signs and symptoms of chronic rhinosinusitis, despite technically adequate endoscopic sinus surgery. Rather than a simple, prolonged bout of acute sinusitis, it instead appears to be secondary to an interaction of a susceptible host with the outside environment. Inflammatory responses to colonizing bacteria appear to be responsible for a significant portion of the pathophysiology. Reduction of bacterial load and inflammation of the mucosa play an important role in controlling the disease. Novel treatment strategies, with an emphasis on topical therapies, seem to offer optimal management. In this review, current concepts on the pathophysiology and current therapies available for RCRS are outlined. A practical management strategy based on the author's personal experience draws upon these concepts, and is detailed in this review of an unusual topic.

Patterns of Innervation of the Anterior Maxilla: A Cadaver Study with Relevance to Canine Fossa Puncture of the Maxillary Sinus

“…The extent of the maxillary sinus disease varies, with some patients having only mucosal edema, whereas others with extensive polyposis or fungal sinusitis may have complete opacification of the maxillary sinuses. Incomplete removal of polyps, pus, or fungus may result in an early recurrence of both symptoms and disease after surgery 1,2 . Furthermore, in a recently published study, 1 we were able to show that patients who underwent canine fossa puncture and clearance of severely diseased maxillary sinuses had significantly improved long‐term outcomes with regard to disease recurrence and symptom scores as compared with patients who did not have the procedure performed.…”

Environmental Toxicants-Induced Immune Responses in the Olfactory Mucosa

“…Here, we focus on the damages associated with inflammatory responses within the nasal cavity (32). Several animal models of human chronic rhinosinusitis have been developed by inoculating bacteria or fungus extract into the mouse nostril (10, 33, 34).…”

Different clinical factors associated with Staphylococcus aureus and Pseudomonas aeruginosa in chronic rhinosinusitis

“…3 In CRS, bacterial infection may be an important event that triggers an inflammatory response within the sinus cavity, resulting in chronic changes and symptoms. 4 However, the importance of bacterial infection in CRS has never been proven. Previous studies have shown that, unlike the well-recognized most common bacteria recovered from adult acute rhinosinusitis (ARS) patients, ie, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, 5,6 the common bacterial isolates from CRS patients are coagulase-negative Staphylococcus (CoNS), Pseudomonas aeruginosa and Staphylococcus aureus.…”