A Practical Approach to Refractory Chronic Rhinosinusitis

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Key points

  • A multidisciplinary and broad approach is required in the diagnostic evaluation of refractory CRS encompassing patient, environmental, and disease-related factors.

  • Treatment of refractory CRSwP requires complete polyp removal and establishment of wide sinus openings to facilitate the postoperative delivery of topical corticosteroids.

  • Treatment of refractory nonpolypoid CRS involves surgery to maximize sinus ventilation and drainage, using systemic or topical antibiotics or other adjunctive agents

General Principles

The approach to the clinical assessment of a patient with refractory CRS differs from that of routine CRS in several ways. The patient’s prior history including disease course and treatment response is typically extensive. Additionally, the various etiologic issues may have evolved throughout the CRS history resulting in the emergence of CRS-related factors that may not have been initially present. Examples of this include osteitic bony changes and biofilm-producing bacteria. Therefore, a broad

Assumptions of Treatment

The approach to treatment of refractory CRS often involves multiple modalities and occasionally the participation of other medical specialists. In all cases, communication between the patient and physician is essential to establish reasonable expectations for treatment. A cornerstone of this process involves educating the patient that CRS is a chronic condition without a specific cure in most cases. Despite this, treatments are available to ameliorate symptoms and minimize impact on quality of

Summary

Refractory CRS is associated with unique challenges in diagnosis given the multifactorial nature, existence of unique subtypes, and limitations in available testing modalities. A broad, multidisciplinary approach is indicated with critical evaluation of patient, environmental, and disease factors. In many cases, evaluation of the patient throughout the disease process including after therapy serves a dual function of providing further characterization of the patient’s disease while enabling

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    Disclosure Statement: There are no commercial or financial grant/assistance associated with this publication. Dr E.D. McCoul is a consultant for Acclarent. Dr A. Tabaee is on the scientific advisory board of Spirox.

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