- •
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
A Practical Approach to Refractory Chronic Rhinosinusitis
Section snippets
Key points
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
References (51)
- et al.
Apoptosis of eosinophils and lymphocytes in allergic inflammation
J Allergy Clin Immunol
(1999) - et al.
Oral steroids and doxycycline: two different approaches to treat nasal polyps
J Allergy Clin Immunol
(2010) Doxycycline or oral corticosteroids for nasal polyps
J Allergy Clin Immunol Pract
(2013)- et al.
Efficacy of omalizumab in eosinophilic chronic rhinosinusitis patients with asthma
Ann Allergy Asthma Immunol
(2013) - et al.
Outcomes of sinus surgery in adults with cystic fibrosis
Otolaryngol Head Neck Surg
(2009) - et al.
Long-term effects of aspirin desensitization–treatment for aspirin-sensitive rhinosinusitis-asthma
J Allergy Clin Immunol
(1990) - et al.
European position paper on rhinosinusitis and nasal polyps 2012
Rhinol Suppl
(2012) - et al.
International consensus statement on allergy and rhinology: rhinosinusitis executive summary
Int Forum Allergy Rhinol
(2016) - et al.
Psychometric validity of the 22-item sinonasal outcome test
Clin Otolaryngol
(2009) - et al.
SNOT-22 quality of life domains differentially predict treatment modality selection in chronic rhinosinusitis
Int Forum Allergy Rhinol
(2014)
Quantification for staging sinusitis. The Staging and Therapy Group
Ann Otol Rhinol Laryngol Suppl
Impact of perioperative systemic steroids on surgical outcomes in patients with chronic rhinosinusitis with polyposis: evaluation with the novel perioperative sinus endoscopy (POSE) scoring system
Laryngoscope
Interrater agreement of nasal endoscopy for chronic rhinosinusitis
Int Forum Allergy Rhinol
Interrater agreement of nasal endoscopy in patients with a prior history of endoscopic sinus surgery
Int Forum Allergy Rhinol
Staging in rhinosinusitis
Rhinology
Paranasal sinus opacification-to-pneumatization ratio applied as a rapid and validated clinician assessment
Int Forum Allergy Rhinol
Structured histopathology profiling of chronic rhinosinusitis in routine practice
Int Forum Allergy Rhinol
Oral steroids for nasal polyps
Cochrane Database Syst Rev
Glucocorticoids suppress inflammation but spare innate immune responses in airway epithelium
Proc Am Thorac Soc
Glucocorticoid-induced apoptosis in human eosinophils: mechanisms of action
Apoptosis
Topical steroids for nasal polyps
Cochrane Database Syst Rev
Pilot study of budesonide inhalant suspension irrigations for chronic eosinophilic sinusitis
J Allergy Clin Immunol
Staphylococci and staphylococcal superantigens in asthma and rhinitis: a systematic review and meta-analysis
Allergy
Immunotherapy suppresses both Th1 and Th2 responses by allergen stimulation, but suppression of the Th2 response is a more important mechanism related to the clinical efficacy of immunotherapy for perennial allergic rhinitis
Scand J Immunol
Omalizumab is effective in allergic and nonallergic patients with nasal polyps and asthma
J Allergy Clin Immunol
Cited by (8)
Recommendations for outpatient parenteral antimicrobial therapy in Brazil
2017, Brazilian Journal of Infectious DiseasesCitation Excerpt :Patients with diagnoses of the infections described below are considered eligible for treatment under an OPAT regimen: Complicated upper respiratory tract infections, including malignant external otitis, necrotizing external otitis and rhinosinusitis8–11; Respiratory infections, including complicated pneumonias, empyemas, lung abscesses, cystic fibrosis, exacerbations of the conditions of chronic obstructive pulmonary disease (COPD), infected bronchiectasis, community-acquired pneumonia, and nosocomial pneumonia12;
The role of cysteinyl leukotrienes and their receptors in refractory nasal polyps
2017, Prostaglandins Leukotrienes and Essential Fatty AcidsCitation Excerpt :Patients who have chronic rhinosinusitis with nasal polyps (CRSwNP), and especially the ones who have eosinophilic infiltration of nasal polyp tissue (NPwEos), were prone to relapse after functional endoscopic sinus surgery (FESS). Recurrent nasal polyposis is difficult to treat due to significant edema or cysts formation, diffuse polypoid tissue, and viscous secretion [1,2]. Steroid hormones, particularly intranasal corticosteroid, have shown positive effect on recovery after FESS.
Efficacy of lianhuaqingwen granules in the management of chronic rhinosinusitis without nasal polyps
2020, American Journal of Otolaryngology - Head and Neck Medicine and SurgeryCitation Excerpt :Nonetheless, there are a small number of patients who cannot benefit from FESS, and 7–10% of these patients may have somewhat exacerbation of olfactory dysfunction [3]. In addition, patients with refractory CRS, have sustained, uncontrolled symptoms and objective inflammatory findings despite full medical and surgical therapies [4]. Therefore, novel therapeutic strategies for CRS should be exploited and developed.
Tips and tricks for management of the dysfunctional maxillary sinus
2023, Current Opinion in Otolaryngology and Head and Neck SurgeryHistopathology in chronic rhinosinusitis varies with sinus culture
2018, American Journal of Rhinology and Allergy
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.