Treatment alternatives for chronic rhinosinusitis persisting after ESS: what to do when antibiotics, steroids and surgery fail.

ABSTRACT

BACKGROUND: It is estimated that over 500,000 individuals in the United States currently suffer from chronic rhinosinusitis (CRS), which has persisted or recurred despite maximal medical therapy and endoscopic sinus surgery (ESS). Management of these individuals remains uncertain, as recent published guidelines on CRS do not extend to this population. OBJECTIVE: Our objective is to provide a framework for the management of patients who fail standard therapy for CRS while providing recommendations based on the strength of the evidence for alternative medical therapies that can be used for the treatment of recurrent CRS. This guideline targets ENT physicians and allergists managing this increasingly frequent clinical situation and attempts to assist them in selecting from the increasing array of potential therapies available. To this end, factors contributing to the pathophysiology of post-ESS CRS are reviewed to identify method of action of existing and potential therapies and recommendations are made for their use. RESULTS: Given the accessibility of the sinus cavities after ESS, topical therapies are privileged. Saline spray or irrigation is recommended for all patients. Corticosteroids in oral or topical forms are recommended for controlling the inflammatory component, while the use of a short term course of oral or topical antibiotics are recommended mainly for the treatment of exacerbations. Long-term therapy with oral macrolides is also recommended as an alternative therapy. Desensitization with acetylsalicylic acid (ASA) for individuals with documented ASA sensitivity is recommended where available, while revision surgery, anti-leukotriene agents and intravenous immunoglobulins are options in management in selected patients. Antifungal therapy is not recommended. No recommendations for potentially experimental strategies are made in the absence of published experience and safety data in human subjects.