management. The principles of management include medically reducing swelling in the nose, sinus irrigation, topical corticosteroids in the nose and sinuses, appropriate antibiotics, and careful education about the chronic nature of the disease and need for on-going treatment. In many instances, medical treatment is chronic and on-going, and aimed at controlling symptoms, but is not curative. Thus, some patients prefer the option of a surgical procedure that might eliminate an anatomical obstruction that could be the cause of RS, in the hope of a definitive cure. The current surgical WAO White Book on Allergy 3 3 Copyright 2011 World Allergy Organization approach to RS is functional endoscopic sinus surgery where the functional ostia which drain the sinuses are identified and enlarged. This approach has an impressive 1-2 year incidence of symptom improvement. However, patients with predisposing diseases that originally led to RS still suffer from these processes and often develop RS again at a later date. Medical management is usually required for on-going symptom relief. Co-morbidities of Rhinosinusitis Asthma patients, particularly those with severe or difficult to manage asthma, often have concomitant sinusitis. In some studies as many as 65% of severe asthmatics have been found to have evidence of RS on CT. Other observations suggest a nearly universal incidence of sinusitis in patients with severe asthma. The evaluation of moderate to severe asthma should routinely involve a careful review for possible sinusitis, as treating the sinuses may ease the severity of asthma remarkably. About 25% of chronic RS patients develop nasal polyps, which are inflammatory growths extending from the sinuses into the nasal cavities. There are several characteristics that distinguish the chronic RS patient with polyps from those that do not develop polyps. Managing nasal polyps is complex and involves a balance between surgery designed to open the ostia and aggressive medical management with corticosteroids instilled into the nose and sinuses and judicial use of antibiotics and oral corticosteroids. Current and Future Needs It is evident that physicians do not recognize RS because of the subtlety in identifying the spectrum of symptoms as RS and distinguishing this condition from upper respiratory tract infections/colds or other on-going forms of rhinitis. Better teaching of PCPs, earlier referral to allergists and otolaryngologists, and more use of rhinoscopies and CT scans will enhance our recognition of this important disease. Some leading specialists utilize liquid suspensions of corticosteroids instilled into the sinuses by lavages in treating RS. Availability of approved formulations of suspensions of corticosteroids would help with this treatment choice. As we try to understand RS better, identification of the characteristics of patients who develop RS, or who then develop nasal polyps, will become more evident and allow us to recognize those patients at higher risk. However, studies of the treatment of RS need higher priority both from governmental agencies and from the pharmaceutical industry. As it stands today, very few medications have been studied or approved for the treatment of RS or related conditions (such as polyps). Research Needs Little is known about why some patients with acute RS develop persistent inflammation of the sinuses that can persist for years or even a lifetime. Theories about persistent bacterial infections caused by biofilms, bacterial osteitis, or other conditions need to be explored and proven, or discredited. The possible role of Staphylococcus and Streptococcus in chronic RS need to be explored as does the possible role of chronic fungal infections. The role of specific immune abnormalities in patients with recurrent RS needs exploration, as do the immune mechanisms involved in the normal response to RS. Therapeutic medical and surgical approaches need careful analysis and long term assessments. Unmet Needs A large percentage of the population has undiagnosed RS, or inadequately treated RS. Even after establishing the diagnosis, the appropriate guidelines for medical management have not been established and there appears to be too much