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Treatment Options for Chronic Rhinosinusitis Jeffrey D. Suh1 and David W. Kennedy2 1 Division of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, California; 2 Department of Otorhinolaryngology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania Chronic rhinosinusitis (CRS) is defined as persistent symptomatic inflammation of the nasal and sinus mucosa. Although insights into the pathophysiology of CRS have largely expanded over the last 2 decades, the exact etiology is still unknown and is likely due to multiple host and environmental factors. Treatments are aimed at reducing mucosal inflammation, controlling infection, and restoring mucociliary clearance within the sinuses. The principal goal of this articleis to outline a rational approach to the treatment ofchronic sinus disease on the basis of currently available diagnostic and therapeutic techniques. Emphasis will be placed on the management, therapeutic response, and objective evaluation of therapeutic efficiency. Keywords: chronic rhinosinusitis; CRS; sinus surgery; management Chronic rhinosinusitis (CRS) is one of the most common chronic diseases, with a prevalence as high as 15% of the population in some studies. Like asthma, a disease with which CRS has significant etiologic and pathologic relationships, the incidence appears to be increasing. CRS also has significant socioeconomic implications. The direct and indirect costs related to CRS are substantial, resulting in millions of office visits and billions of dollars of health care costs each year (1). DEFINITIONS Rhinosinusitis is a group of disorders characterized by inflammation of the mucosa of the nose and the paranasal sinuses. In 2007, the American Academy of Otolaryngology – Head and Neck Surgery published their most recent and revised guidelines on the diagnosis and management of rhinosinusitis (2). Rhinosinusitis is traditionally classified by duration as acute (,4 wk), subacute (4–12 wk), or chronic (.12 wk, with or without exacerbations) (2). Briefly, the diagnosis of CRS requires that inflammation be documented on physical examination, in addition to persistent symptoms that usually include at least two of the following: nasal obstruction (81–95%), facial congestion/ pressure/fullness (70–85%), discolored nasal discharge (51–83%), and hyposmia (61–69%) (2, 3). Nasal endoscopy is an office procedure used to augment the physical examination to better evaluate the nasal cavity and paranasal sinuses. Endoscopy is used to assess sinonasal mucosal inflammation, polyps, or purulence, and can confirm the diagnosis of CRS when symptoms are nonspecific. CRS often coexists with other medical conditions, such as allergic rhinitis, asthma, and cystic fibrosis, and with less common conditions, such as sarcoidosis, Churg-Strauss, and Wegener granulomatosis (2). PATHOPHYSIOLOGY There has been an evolution of our understanding of the pathophysiology of CRS. Historically, CRS was believed, perhaps simplistically, to arise from sinus ostium obstruction leading to bacterial infection. Currently, CRS is believed to arise primarily from persistent inflammation of the mucosa and perhaps the underlying bone, caused by a number of factors (Table 1) (1–3). Perhaps the most appropriate broad classification of predisposing factors for chronic sinusitis is into environmental factors (e.g., pollution, allergens, viruses, bacteria, and molds), general host factors (genetic, granulomatous disorders, immune deficiency, cystic fibrosis, and ciliary defects
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