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medical intervention, and symptomatic nasal polyp disease that is not adequately managed on medical therapy alone. However, many other medical problems may require surgical intervention, including complicated acute sinusitis, allergic fungal sinusitis, and mucoceles (Figures 3, 4 and 5) (79, 80). Recently, the indications for this sinus surgery have extended well beyond inflammatory causes to include intranasal, sinus, and skull base tumor removal; closure of skull base defects; orbital decompression; dacryocystorhinostomy; and resection of medially placed intraorbital lesions. Whereas surgical intervention for CRS used to primarily involve open surgery aimed at mucosal stripping within the maxillary or frontal sinuses, or ethmoidectomy performed with the limited visualization, such surgery has almost completely been replaced by endoscopic intranasal intervention. FESS is associated with significantly lower morbidity and higher success rates than previous surgical approaches, and the techniques for such surgery continue to evolve (81). More recent work has demonstrated the efficacy of extended approaches to the frontal sinus, using angled drills and instrumentation intranasally to create a partial septectomy and one large bilateral intranasal opening. (Figures 6 and 7). Meticulous surgical dissection using mucosa-sparing techniques has allowed surgeons to treat sinus disease while preserving the natural function of the sinus mucosa. Mucosal integrity is maximally preserved so that healing occurs quickly and normal mucociliary transport is restored (79, 80). However, surgery alone is rarely curative and needs to be combined with intensive medical therapy in the postoperative period. Persistent asymptomatic disease is common after surgical intervention and the goal of therapy has shifted away from short-term symptomatic improvement toward long-term disease resolution. This requires continued medical therapy after surgery, endoFigure 3. Coronal computed tomography scan demonstrating areas of increased density strongly suggestive of allergic fungal sinusitis. *Indicates hyperdense area; #indicates hypodense area. Figure 4. Polyps and allergic mucin in the nasal cavity. *Indicates nasal polyp; #indicates allergic mucin. IT 5 inferior turbinate; MT 5 middle turbinate; S 5 septum. Figure 5. Coronal computed tomography scan demonstrating left frontal sinus mucocele with expansion into the left superior orbit and displacement of the orbital contents. *Indicates area of mucocele. Suh and Kennedy: Treatment Options for Chronic Rhinosinusitis 137 scopic surveillance, and management of environmental and general host factors that may predispose to disease. With the advent of delicate instrumentation, angled telescopes, mechanical microdebriders, and an improved understanding of the pathogenesis of CRS, open surgical intervention is rarely required (82). However, there are still occasional indications for an open osteoplastic approach to the frontal sinus in patients with unusual pathology or neoplasia. In recent years, there has also been a suggestion that merely dilating the sinus ostia (balloon sinuplasty) may be sufficient for disease resolution in CRS (83). However, the evidence for this, at this point in time, remains controversial and seems at odds with some of our understanding of the pathogenesis of this disease. However, it is possible that in the future, when combined with drug-eluting stents and other local therapy to resolve residual inflammation, such therapies may indeed provide an alternative less-invasive therapy to those currently available. Studies suggest that balloon dilation is both safe and well tolerated, with the potential benefit of minimizing
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