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The most common conditions that predispose patients to CRS include allergic and nonallergic rhinitis, nasal polyps, and occasionally anatomic factors, such as a deviated nasal septum (2, 4). The inflammatory process appears to be at least exacerbated by the presence of bacteria and fungi. Therefore, reducing bacterial and fungal contamination, whether by improving sinus drainage, improving mucociliary clearance, antimicrobial therapy, or reducing mucosal edema, has a positive effect. It is clear that CRS is not one disease, but rather is a spectrum of symptoms and signs arising from multiple different causes. To better classify the disorder, a division into polypoid and nonpolypoid CRS has been recommended, based on some significant differences in cytokine profile (3). However, the clinical significance of this finding is not clear, as many patients without nasal polyps will actually have polypoid changes of the sinus mucosa. Thus, treatment of CRS is aimed at reducing mucosal inflammation, controlling infection, and restoring mucociliary clearance within the sinuses (Figure 1). Eosinophilic inflammation is one of the frequent hallmarks of CRS, and reducing mucosal eosinophilia is one of the therapeutic goals (3). However, there is no one regimen for the management of CRS, and treatments should be individualized. Environmental control is obviously an important part of the management in those patients for whom allergy, pollution, or mold exposures appear to be significant predisposing factors. Sinus surgery is generally reserved for patients who remain symptomatic despite maximal medical therapy. This article discusses the various treatment options for CRS. STEROIDS Background Topical corticosteroids constitute first-line therapy in the medical management of CRS. Long-term treatment with topical nasal steroid sprays has been shown to reduce sinus inflammation and nasal polyp size and improve symptoms associated with CRS (5–7). Short courses of oral steroids are used in the treatment of CRS with nasal polyps but may also be used in cases of severe CRS when rapid symptomatic improvement is needed (6, 8). Topical and systemic steroids reduce mucosal eosinophil chemotaxis and increase eosinophil apoptosis. Corticosteroids also decrease white blood cell migration, production of inflammatory mediators, antibody production, histamine release, and swelling through a variety of mechanisms (9). The daily use of topical nasal steroids appears to be associated with minimal risks; however, long-term systemic steroid use is associated with significant side effects (7, 8). Therefore, a tapered regimen of oral steroids is most commonly given during severe (Received in original form March 21, 2010; accepted in final form July 5, 2010) Correspondence and requests for reprints should be addressed to David W. Kennedy, M.D., Professor of Rhinology, Department of Otorhinolaryngology–Head and Neck Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 5 Ravdin, Philadelphia, PA 19104. E-mail: David.Kennedy@uphs.upenn.edu Proc Am Thorac Soc Vol 8. pp 132–140, 2011 DOI: 10.1513/pats.201003-028RN Internet address: www.atsjournals.org CRS flare-ups or in the postoperative period after sinus surgery. Topical Nasal Steroids The use of topical nasal steroids has been widely advocated in the treatment of CRS. Several studies have demonstrated that topical corticosteroids are beneficial in the treatment of small to mediumsized polyps and for rhinitis symptoms (10, 11). When combined with antibiotic use, efficacy in symptom reduction was also found during acute exacerbations (12). Corticosteroid nasal sprays have been shown to delay the recurrence of polyps after surgery (13); however, the benefit for nonpolypoid CRS has been harder to demonstrate (14). Common adverse effects with nasal steroids include nasal irritation, mucosal bleeding, and crusting (7, 8).
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