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Systemic Steroids Oral corticosteroids have been effective in treating allergic rhinitis, reducing nasal polyps and allergic fungal sinusitis (6, 8, 15). Years of clinical practice support their effectiveness in providing rapid relief of facial pressure and nasal blockage by reducing mucosal edema, especially in patients with nasal polyps. Lennard and colleagues (16) demonstrated the effects of steroids in inflammatory cytokines for patients with CRS by nasal biopsy before and after treatment. The authors found significant decreases in IL-6 levels after treatment, with tumor necrosis factor-a trending toward significance. In a study of 25 patients with CRS with massive nasal polyps, treatment with high-dose oral prednisolone was associated with both subjective and objective improvement and involution of nasal polyps (17). Effects were best in the frontal and sphenoid sinuses; however, recurrence was seen after 5 months. Woodworth and colleagues (18) treated 21 patients with CRS with nasal polyps with 60 mg oral prednisone tapered over 3 weeks. The study found that oral steroids decreased all measured chemokines and cytokines compared with placebo and improved Sino-Nasal Outcome Test-20 (SNOT-20; a widely used, disease-specific, health-related qualityof-life measure for rhinosinusitis [19]) scores and the endoscopic examination for the patient population. However, despite widespread use of oral corticosteroids for CRS, there are few randomized trials. A double-blind placebocontrolled trial of prednisolone 50 mg daily for 14 days versus placebo demonstrated improvement of sinonasal polyposis and symptoms as measured by the 31-item rhinosinusitis outcome measure (RSOM-31) questionnaire, nasal endoscopy, and preand post-treatment MRI scans (20). With the available data, it seems reasonable to recommend the judicious use of corticosteroids in CRS as part of a multifaceted treatment regimen, particularly in patients with nasal polyps. NASAL IRRIGATION Background Saline nasal irrigation has been advocated as an adjunct therapy for CRS (1, 5, 6, 21). A recent Cochrane Review reviewed eight randomized clinical trials on the use of nasal saline irrigation for CRS, and included studies demonstrated improvement in sympTABLE 1. FACTORS IN THE PATHOPHYSIOLOGY OF SINUSITIS Infectious Viral, bacterial, fungal Biofilms Local factors Nasal obstruction Allergic and nonallergic rhinitis Polyps Foreign bodies, nasogastric tubes Adenoid infection Tumors Trauma Dental infection Prior surgery Anatomic variations/aberrations Septal deviation Concha bullosa Haller cells Ciliary dyskinesias Gastroesophageal reflux Sinus osteitis Bacterial superantigens Systemic factors Asthma Cystic fibrosis Granulomatous diseases Immune deficiencies Congenital Selective antibody deficiency IgA deficiency IgG subclass deficiencies Common variable immune deficiency C4 deficiency X-linked agammaglobulinemia Acquired HIV/AIDS Organ transplant/cancer chemotherapy Environmental factors Air pollution Cigarette smoke, exhaust fumes Swimming Adapted with permission from Reference (95). Figure 1. Mucociliary clearance. The mucociliary stream is propelled from the inferior portion of the maxillary antrum upward and around the walls of the sinus toward the primary ostium of the maxillary sinus. IT 5 inferior turbinate; MT 5 middle turbinate; NS 5 nasal septum. Adapted with permission from Reference (95). Suh and Kennedy: Treatment Options for Chronic Rhinosinusitis 133 toms, quality of life, and endoscopy findings (21). The procedure involves rinsing the nasal cavity with saline to promote mucociliary clearance by flushing out mucus, crusts, and irritants. Nasal irrigation is well tolerated by patients, without any
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