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evaluated appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) (14-16). Interestingly and contrary to earlier findings (17) socioeconomic differences do not seem to have an influence on the prevalence of CRS (18). Apart from the EUFOREA report, we have a lot of very interesting papers on diverse subjects from allergic rhinitis (19,20), via risk factors for epistaxis (21), to surgical papers on inverted papilloma (22) and CSF leak repair (23). In this issue of the journal, the group of Sarah Vreugde en PJ Wormald describe that S. aureus is found intracellularly within CRSwNP tissue of patients with recalcitrant disease at multiple time points without an increase in inflammatory response supporting their hypothesis that S. aureus is able to escape from host detection and resides within the sinonasal mucosa despite intense treatment (24). This might be an explanation why the effect of antibiotics, even given long-term in CRS are limited (25-27). But maybe the idea that one unique microbe can be the cause of CRS is too simplistic. In recent years the cultivation-independent, molecular methods and the bioinformatics tools used to analyse sequence data, have offered us unprecedented insights into potential microbial involvement in CRS. We learned that our sinuses are not sterile as was thought for decades. Since the first paper from the group of Susan Lynch (28) pointing at the dysbiosis in CRS with overrepresentation of Corynebacterium tuberculostearicum suggesting both a new sino-pathogen and a strong bacterial candidate for therapeutic intervention, a significant number of papers have been published (29-31). A systematic review of the sinonasal microbiome in chronic rhinosinusitis published last year was a little disheartening in its conclusion: although there are common phyla present in both control patients and patients with CRS, no consistent enrichment of any particular taxon was identified (30). The group of Richard Douglas explains the technical details of the bioinformatic approach to microbiome research beyond description of diversity (32). They used these techniques to reanalyse available sinonasal genomic data and observed that an increased relative abundance of the members belonging to the phylum Actinobacteria and members from the genera Propionibacterium appeared to differentiate healthy sinuses from those that were chronically inflamed. Furthermore, they observed that an absence of Burkholderia and Propionibacterium phylotypes from the healthy community dataset was correlated with a significant increase in network fragmentation, suggesting a “gate-keeper” role of these phyla in sinonasal microbiota homeostasis (31). Coming back to the use of antibiotics: maybe they do more bad than good: removal of keystone or gatekeeper bacterial species, an increase in antibiotic resistance, and loss of diversity which can contribute to disease predisposition and perpetuation of an aberrant bacterial community structure Allergy. 2011 Nov;66(11):1457-68. 28. Abreu NA, Nagalingam NA, Song Y, et al. Sinus microbiome diversity depletion and Corynebacterium tuberculostearicum enrichment mediates rhinosinusitis. Science translational medicine. 2012;4(151):151ra24. 29. Ivanchenko OA, Karpishchenko SA, Kozlov RS, et al. The microbiome of the maxillary sinus and middle nasal meatus in chronic rhinosinusitis. Rhinology. 2016;54(1):68-74. 30. Anderson M, Stokken J, Sanford T, Aurora R, Sindwani R. A systematic review of the sinonasal microbiome in chronic rhinosinusitis. Am J Rhinol Allergy. 2016 May;30(3):161-6. 31. Wagner Mackenzie B, Waite DW, Hoggard M, Douglas RG, Taylor MW, Biswas K. Bacterial community collapse: a meta-analysis of the sinonasal microbiota in chronic rhinosinusitis. Environ Microbiol. 2017 Jan;19(1):381-392. 32. Wagner Mackenzie B, Waite DW, Hoggard M, Taylor MW, Biswas K, Doug Description Chronic and Recurrent Acute Rhinosinusitis Chronic rhinosinusitis (CRS) is characterized by purulent nasal discharge, usually without fever, that persists for weeks to months. Symptoms of congestion often accompany the nasal discharge. There also may be mild pain and/or a headache. Thickening of mucosa may restrict or close natural openings between sinus cavities and the nasal fossae, although symptoms vary considerably because of the location and shape of these sinus ostia. Recurrent acute rhinosinusitis (RARS) is defined as 4 or more episodes per year of acute bacterial rhinosinusitis without signs or symptoms of rhinosinusitis between episodes. Medical Treatment Most cases of CRS and RARS are treated with medical therapy (e.g., antihistamines, steroids, nasal lavage, and antibiotics).1 Functional Endoscopic Sinus Surgery FESS involves the insertion of an endoscope into the nose for a direct visual examination of the openings into the sinuses. Using the
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