Endoscopic sinus surgery (ESS) can fail for many reasons: patient/disease factors, anatomy, incomplete surgery, ostial stenosis, recirculation, neo-osteogenesis, and recurrent mucosal disease. When it fails, otolaryngologists may be tempted to perform another surgery. Before doing so, however, it is important to first develop a clear picture of the anatomy, assess for comorbidities and mitigating factors, and set realistic expectations for the patient.
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November 2017“The frontal sinus can often be the most difficult and challenging to treat,” said Edward McCoul, MD, MPH, an otolaryngologist at Ochsner Health System in New Orleans, to a crowded room during a session at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery. His session was dedicated to recognizing the various pathophysiologic processes that may contribute to refractory chronic rhinosinusitis (CRS) and to describing the available medical and treatment options.
Approximately one-fourth of the patients who fail medical therapy and then undergo ESS will be diagnosed with refractory CRS. These patients will not make clinically significant improvements after surgery, and their symptoms cannot be controlled by appropriate medical therapy. They are more impaired than patients with Parkinson’s disease or moderate chronic obstructive pulmonary disease (COPD). “It is a very impactful disease on the people who have it,” said Dr. McCoul.
Pathophysiology of CRS
Abtin Tabaee, MD, an otolaryngologist at Weill Cornell Medicine in New York City, acknowledged that scientists still do not know the role of the normal microbiome in sinusitis. They do know, however, that the host, environment, and microbiology all come together to influence CRS. For the most part, attention on the host has focused on the paranasal anatomy. Unfortunately, this has not always been helpful, because there are anatomical variants that occur at a similar rate in both healthy patients and patients with CRS. Thus, these apparent anatomical vulnerabilities must be only one piece of the puzzle. For example, it may be that the anatomy blocks outflow tract physiology and, in this way, serves as an obstacle to topical treatment. If so, then it is a reasonable target for surgery if indicated by disease.
The microbiology of the sinuses includes viruses such as rhinovirus, acute bacterial infections, chronic bacterial infections, and fungal infections. There is a growing recognition that these organisms can form biofilms, which are surface-associated bacterial/fungal communities that allow microbial survival in non-optimal conditions. Otolaryngologists also now realize that the paranasal sinuses are not sterile. Instead, they are populated with a natural microbiome of multiple commensal bacteria that may be protective. While this knowledge is important, many questions remain unanswered, perhaps the most important of which is how best to optimize the sinus microbiome.
Treatment Options
Peter Hwang, MD, professor of otolaryngology and chief of the division of rhinology and endoscopic skull base surgery at Stanford University Medical Center in Calif., concluded the session by reviewing the available anti-inflammatory therapies and anti-infective therapies. Anti-inflammatory therapies include topical steroid irrigation, drug-eluting stents, and biologic therapies. Anti-infective therapies include both oral and topical agents.