From the Guidelines
For patients with chronic sinusitis who haven't responded to medical therapy, endoscopic sinus surgery (ESS) is the primary surgical intervention to consider, as it has been shown to result in significant improvement in the majority of patients 1. This procedure involves removing diseased tissue and opening blocked sinus passages while preserving normal mucosa. Before pursuing surgery, patients should have completed appropriate medical therapy including:
- intranasal corticosteroids (such as fluticasone 50mcg 1-2 sprays per nostril daily or mometasone 50mcg 2 sprays per nostril daily)
- saline irrigations (using devices like NeilMed twice daily)
- and typically at least one course of antibiotics (such as amoxicillin-clavulanate 875/125mg twice daily for 14 days) for bacterial infections Some patients may also have tried oral corticosteroids (prednisone 20-40mg daily for 5-7 days). Post-surgery, patients require continued medical management including:
- saline irrigations beginning 24-48 hours after surgery
- intranasal corticosteroids resuming 1-2 weeks postoperatively Surgery works by improving sinus drainage and ventilation, enhancing medication delivery to the sinuses, and removing chronically infected tissue or polyps. Alternative procedures include balloon sinuplasty for milder cases, which dilates sinus openings with less tissue removal. Surgery is most effective when combined with ongoing medical therapy to address the underlying inflammatory condition, and should be reserved for patients who do not satisfactorily respond to medical treatment 1. It is essential to evaluate the patient's condition thoroughly, including coronal sinus CT with extra cuts through the ostiomeatal complex, to clarify the extent of disease and specific location or locations 1. Functional endoscopic surgery is superior to minimal conventional procedures, including polypectomy and antral irrigations 1. Major complications occur in less than 1%, and revision surgery is performed in approximately 10% within 3 years 1. Overall, ESS is a safe and effective treatment option for patients with chronic sinusitis who have not responded to medical therapy, and can significantly improve their quality of life.
From the Research
Treatment Options for Chronic Sinusitis
- Patients with chronic sinusitis who have not responded to medical therapy may be candidates for surgical intervention, such as functional endoscopic sinus surgery (FESS) 2.
- FESS is a minimally invasive procedure that can be used to treat various sinus diseases, including chronic rhinosinusitis (CRS) and nasal polyps 2.
- The goals of surgery in CRS are to improve symptoms, reduce inflammation, and promote healing, but the indications and limitations of surgery must be carefully considered 2.
Medical Therapies for Chronic Sinusitis
- Medical therapies for chronic sinusitis include saline irrigation, topical corticosteroids, systemic corticosteroids, and antibiotics 3.
- Saline irrigation and topical corticosteroid therapy are recommended as first-line treatments for chronic sinusitis 3.
- Systemic corticosteroids and antibiotics may be considered for patients with nasal polyps or other complications 3.
Postoperative Care after Sinus Surgery
- The use of postoperative antibiotics after FESS is not well established, and studies have shown that they may not improve outcomes or reduce bacterial growth 4, 5.
- A randomized controlled trial found that placebo was noninferior to prophylactic antibiotics after ESS for CRS regarding postoperative sinonasal-specific quality of life 5.
- The rate of diarrhea was significantly higher in the antibiotic group, suggesting that routine use of prophylactic postoperative antibiotics may not be necessary 5.