What treatment is recommended for a patient with recurrent pansinusitis before undergoing sinus surgery?

Pre-Surgical Medical Management for Recurrent Pansinusitis

Before proceeding with sinus surgery for recurrent pansinusitis, patients must undergo adequate medical therapy including treatment of gastroesophageal reflux disease (GERD), evaluation and management of underlying allergies, assessment for immunodeficiency, and appropriate antibiotic courses. 1

GERD Evaluation and Treatment (Priority #1)

In patients with sinusitis refractory to medical therapy, treatment of associated GERD should be considered before surgical intervention. 1

• pH probe monitoring shows a high incidence of both esophageal and nasopharyngeal reflux in patients with chronic sinusitis, with studies demonstrating 63% of children and similar rates in adults having gastroesophageal reflux. 1
• Medical treatment of GERD results in significant improvement in sinusitis symptoms, with 79% of patients showing improvement after GERD treatment. 1
• The mechanism involves direct reflux of gastric acid into the pharynx and nasopharynx, causing inflammation of the sinus ostium. 1
• Treat with proton-pump inhibitors for an adequate trial period before considering surgery. 1

Allergy Evaluation and Management

Patients with recurrent rhinosinusitis or chronic rhinosinusitis should be evaluated for underlying allergy before sinus surgery. 1

• Up to 60% of patients with chronic rhinosinusitis have substantial allergic sensitivities, primarily to perennial allergens such as house dust mites, cockroaches, pet dander, and fungi. 1
• Skin testing is the preferred method for allergy evaluation. 1
• It is not uncommon for patients with chronic rhinosinusitis to be referred for allergy evaluation only after having undergone surgical procedures without benefit—many of these patients could have had better responses to medical management had their allergies been identified in advance of sinus surgery. 1
• Management of concomitant allergic rhinitis decreases the frequency of rhinosinusitis through reduction in nasal mucosal swelling and inflammation adjacent to the sinus outflow tract. 1

Immunodeficiency Assessment

Immune deficiency should be considered in cases of sinusitis resistant to usual medical therapy. 1

• The majority of immunodeficient patients with recurrent sinusitis have defects in humoral immunity, though other immunodeficiencies including AIDS can present with recurrent sinusitis. 1
• Analysis of radiographically confirmed cases of recurrent or refractory rhinosinusitis uncovered common variable immunodeficiency in 10% of patients and selective IgA deficiency in 6%. 1
• Appropriate laboratory studies should include quantitative immunoglobulin measurement (IgG, IgA, and IgM), specific antibody responses to tetanus toxoid and pneumococcal vaccine (both before and after immunization), and measurement of T-cell number and function. 1

Adequate Antibiotic Therapy

Adequate medical management minimally involves multiple courses of antibiotics chosen to cover the spectrum of pathogens anticipated to be causing the disease. 1

• For acute bacterial sinusitis, azithromycin 500 mg once daily for 3 days is an FDA-approved regimen. 2
• Appropriate antibiotic therapy requires at least 5-7 days for acute exacerbations, or long-term therapy exceeding 12 weeks for chronic disease. 3
• Approximately 70-80% of chronic rhinosinusitis patients respond adequately to appropriate medical treatment, making proper medical management essential before surgical consideration. 3

Additional Medical Therapies Required

The surgeon should NOT endorse or require a predefined, one-size-fits-all regimen or duration of medical therapy as a prerequisite to sinus surgery, but appropriate medical therapy should include nasal corticosteroids and nasal saline irrigation. 4

• Intranasal corticosteroids reduce mucosal inflammation and are essential components of medical management. 4
• Nasal saline irrigation improves mucociliary clearance and reduces inflammatory mediators. 4

Assessment for Other Contributing Factors

Clinicians should assess patients with chronic rhinosinusitis or recurrent acute rhinosinusitis for factors that modify management, such as allergic rhinitis, cystic fibrosis, immunocompromised state, ciliary dyskinesia, and anatomic variation. 5

• Aspirin-exacerbated respiratory disease (AERD) should be evaluated, as patients may benefit from aspirin desensitization post-operatively. 4
• Dental disease and odontogenic sources should be excluded, as they may be the etiology of maxillary sinusitis in 10-12% of patients. 1

Common Pitfalls to Avoid

• Do not proceed to surgery without addressing GERD in refractory cases—this is specifically emphasized in guidelines as a pre-surgical requirement. 1
• Do not skip allergy testing in patients being considered for surgery—identifying and treating allergies preoperatively improves surgical outcomes. 1
• Do not assume adequate antibiotic therapy has been given without documenting multiple appropriate courses—single short courses are insufficient. 1, 3
• Do not overlook immunodeficiency evaluation in patients with recurrent infections—10-16% may have identifiable immune defects. 1