From the Guidelines
The treatment of refractory chronic sinusitis typically involves a combination of medical and surgical interventions. Patients may be prescribed oral corticosteroids, such as prednisone 30-50 mg daily for 2-4 weeks, and/or antibiotics, including amoxicillin-clavulanate 875/125 mg twice daily for 3-6 weeks or levofloxacin 500 mg daily for 3-6 weeks 1. Additionally, topical nasal corticosteroids, such as fluticasone 200 mcg twice daily, and saline irrigations may be recommended for long-term management 1. In cases where medical therapy fails, functional endoscopic sinus surgery (FESS) or balloon sinuplasty may be considered to restore sinus drainage and ventilation 1.
Medical Management
- Oral corticosteroids: prednisone 30-50 mg daily for 2-4 weeks
- Antibiotics: amoxicillin-clavulanate 875/125 mg twice daily for 3-6 weeks or levofloxacin 500 mg daily for 3-6 weeks
- Topical nasal corticosteroids: fluticasone 200 mcg twice daily
- Saline irrigations: recommended for long-term management
Surgical Management
- Functional endoscopic sinus surgery (FESS): may be considered to restore sinus drainage and ventilation
- Balloon sinuplasty: may be considered to restore sinus drainage and ventilation
It is essential to note that the treatment of refractory chronic sinusitis should be individualized and based on the specific needs of each patient. Consultation with a specialist, such as an otolaryngologist, may be necessary to determine the best course of treatment 1.
From the Research
Treatment Options for Refractory Chronic Sinusitis
The treatment options for refractory chronic sinusitis include:
- Medical therapy, with topical corticosteroid therapy and high volume saline irrigation being the cornerstone of treatment 2
- Systemic corticosteroids and antibiotics, which may be used depending on the phenotype of chronic rhinosinusitis (CRS) and the presence of acute exacerbation 2
- Novel immunomodulatory therapies, such as anti-IL-4 receptor α antibodies and calcium channel blockers, which have shown promising early results but require further research before routine use 2
- Endoscopic sinus surgery (ESS), which may be considered for patients with refractory CRS who have failed maximal medical therapy (MMT) 3, 4
- Functional endoscopic sinus surgery (FESS) combined with an intra-oral approach, which has been shown to be effective in treating chronic infectious complications following maxillary sinus floor elevation procedures 3
- Topical antibiotic therapy delivered by means of a large-particle nebulizer, which has been shown to improve symptoms and quality of life in patients with refractory chronic rhinosinusitis 5
Maximal Medical Therapy (MMT) Protocols
MMT protocols prior to considering ESS for chronic rhinosinusitis include:
- Topical nasal corticosteroids for a mean of 8 weeks 4
- Oral antibiotics for 23 days 4
- Systemic corticosteroids for 18 days 4
- Saline irrigations, oral antihistamines, oral mucolytics, and topical/oral decongestants may also be used, but are less commonly reported 4
Pathophysiology and Management of Refractory Chronic Rhinosinusitis
Refractory chronic rhinosinusitis is defined as persistence of signs and symptoms of chronic rhinosinusitis despite technically adequate ESS 6
- Inflammatory responses to colonizing bacteria appear to be responsible for a significant portion of the pathophysiology 6
- Reduction of bacterial load and inflammation of the mucosa play an important role in controlling the disease 6
- Novel treatment strategies, with an emphasis on topical therapies, seem to offer optimal management 6