The rhinotopic protocol for chronic refractory rhinosinusitis: how we do it.

Dear Editor, In the hands of experienced surgeons, the majority of chronic rhinosinusitis patients who undergo endoscopic sinus surgery (ESS) experience significant improvement in symptoms in the first 12 months postoperatively; however, this does not seem to be long-lasting. Three-year outcome analysis indicates that the beneficial effect dissipates over time and that the symptoms continue to worsen in 5–25% of the patients, despite maximal medical therapy. Possible contributing risk factors include atopy, immune deficiency, disrupted mucociliary transport, foreign bodies in the sinus cavities, non-compliant patient, error in diagnosis, primary mucosal disease (such as sarcoidosis, cystic fibrosis, ciliary dyskinesia), residual or obstructive sinus disease (residual uncinate process, retained agger nasi or Haller cells, missed maxillary sinus ostia, lateralised middle turbinate, scarred frontal sinus, incomplete ethmoidectomy, etc.), resistant organisms, mucosal biofilm and ⁄or underlying osteitis. The management of these patients has proven to be challenging, and has traditionally included control of the predisposing factor(s), oral antibiotics, nasal and ⁄or systemic corticosteroids and ⁄or saline pressure hydrotherapy. Nasal endoscopy of patients who have persistent symptoms often shows patent sinus antrostomies but inflamed or polypoid mucosa, with and without crusts and mucopurulence (Figs 1 and 2). For those patients, who as labelled as having refractory chronic rhinosinusitis, topical therapy offers one effective alternative.