Evolution in the surgical management of chronic rhinosinusitis: Current indications and pitfalls
2018; Elsevier BV; Volume: 141; Issue: 5 Linguagem: Inglês
10.1016/j.jaci.2018.03.003
ISSN1097-6825
AutoresMichael A. Kohanski, Elina Toskala, David W. Kennedy,
Tópico(s)Allergic Rhinitis and Sensitization
ResumoChronic rhinosinusitis (CRS) consists of a range of inflammatory conditions in the sinuses that can result in clinical symptoms. The underlying pathophysiology and its relationship to lower airway disease are complex. Current definitions of CRS can serve more as an indication for potential surgical intervention rather than a marker of disease state. CRS can be asymptomatic and may require medical management to avoid disease progression and minimize the risk of lower airway disease. Endoscopic surgery has undergone a significant evolution and refinement, but the most common surgical complication remains persistent inflammation and disease recurrence. It is important to recognize that surgery alone rarely cures CRS and patients require long-term medical therapy for continued asymptomatic inflammation. Careful postoperative care and endoscopic follow-up to ensure resolution of inflammation are key to ensuring optimal surgical outcomes and reduce the risk of revision surgery. Future work on CRS endotypes will allow discovery of new therapies to treat CRS, as well as refine indications for medical or surgical intervention and postoperative care. Chronic rhinosinusitis (CRS) consists of a range of inflammatory conditions in the sinuses that can result in clinical symptoms. The underlying pathophysiology and its relationship to lower airway disease are complex. Current definitions of CRS can serve more as an indication for potential surgical intervention rather than a marker of disease state. CRS can be asymptomatic and may require medical management to avoid disease progression and minimize the risk of lower airway disease. Endoscopic surgery has undergone a significant evolution and refinement, but the most common surgical complication remains persistent inflammation and disease recurrence. It is important to recognize that surgery alone rarely cures CRS and patients require long-term medical therapy for continued asymptomatic inflammation. Careful postoperative care and endoscopic follow-up to ensure resolution of inflammation are key to ensuring optimal surgical outcomes and reduce the risk of revision surgery. Future work on CRS endotypes will allow discovery of new therapies to treat CRS, as well as refine indications for medical or surgical intervention and postoperative care. Chronic rhinosinusitis (CRS) encompasses a broad spectrum of inflammatory conditions of the sinuses that can result in clinical symptoms. Like asthma, CRS can be symptomatic or asymptomatic, and its optimal management requires close cooperation between surgeon and allergist. The syndrome is complex, and the pathology is multifactorial and partially unknown, involving elements of innate mucosal immunity and the adaptive inflammatory response. Mucociliary clearance is diminished in patients with CRS, which can, in part, relate to local hypoxia in an obstructed sinus that could push epithelial cells away from a fully differentiated state into a state of epithelial to mesenchymal transition.1Hariri B.M. Cohen N.A. New insights into upper airway innate immunity.Am J Rhinol Allergy. 2016; 30: 319-323Crossref PubMed Scopus (44) Google Scholar, 2Shin H.W. Cho K. Kim D.W. Han D.H. Khalmuratova R. Kim S.W. et al.Hypoxia-inducible factor 1 mediates nasal polypogenesis by inducing epithelial-to-mesenchymal transition.Am J Respir Crit Care Med. 2012; 185: 944-954Crossref PubMed Scopus (88) Google Scholar Mucosal barrier integrity is also compromised in patients with CRS, in whom there is altered or decreased expression of tight junction proteins.3Schleimer R.P. Immunopathogenesis of chronic rhinosinusitis and nasal polyposis.Annu Rev Pathol. 2017; 12: 331-357Crossref PubMed Scopus (264) Google Scholar, 4Soyka M.B. Wawrzyniak P. Eiwegger T. Holzmann D. Treis A. Wanke K. et al.Defective epithelial barrier in chronic rhinosinusitis: the regulation of tight junctions by IFN-gamma and IL-4.J Allergy Clin Immunol. 2012; 130: 1087-1096.e10Abstract Full Text Full Text PDF PubMed Scopus (319) Google Scholar Prolonged alterations in mucosal integrity might allow for enhanced transmission of bacterial, viral, or fungal byproducts or epithelial products secreted into the mucus across the epithelium that can result in prolonged and ultimately pathologic inflammatory signaling. Altered expression or polymorphisms in pathogen and pathogen byproduct recognition by pattern recognition molecules or bitter taste receptors can reduce the ability of the immune response to clear a pathogen from the upper respiratory system.3Schleimer R.P. Immunopathogenesis of chronic rhinosinusitis and nasal polyposis.Annu Rev Pathol. 2017; 12: 331-357Crossref PubMed Scopus (264) Google Scholar, 5Carey R.M. Adappa N.D. Palmer J.N. Lee R.J. Cohen N.A. Taste receptors: regulators of sinonasal innate immunity.Laryngoscope Investig Otolaryngol. 2016; 1: 88-95Crossref PubMed Scopus (41) Google Scholar, 6Lee R.J. Kofonow J.M. Rosen P.L. Siebert A.P. Chen B. Doghramji L. et al.Bitter and sweet taste receptors regulate human upper respiratory innate immunity.J Clin Invest. 2014; 124: 1393-1405Crossref PubMed Scopus (271) Google Scholar, 7Lee R.J. Xiong G. Kofonow J.M. Chen B. Lysenko A. Jiang P. et al.T2R38 taste receptor polymorphisms underlie susceptibility to upper respiratory infection.J Clin Invest. 2012; 122: 4145-4159Crossref PubMed Scopus (403) Google Scholar Variations in the expression of these pattern recognition molecules or bitter taste receptors could affect the biodiversity of the sinus flora and make subjects more susceptible to CRS. The richness and diversity of the upper respiratory microbiome is reduced in patients with CRS,8Mahdavinia M. Keshavarzian A. Tobin M.C. Landay A.L. Schleimer R.P. A comprehensive review of the nasal microbiome in chronic rhinosinusitis (CRS).Clin Exp Allergy. 2016; 46: 21-41Crossref PubMed Scopus (87) Google Scholar, 9Anderson M. Stokken J. Sanford T. Aurora R. Sindwani R. A systematic review of the sinonasal microbiome in chronic rhinosinusitis.Am J Rhinol Allergy. 2016; 30: 161-166Crossref PubMed Scopus (30) Google Scholar, 10Lee J.T. Frank D.N. Ramakrishnan V. Microbiome of the paranasal sinuses: update and literature review.Am J Rhinol Allergy. 2016; 30: 3-16Crossref PubMed Scopus (52) Google Scholar and this might be a reflection of the underlying inflammation in the sinonasal mucosa or a result of prolonged and repetitive antibiotic overuse. It remains to be seen whether changes in the microbial community are a driver of inflammation observed in patients with CRS or a reflection of the underlying inflammatory status. CRS can be classified into 2 main cohorts: chronic rhinosinusitis with nasal polyps (CRSwNP) and chronic rhinosinusitis without nasal polyps (CRSsNP).11Fokkens W.J. Lund V.J. Mullol J. Bachert C. Alobid I. Baroody F. et al.EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists.Rhinology. 2012; 50: 1-12Crossref PubMed Google Scholar CRSsNP is characterized mostly by fibrosis and neutrophilic inflammation, as well as by TH1 or TH17 responses.12Cho S.H. Kim D.W. Gevaert P. Chronic rhinosinusitis without nasal polyps.J Allergy Clin Immunol Pract. 2016; 4: 575-582Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar CRSwNP (Fig 1) is associated with moderate or severe TH2 eosinophilic inflammation and comorbid asthma. However, several studies in recent years have suggested that the molecular diversity in CRS pathogenesis is more complex and that this classification might not be sufficient.13Gurrola 2nd, J. Borish L. Chronic rhinosinusitis: endotypes, biomarkers, and treatment response.J Allergy Clin Immunol. 2017; 140: 1499-1508Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 14Stevens W.W. Ocampo C.J. Berdnikovs S. Sakashita M. Mahdavinia M. Suh L. et al.Cytokines in chronic rhinosinusitis. Role in eosinophilia and aspirin-exacerbated respiratory disease.Am J Respir Crit Care Med. 2015; 192: 682-694Crossref PubMed Scopus (179) Google Scholar, 15Tomassen P. Vandeplas G. Van Zele T. Cardell L.O. Arebro J. Olze H. et al.Inflammatory endotypes of chronic rhinosinusitis based on cluster analysis of biomarkers.J Allergy Clin Immunol. 2016; 137: 1449-1456.e4Abstract Full Text Full Text PDF PubMed Scopus (612) Google Scholar Several different endotypes were identified in a recent study based on molecular inflammatory profiles in patients with CRS rather than phenotypic profiles.15Tomassen P. Vandeplas G. Van Zele T. Cardell L.O. Arebro J. Olze H. et al.Inflammatory endotypes of chronic rhinosinusitis based on cluster analysis of biomarkers.J Allergy Clin Immunol. 2016; 137: 1449-1456.e4Abstract Full Text Full Text PDF PubMed Scopus (612) Google Scholar Biologics for the treatment of asthma that target IgE or IL-5 or IL-4/IL-13 receptors are being assessed for efficacy in the treatment of CRSwNP,16Bachert C. Mannent L. Naclerio R.M. Mullol J. Ferguson B.J. Gevaert P. et al.Effect of subcutaneous dupilumab on nasal polyp burden in patients with chronic sinusitis and nasal polyposis: a randomized clinical trial.JAMA. 2016; 315: 469-479Crossref PubMed Scopus (537) Google Scholar, 17Gevaert P. Calus L. Van Zele T. Blomme K. De Ruyck N. Bauters W. et al.Omalizumab is effective in allergic and nonallergic patients with nasal polyps and asthma.J Allergy Clin Immunol. 2013; 131: 110-116.e1Abstract Full Text Full Text PDF PubMed Scopus (499) Google Scholar, 18Gevaert P. Van Bruaene N. Cattaert T. Van Steen K. Van Zele T. Acke F. et al.Mepolizumab, a humanized anti-IL-5 mAb, as a treatment option for severe nasal polyposis.J Allergy Clin Immunol. 2011; 128 (e1-8): 989-995Abstract Full Text Full Text PDF PubMed Scopus (457) Google Scholar and more refined CRS endotyping in the future will hopefully allow for optimal selection of an appropriate biologic agent for the treatment of CRS. Both phenotypic characterization of CRS and endotype profiling indicate that there is a relationship between CRS and lower airway disease. The advantage of upper airway control of inflammation on lower airway disease has been well documented.19Lin D.C. Chandra R.K. Tan B.K. Zirkle W. Conley D.B. Grammer L.C. et al.Association between severity of asthma and degree of chronic rhinosinusitis.Am J Rhinol Allergy. 2011; 25: 205-208Crossref PubMed Scopus (161) Google Scholar, 20Marple B.F. Allergic rhinitis and inflammatory airway disease: interactions within the unified airspace.Am J Rhinol Allergy. 2010; 24: 249-254Crossref PubMed Scopus (76) Google Scholar Recent studies have also suggested that earlier surgery in appropriately selected patients decreases the risk and lessens the severity of asthma.21Benninger M.S. Sindwani R. Holy C.E. Hopkins C. Early versus delayed endoscopic sinus surgery in patients with chronic rhinosinusitis: impact on health care utilization.Otolaryngol Head Neck Surg. 2015; 152: 546-552Crossref PubMed Scopus (62) Google Scholar, 22Hopkins C. Andrews P. Holy C.E. Does time to endoscopic sinus surgery impact outcomes in chronic rhinosinusitis? Retrospective analysis using the UK clinical practice research data.Rhinology. 2015; 53: 18-24Crossref PubMed Google Scholar However, it is important to recognize that essentially all patients undergoing surgery for CRS have persistent inflammation, which is frequently asymptomatic, after surgical intervention (Fig 2). These postoperative patients require ongoing medical management in the form of oral steroids, topical steroid sinus washes, and a prolonged oral antibiotic treatment for exposed bone to reduce the inflammatory burden in the sinuses. Endoscopic surveillance should continue until the mucosa has clearly stabilized and again returned to normal after upper respiratory tract infections or environmental exposures. It is in this medical management that a close working relationship between a surgeon and an allergist is invaluable, and such care highlights the importance of allergists as skilled nasal endoscopists able to recognize minor asymptomatic mucosal changes and appropriately adjust medical therapy. The breadth of medical therapeutic options continues to expand. Efforts to better classify CRS are underway23Adnane C. Adouly T. Khallouk A. Rouadi S. Abada R. Roubal M. et al.Using preoperative unsupervised cluster analysis of chronic rhinosinusitis to inform patient decision and endoscopic sinus surgery outcome.Eur Arch Otorhinolaryngol. 2017; 274: 879-885Crossref PubMed Scopus (16) Google Scholar, 24Akdis C.A. Bachert C. Cingi C. Dykewicz M.S. Hellings P.W. Naclerio R.M. et al.Endotypes and phenotypes of chronic rhinosinusitis: a PRACTALL document of the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy, Asthma & Immunology.J Allergy Clin Immunol. 2013; 131: 1479-1490Abstract Full Text Full Text PDF PubMed Scopus (418) Google Scholar, 25Soler Z.M. Hyer J.M. Rudmik L. Ramakrishnan V. Smith T.L. Schlosser R.J. Cluster analysis and prediction of treatment outcomes for chronic rhinosinusitis.J Allergy Clin Immunol. 2016; 137: 1054-1062Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar and will be important moving forward toward more targeted efforts to treat patients and to assist in decision making for surgical intervention. Surgery is usually reserved for patients in whom medical therapy fails. CRS is a clinical syndrome classically defined by the presence of rhinologic symptoms together with evidence of sinus inflammation on nasal endoscopy, computed tomographic (CT) imaging, or both. Although the overarching phenotypic diagnostic criteria are defined, the specific diagnostic criteria and approach to treatment continue to evolve along with our understanding of CRS. According to the American Academy of Otolaryngology–Head and Neck Surgery guidelines from 201526Rosenfeld R.M. Piccirillo J.F. Chandrasekhar S.S. Brook I. Ashok Kumar K. Kramper M. et al.Clinical practice guideline (update): adult sinusitis.Otolaryngol Head Neck Surg. 2015; 152: S1-S39PubMed Google Scholar and the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS 2012),11Fokkens W.J. Lund V.J. Mullol J. Bachert C. Alobid I. Baroody F. et al.EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists.Rhinology. 2012; 50: 1-12Crossref PubMed Google Scholar CRS is defined as the presence of 2 or more of the following: mucopurulent anterior or posterior nasal discharge, nasal congestion, sinus pressure, and diminished sense of smell present for 12 or more consecutive weeks plus endoscopic evidence of mucopurulence or inflammation in the middle meatus or polyps for CRSwNP or evidence of inflammation on CT scanning. The International Consensus on Allergy and Rhinosinusitis put forth by a multinational panel of rhinologists defines CRS by the same set of clinical symptoms along with evidence of mucopurulence from the paranasal sinuses or osteomeatal complex and evidence of inflammation on CT scans.27Orlandi R.R. Kingdom T.T. Hwang P.H. Smith T.L. Alt J.A. Baroody F.M. et al.International consensus statement on allergy and rhinology: rhinosinusitis.Int Forum Allergy Rhinol. 2016; 6: S22-S209Crossref PubMed Scopus (643) Google Scholar However, these definitions of CRS are flawed and serve more as an indication for potential consideration of surgical intervention than as a true indicator of disease state. We now recognize that even significant CRS can be asymptomatic and require medical management both in terms of avoiding disease progression and in terms of minimizing the risk of lower airway disease.19Lin D.C. Chandra R.K. Tan B.K. Zirkle W. Conley D.B. Grammer L.C. et al.Association between severity of asthma and degree of chronic rhinosinusitis.Am J Rhinol Allergy. 2011; 25: 205-208Crossref PubMed Scopus (161) Google Scholar, 28Baguley C. Brownlow A. Yeung K. Pratt E. Sacks R. Harvey R. The fate of chronic rhinosinusitis sufferers after maximal medical therapy.Int Forum Allergy Rhinol. 2014; 4: 525-532Crossref PubMed Scopus (52) Google Scholar Patients who meet the objective criteria for CRS should be offered a course of appropriate medical therapy before surgery is considered, unless there is a concern about the possibility of a tumor or another disease entity (Fig 3). Medical therapy for CRS is widely variable29Dautremont J.F. Rudmik L. When are we operating for chronic rhinosinusitis? A systematic review of maximal medical therapy protocols prior to endoscopic sinus surgery.Int Forum Allergy Rhinol. 2015; 5: 1095-1103Crossref PubMed Scopus (32) Google Scholar but can include sinus irrigation and topical intranasal corticosteroids with or without oral antibiotics, steroids, or both. Based on current guidelines,11Fokkens W.J. Lund V.J. Mullol J. Bachert C. Alobid I. Baroody F. et al.EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists.Rhinology. 2012; 50: 1-12Crossref PubMed Google Scholar, 26Rosenfeld R.M. Piccirillo J.F. Chandrasekhar S.S. Brook I. Ashok Kumar K. Kramper M. et al.Clinical practice guideline (update): adult sinusitis.Otolaryngol Head Neck Surg. 2015; 152: S1-S39PubMed Google Scholar, 27Orlandi R.R. Kingdom T.T. Hwang P.H. Smith T.L. Alt J.A. Baroody F.M. et al.International consensus statement on allergy and rhinology: rhinosinusitis.Int Forum Allergy Rhinol. 2016; 6: S22-S209Crossref PubMed Scopus (643) Google Scholar use of nasal irrigation and topical intranasal corticosteroids is recommended for CRSsNP and CRSwNP. The level of evidence for the off-label use of high-dose, high-volume steroid nasal irrigations (0.6 to 2 mg of mometasone or 0.5 mg of budesonide in 240 mL of normal saline irrigation) is reported as level Ib in patients with CRS,27Orlandi R.R. Kingdom T.T. Hwang P.H. Smith T.L. Alt J.A. Baroody F.M. et al.International consensus statement on allergy and rhinology: rhinosinusitis.Int Forum Allergy Rhinol. 2016; 6: S22-S209Crossref PubMed Scopus (643) Google Scholar, 30Harvey R.J. Snidvongs K. Kalish L.H. Oakley G.M. Sacks R. Corticosteroid nasal irrigations are more effective than simple sprays in a randomized double-blinded placebo-controlled trial for chronic rhinosinusitis after sinus surgery.Int Forum Allergy Rhinol. 2018; ([Epub ahead of print])Crossref Scopus (80) Google Scholar but it is the authors' opinion that this topical therapy has also significantly reduced the need for surgical intervention. The use of oral antibiotics as a first-line treatment for CRS is more variable. The International Consensus on Allergy and Rhinosinusitis position paper27Orlandi R.R. Kingdom T.T. Hwang P.H. Smith T.L. Alt J.A. Baroody F.M. et al.International consensus statement on allergy and rhinology: rhinosinusitis.Int Forum Allergy Rhinol. 2016; 6: S22-S209Crossref PubMed Scopus (643) Google Scholar discusses the paucity of high-quality trials for antibiotics in the treatment of CRS and makes a limited recommendation for the use of macrolides in the treatment of CRS. Per American Academy of Otolaryngology–Head and Neck Surgery guidelines,26Rosenfeld R.M. Piccirillo J.F. Chandrasekhar S.S. Brook I. Ashok Kumar K. Kramper M. et al.Clinical practice guideline (update): adult sinusitis.Otolaryngol Head Neck Surg. 2015; 152: S1-S39PubMed Google Scholar first-line treatment for acute rhinosinusitis should be with amoxicillin or amoxicillin plus clavulanic acid; however, there are no explicit recommendations for antibiotic treatment specifically for CRS. The EPOS guidelines11Fokkens W.J. Lund V.J. Mullol J. Bachert C. Alobid I. Baroody F. et al.EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists.Rhinology. 2012; 50: 1-12Crossref PubMed Google Scholar recommend steroids as first-line treatment for CRSsNP and CRSwNP with level Ia evidence and that long-term antibiotic therapy should be considered in those cases in which steroids and saline rinses have not adequately controlled symptoms. The indications to offer surgery for failure of medical therapy are evolving. The primary goals of surgery are to reduce inflamed/diseased tissue, open natural drainage pathways, and allow for better application of topical therapeutics and rinses (Fig 4). Failure of appropriate medical therapy constitutes a lack of objective improvement on endoscopy and opacification seen on CT scans, as well as a failure to improve symptoms as measured with quality-of-life metrics, such as the Sino-Nasal Outcome Test (SNOT) 22.31Soler Z.M. Jones R. Le P. Rudmik L. Mattos J.L. Nguyen S.A. et al.Sino-Nasal Outcome Test-22 outcomes after sinus surgery: a systematic review and meta-analysis.Laryngoscope. 2018; 128: 581-592Crossref PubMed Scopus (59) Google Scholar, 32Patel Z.M. Thamboo A. Rudmik L. Nayak J.V. Smith T.L. Hwang P.H. Surgical therapy vs continued medical therapy for medically refractory chronic rhinosinusitis: a systematic review and meta-analysis.Int Forum Allergy Rhinol. 2017; 7: 119-127Crossref PubMed Scopus (35) Google Scholar Minimal clinically important differences in symptom scores can be used in a standardized fashion to help guide treatment decisions.33Chowdhury N.I. Mace J.C. Bodner T.E. Alt J.A. Deconde A.S. Levy J.M. et al.Investigating the minimal clinically important difference for SNOT-22 symptom domains in surgically managed chronic rhinosinusitis.Int Forum Allergy Rhinol. 2017; 7: 1149-1155Crossref PubMed Scopus (77) Google Scholar Objective findings on endoscopy can correlate with SNOT-22 scores,34Snidvongs K. Dalgorf D. 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White A.A. et al.Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis: a RAND/UCLA appropriateness study.Rhinology. 2016; 54: 117-128Crossref PubMed Google Scholar Surgical decision making should also take into account the effect of sinonasal disease on the lower airways and the improved control of lower airway disease demonstrated in some recent studies with earlier surgical intervention.21Benninger M.S. Sindwani R. Holy C.E. Hopkins C. Early versus delayed endoscopic sinus surgery in patients with chronic rhinosinusitis: impact on health care utilization.Otolaryngol Head Neck Surg. 2015; 152: 546-552Crossref PubMed Scopus (62) Google Scholar, 22Hopkins C. Andrews P. Holy C.E. Does time to endoscopic sinus surgery impact outcomes in chronic rhinosinusitis? Retrospective analysis using the UK clinical practice research data.Rhinology. 2015; 53: 18-24Crossref PubMed Google Scholar For those with aspirin-exacerbated respiratory disease, higher SNOT-22 scores correlate with increased severity of reactions during aspirin desensitization.37Waldram J. Walters K. Simon R. Woessner K. Waalen J. White A. Safety and outcomes of aspirin desensitization for aspirin-exacerbated respiratory disease: a single-center study.J Allergy Clin Immunol. 2018; 141: 250-256Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar Complete sinus surgery before aspirin desensitization can effectively reduce sinus symptoms and need for revision surgery.38Adappa N.D. Ranasinghe V.J. Trope M. Brooks S.G. Glicksman J.T. 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Gouma P. et al.The effects of smoking on quality of life recovery after surgery for chronic rhinosinusitis.Rhinology. 2014; 52: 341-347Crossref PubMed Scopus (15) Google Scholar but in our experience continued smoking significantly adversely affects the surgical outcome to the extent that the senior author will no longer perform elective surgery for CRS in patients who have not yet quit smoking. Continued smoking appears to result in significant granulation tissue on exposed bone, resultant stenosis, and persistent disease. There is still significant debate about the appropriate extent of surgical intervention in patients with CRS,45DeConde A.S. Suh J.D. Mace J.C. Alt J.A. Smith T.L. Outcomes of complete vs targeted approaches to endoscopic sinus surgery.Int Forum Allergy Rhinol. 2015; 5: 691-700Crossref PubMed Scopus (49) Google Scholar but the importance of mucoperiostial preservation is generally accepted and has become more easily achievable as surgical instrumentation has advanced.46Kennedy D.W. First-line management of sinusitis: a national problem? Surgical update.Otolaryngol Head Neck Surg. 1990; 103: 884-886Crossref PubMed Google Scholar, 47Schlosser R.J. Surgical salvage for the non-functioning sinus.Otolaryngol Clin North Am. 2010; 43 (ix-x): 591-604Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar The advent of balloon dilatation of sinus ostia has further raised the question as to whether just opening the sinuses and recreating a mucus drainage pathway is sufficient therapy in patients with CRS.48Hathorn I.F. Pace-Asciak P. Habib A.R. Sunkaraneni V. Javer A.R. Randomized controlled trial: hybrid technique using balloon dilation of the frontal sinus drainage pathway.Int Forum Allergy Rhinol. 2015; 5: 167-173Crossref PubMed Scopus (11) Google Scholar However, this approach does little in terms of resolving the inflammation or allowing access for topical therapies, and the latter has increasingly become a goal of surgery. Balloon dilatation is not US Food and Drug Administration approved for the treatment of polypoid disease, and studies have demonstrated early involvement of the underlying bone in patients with CRS, something that might be a factor in terms of why the inflammation can be difficult to manage with medical therapy alone.49Kennedy D.W. Senior B.A. Gannon F.H. Montone K.T. Hwang P. Lanza D.C. Histology and histomorphometry of ethmoid bone in chronic rhinosinusitis.Laryngoscope. 1998; 108: 502-507Crossref PubMed Scopus (147) Google Scholar, 50Perloff J.R. Gannon F.H. Bolger W.E. Montone K.T. Orlandi R. Kennedy D.W. 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