When FESS fails: The inflammatory load hypothesis in refractory chronic rhinosinusitis

Authors

  • Ahmed Bassiouni MBBCh,

    1. Department of Surgery–Otorhinolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, Australia
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  • Yuresh Naidoo FRACS,

    1. Department of Surgery–Otorhinolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, Australia
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  • Peter-John Wormald MD

    Corresponding author
    1. Department of Surgery–Otorhinolaryngology, Head and Neck Surgery, University of Adelaide, Adelaide, Australia
    • Department of Otorhinolaryngology, Head and Neck Surgery, 3C, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville, South Australia, Australia 5011
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  • Peter-John Wormald, MD, receives royalties from Medtronic ENT for instruments designed and is a consultant for Neilmed. The authors have no other funding, financial relationships, or conflicts of interest to disclose.

Abstract

Through recent advances in research, our understanding of chronic rhinosinusitis (CRS) has evolved to consider it as an inflammatory condition of the mucosa brought about by multiple factors. However, surgical management is still ruled by the classical concepts of functional endoscopic sinus surgery (FESS), which emphasizes the importance of ostial obstruction and sinus ventilation. These concepts fail to provide sufficient explanation for the presence of a subset of patients with refractory CRS who fail to respond to conventional FESS. Recent outcome studies have shown that high-grade mucosal inflammation often results in a poor outcome and that this patient group may show improved results with more radical surgery. This review examines the “inflammatory load hypothesis” as a possible explanation. We hypothesize that the grade of the inflammation is the most important predictor of long-term outcomes. Surgery, therefore, has a significant role not only in reestablishing ventilation, but also with removing the inflammatory load in the affected sinuses. We suspect that in these severely diseased patients, a more radical removal of local proinflammatory factors during surgery may improve patient outcomes.

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