Medical Management after Primary Surgery Failure and Preoperative Medical Management

Abstract

• Despite growing evidence of common pathways in underlying immunologic deficiencies or sensitizations, medical therapy has still to address a spectrum of potentially causative etiologic factors of chronic rhinosinusitis (CRS).

• A complete etiological workup is the key to defining an individualized medical treatment protocol suitable to prevent or reduce the risk of repeated recurrence after primary surgery failure.

• In postoperative medical management, effective topical treatment should be combined with well-tolerated, long-term systemic therapy as the causative mechanisms in CRS always represent a systemic disease.

• Disturbances of the arachidonic acid pathway and consecutive pathologic leukotriene release have been identified as a common pathway and frequent driving force behind mucosal inflammatory disease of the upper as well as the lower airway, especially, but not only, in patients with aspirin intolerance.

• Aspirin desensitization can be performed successfully and, using a novel low-dose protocol, can be applied as a life-long treatment. As this is effective at the enzyme level of the arachidonic acid pathway, it is more causative and, based on clinical trials, more effective than leukotriene antagonists.