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Transcript of Treatment alternatives for chronic rhinosinusitis persisting after ESS:What to do when...
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7/30/2019 Treatment alternatives for chronic rhinosinusitis persisting after ESS:What to do when antibiotics,steroids and surg
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7/30/2019 Treatment alternatives for chronic rhinosinusitis persisting after ESS:What to do when antibiotics,steroids and surg
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0 Dipb|edpgb pfb|dzw ca| Zasp-B__ O\_
mbe`dpgaes ca| zdpgbeps ~fa cdgi pa |bszae` pa B__) ~gpf zb|-
sgspbeob a| |bor||beob ac `gsbdsb `bszgpb pbofegodiiw d`btrdpb
sr|nb|w&3'
% Pfbsb ge`gg rdis d|b `bbmb` pa fdb |bc|dopa|w
of|aego |fgeasgersgpgs &\O\_'&>'
&Cgnr|b 4'%
Bvgspgen dina|gpfms `a eap d``|bss `gsbdsb zb|sgspgen dcpb| B__&6'
% Gp acpbe sbbms pa pfb zdpgbep pfdp pfb zfwsgogde fds igppib paaccb| lbwae` depglgapgos) oa|pgoaspb|ag`s) a| cr|pfb| sr|nb|w%
Ca| ge`gg rdis ~gpf of|aego oar|sbs a| ae pfb iaakarp ca| d
eb~ pfb|dzbrpgo dzz|adof) pfgs mdw azbe pfbm pa mgsibd`gen
oidgms c|am z|azaebeps a| srzzigb|s ac dipb|edpgb pfb|dzgbs%
NADI_ AC PFG_ \BSGB^
Pfgs |bgb~ d|pgoib sbbks pa z|ag b pfb fbdipf-od|b z|dopgpgaeb|
~gpf geca|mdpgae |bnd|`gen ddgidlib dipb|edpgb pfb|dzgbs ca|
pfb mdednbmbep ac O\_ ac zdpgbeps |bc|dopa|w pa B__) sa ds
pa bedlib pfbm pa lbppb| mbbp pfb ebb s ac pfgs of|aegodiiw gii
zazridpgae% Pfb bvgspgen p|bdpmbep azpgaes de` pfb bg`beob
srzza|pgen pfbm d|b |bgb~b` ge pfb oaepbvp ac pfb or||bep
kea~ib`nb ae pfb zdpfanbebsgs ac O\_%
Ds O\_ fds aeiw |bobepiw lbbe doobzpb` ds d oigegodi bepgpw lw
pfb |bnridpa|w drpfa|gpgbs ge pfb Regpb` _pdpbs&7'
) `arlib-lige`)
zidobla oaep|aiib` p|dgis ac pfb|dzw ca| zasp-B__ `gsbdsb d|b
|d|b de` pfasb pfdp fdb lbbe zb|ca|mb fdb |d|biw lbbe dig-
`dpb` lw d sboae` p|gdi% Pfb|dzw gs pfbe acpbe ldsb bgpfb| ae
de bvpbesgae c|am cg|sp z|geogzibs &pfb g`bepgcgodpgae ac d sp|dpb-
nw ldsb` ae zdpfazfwsgaianw' a| ldsb` rzae pfb alsb|b`
|bszaesb ge apfb| `gsbdsbs srof ds dorpb ldopb|gdi sgersgpgs a|
reazb|dpb` edsdi zaiwzasgs% \bsrips d|b disa acpbe |bza|pb`
debo`apdiiw) ge igmgpb` sb|gbs) |bp|aszbopgbiw) de` ~gpfarp d
dig` oaep|ai n|arz% Ebb|pfbibss) O\_ ea~ dccbops d id|nb
ermlb| ac zdpgbeps nialdiiw) de` pfarnf bg`beob gs igmgpb`)
nrg`deob gs |btrg|b` pa bedlib d z|dopgp gaeb|) ~fam gs ibss
bvzb|gbeob` ge pfb mdednbmbep ac pfbsb zdpgbeps) pa accb|
|dpgaedi od|b%
Z\AOB__ @B_O\GZPGAE
D pbdm ac p~a pb|pgd|w |fgeaiangsps |bgb~b` ddgidlib igpb|dpr|b
ae zasp-B__ `gsbdsb de` pfb|dzw rsgen de Benigsf idenrdnb
Mb`igeb
de` Naanib sbd|of ge pfb d|bds ac of|aego sgersgpgs
de` zaiwzasgs &igmgpb` pa pfb d`rip zazridpgae) frmde) oigegodi
p|gdis) gpbms ~gpf dlsp|dops' ~ds oae`ropb` de` cr|pfb| |bcgeb`
ldsb` ae pfb ge`gg rdi pazgos% Aeiw d|pgoibs zrligsfb dcpb|
Hderd|w 477> ~b|b geoir`b`% Dew zbb|-|bgb~b` zrligodpgaes
odzpr|b` ge d Mb igeb
sbd|of lrp eap ge pfb apfb| p~a sacp-
~d|b dzzigodpgaes) wbp `bbmb` gmza|pdep) ~b|b disa geoir`b %
D|pgoibs ~b|b n|d`b` ca| sp|benpf ac bg`beob dooa|`gen pa
DDZ _OTGM &Dmb|gode Dod`bmw ac Zb`gdp| gos _pbb|gen
Oammgppbb ae Trdigpw Gmz|abmbep de` Mdednbmbep'nrg`b-
igebs%&6>'
\boammbe`dpgaes ca| mdednbmbep ~b|b bspdligsfb` lw `|d~-
gen rzae sp|dpbngbs d`dzpb` c|am pfb N|d`bs ac
\boammbe`dpgae) Dssbssmbep) @bbiazmbep de` Bdirdpgae
&N\D@B' n|d gen swspbm) ~fgof oidssgcgbs sp|benpf ac |boam-
mbe`dpgaes dooa| gen pa pfb ldideob ac pfb lbebcgps de` `a~e-
sg bs dcpb| oaesg`b|gen pfb trdigpw ac pfb bg`beob &4:') de`
c|am pfb |bobepiw zrligsfb` DDA-FE_ nrg`bigebs ge sgersgpgs
~fgof rsbs d sgmgid| sp|dpbnw%&6'
Pfbsb swspbms d``|bss pfb `gsd`depdnbs gefb|bep pa apfb|n|d gen swspbms) srof ds d idok ac sbzd|dpgae lbp~bbe pfb trdi-
gpw ac pfb bg`beob de` pfb sp|benpf ac |boammbe`dpgaes) pfb
idok ac p|deszd|beow dlarp hr`nmbeps) de` pfb idok ac bvzigogp
dokea~ib`nbmbep ac dirbs de` z|bcb|beobs% Pfgs pwzb ac sws-
pbm gs zd|pgorid|iw rsbcri ge d|bds pfdp d|b oaep|ab|sgdi a|
~fb|b |boammbe`dpgaes d|b oibd| lrp aeiw alsb|dpgaedi spr -
gbs a| bvzb|p azgegae d|b ddgidlib%
\boammbe`dpgaes ~b|b ca|mridpb` ldsb` ae pfb sp|benpf ac
pfb bg`beob de` gps zapbepgdi |gsk!lbebcgp |dpga% Ds mdew pfb|-
dzgbs fdb eap lbbe srlhbopb pa sdcbpw bdirdpgae ge d oigegodi
p|gdi sbppgen) pfb zapbepgdi ca| fd|m ~ds dssbssb` ca| bdof pfb|d-
zw de` ~bgnfs ge pfb |boammbe`dpgae% \boammbe`dpgae
azpgaes ~b|b pa |boammbe` ~bdkiw) ma`b|dpbiw a| sp|aeniw;
accb| ds de azpgae ca| pfb|dzw; a| pa eap |boammbe` d ngbe
pfb|dzw ds bgpfb| oigegodi p|gdi `dpd `g eap srzza|p gps rsb a| d
oaeob|e ca| pavgogpw ~ds eapb`%
_OAZB AC PFB Z\ALIBM
Gp gs bspgmdpb pfdp dzz|avgmdpbiw 3 lgiigae `aiid|s gs szbep ge
pfb R%_% deerdiiw ae pfb|dzw ca| |fgegpgs de` sgersgpgs&44'
% Gp gs
rekea~e ~fdp zb|obepdnb ac pfgs gs ca| zasp-B__ `gsbdsb) lrp
pfb zibpfa|d ac ~bl sgpbs de` zfwsgogdes szbogcgodiiw pd|nbpgen
pfgs md|kbp gs d pbspgmaegdi pa pfb gepb|bsp de` pfb zapbepgdi
bvzbesb dssaogdpb ~gpf gp%
Cgnr|b 4% Zb|sgspbep `gsbdsb ac pfb mdvgiid|w sgers `bszgpb ~g biw zdpbep
mdvgiid|w sgers aspgrm zasp B__%
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7/30/2019 Treatment alternatives for chronic rhinosinusitis persisting after ESS:What to do when antibiotics,steroids and surg
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@bs|agsgb|s de` Kgipw 2
^fgib pfb ermlb| ac ge`gg rdis ~gpf zb|sgspbep `gsbdsb dcpb|
B__ odeeap lb z|bogsbiw p|dokb`) pfb ermlb|s ode lb bspgmdp-
b` c|am zrligsfb spr gbs ae pfb sroobss ac B__ ca| O\_ ~gpf
a| ~gpfarp edsdi zaiwzasgs% B__ |bmdges aeb ac pfb masp oam-
mae sr|ngodi z|aob`r|bs) ~gpf ab| 2::%::: zb|ca|mb wbd|iw
ge pfb R%_% diaeb &4
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7/30/2019 Treatment alternatives for chronic rhinosinusitis persisting after ESS:What to do when antibiotics,steroids and surg
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3 Dipb|edpgb pfb|dzw ca| Zasp-B__ O\_
aoor| lbp~bbe bvdob|ldpgaes ac `gsbdsb ge zdpgbeps oaiaegxb
~gpf pfgs dnbep&'
) GI-4\&?6'
) O0&?7'
)
DIAV-2) DIAV-2DZ) de` OW_IP4&0:'
) lrp pfb creopgaedi sgn-
egcgodeob ac pfbsb cge gens |bmdges rekea~e% D signfpiw fgnfb|
c|btrbeow ac O\_ ~ds eapb ge ge`gg rdis fbpb|anbebars ca|
pfb OC 2:6 nbeb&04'
) lrp pfgs igmgpb bccbop gs gesrccgogbep pa
bvzidge dii odsbs%
Ge d cgedi oaesg b|dpgae ds pa pfb reob|pdge dbpgaianw ac zasp-
B__ `gsbdsb) pfb gecirbeob ac be`asoazgo sgers sr|nb|w &B__'
ae pfb zfwsgaianw de`!a| ldopb|gaianw ac pfb zd|dedsdi sgersbs
|bmdges id|nbiw rekea~e% Ofdenbs ge pfb sgers beg|aembep
dcpb| B__ mdw dipb| geedpb mbofdegsms ac gmmregpw a| l|gen
dlarp bvobss spgmridpgae ac szbogcgo `bcbeobs% Ge pfb ea|mdi
sgprdpgae) pfb pa|prars `|dgednb zdpf ac pfb sgers cgipb|s arps
zd|pgoridpb mdppb| de` z|bbeps gps `bzasgpgae ge pfb sgers odg-
pgbs% \bmadi ac pfgs mbofdegodi ld||gb| diia~s pfb bvpb|edi
beg|aembep doobss pa de d|bd pfdp ~ds ca|mb|iw z|apbopb`
c|am bvzasr|b&0
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7/30/2019 Treatment alternatives for chronic rhinosinusitis persisting after ESS:What to do when antibiotics,steroids and surg
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@bs|agsgb|s de` Kgipw >
pgaes pa pfb edsdi mroasd d|b ddgidlib% D spr w ac pfbg| bccbo-
pgbebss dp `bzasgpgae fds reca|predpbiw lbbe `aeb ae reazb|-
dpb` sgersbs |dpfb| pfde zdpbep) zasp-sr|ngodi aebs&0>'
% Ge reaz-
b|dpb` sgersbs) zbebp|dpgae ca| eblrigsb` zd|pgoibs gs |dpfb|
zaa|&06'
) ~gpf edsdi g||gndpgae dcca|`gen lbppb| `bzasgp gae%
Ldsb` ae mdpfbmdpgodi ma`bis) `bzasgpgae gs fa~bb| z|ald-
liw mrof befdeob` dc pb| ~g`begen ac pfb asp gd dc pb| B__%
Zbebp|dpgae ac zrisdpgib-pwzb `bgobs srof ds pfb ^dpb|-Zgk
fdb eap lbbe bdirdpb ge pfgs sbppgen% @g|bop gep|dsgers `bza-
sgpgae gd ge`~biigen odpfbpb| accb|s fgnfb| |dpbs ac `bzasgpgae
lrp mdw lb paa gedsgb ge samb sbppgens a| ca| iaen-pb|m rsb%
_digeb8_p|aen |boammbe dpgae) ma`b|dpb bg beob%
\dpgaedib8_digeb g||gndpgae fds lbbe sfa~e pa gmz|ab sgnes
de` swmzpams ac |fgeasgersgpgs zasp-B__ ge aeb z|aszbopgb
spr w% Pfb |gsk ac pfb|dzw gs ebnignglib de` pfb zapbepgdi lbeb-
cgp oaesg b|dlib%
G||gndpgae ~gpf sdigeb |bmdges de gmza|pdep zd|p ac pfb pfb|d-
zbrpg o d| sbedi ) de` fd s lbbe |boammbe`b` ge d |bobe p
Oaof|deb |bgb~ ae pfgs srlhbop&07'
% Pfba|bpgodi d`depdnbs d|b
pfdp gp gmz|abs mroaogigd|w cia~) fw |dpbs pfb mroasd) de`
cirsfbs d~dw pavgo de` a| g||gpdpgb srlspdeobs c|am pfb sr|cdob
ac pfb mroasd% Pfb azpgmdi oaeobep|dpgae ac sdigeb fds eap
lbbe `bpb|mgeb ) lrp g||gndpgae ~gpf fwzb|paego sairpgaes mdw
odrsb g||gpdpgae ge srsobzpglib ge`gg`rdis%
Edsdi g||gndpgae fds lbbe rsb` sgeob deogbep pgmbs&2:'
% \bobep
`bsgnes fdb sarnfp pa gmz|ab ae pfb mbpfa` lw |boam-
mbe gen de` gesp|ropgen ae d ma|b oaebegbep fbd` zasgpgae-gen &~dpb| strg|pb` gepa pfb zdssdnbs ~gpf pfb fbd` cibvb` ca|-
~d| ' de` ae pfb rsb ac mbdes ca| nbppgen pfb sairpgae gepa pfb
zdssdnbs &lril de` sw|genb pbofegtrbs' dp d fgnfb| z|bssr|b%
Ca| bvdmzib) gepb|bspgen d`dzpdpgaes ac pfb ^dpb|-Zgk swspbm
rsb` ca| |bmadi ac `bepdi zidtrb d|b ddgidlib% Pfgs mbpfa`
rsbs zrisdpgib g||gndpgae `bigb|b` gd d d|gbpw ac d dzpb|s pa
gmz|ab oibdegen% Pfbg| rsb mdw pfba|bpgodiiw lb ma|b bccbo-
pgb dp |b`rogen ldopb|gdi iad` ge sgprdpgaes ~fb|b sbo|bpgaes
d|b pbedogars% Ia~-pbof sairpgaes srof ds segccgen ~dpb| arp ac
pfb zdim ac pfb fde` sfari` lb `gsoar|dnb`) ds pfbw mdw
geo|bdsb pfb |gsk ac oaepdmgedpgae ac pfb edsdi zdssdnbs%
Niroaoa|pgoaspb|ag`s8_p|aen |boammbe`dpgae) ma`b|dpb bg-
`beob%
\dpgaedib8Pazgodi oa|pgoaspb|ag s fdb lbbe sfa~e pa |b`rob
gecidmmdpgae ge O\_ de` pa lb dssaogdpb` ~gpf d |b ropgae ac
|boab|w acs% dr|brs ge zdpgbeps re`b|nagen |bgsgae B__%
Pfbg| bccbopgbebss ge |b`rogen edsdi zaiwzasgs fds lbbe
`bmaesp|dpb` ge \OPs) de` pfbw fdb lbbe sfa~e bccbopgb ge
|b`rogen sgnes de` swmzpams ac zasp-B__ `gsbdsb ~fbe
dzzigb` `g|bopiw gepa pfb sgers gd ge`~biigen odpfbpb|% \gsk
dzzbd|s mgea| ds ea bccbop ae zgprgpd|w-d |bedi dvgs fds lbbe
sfa~e ge d smdii z|aszbopgb p|gdi%
Oa|pgoaspb|ag s ge d|gars ca|ms fdb iaen lbbe rsb` ge pfb
mdednbmbep ac of|aego sgersgpgs de` edsdi zaiwzasgs) lapf z|b-
de` zasp-azb|dpgbiw) de` |bz|bsbep pfb mdgespdw ac pfb|dzw ca|
ge`gg rdis ~gpf zasp-B__ `gsbdsb% Pfb mbofdegsm ac dopgae ac
oa|pgoaspb|ag s gs pa z|bbep lge gen ac p|deso|gzpgae cdopa|s ge
pfb eroibrs pfb|blw ma`ridpgen pfb p|deso|gzpgae ac d id|nb
ermlb| ac nbebs ae obiis geaib` ge gmmreb de` gecidmmd-
pa|w |bszaesbs% Pfbw d|b disa dlib pa gecirbeob pfb p|desidpgaedi
de` zasp-p|desidpgaedi mbofdegsms lw ~fgof z|apbges d|b swe-
pfbsgxb ) z|aobssb` de` bvza|pb` c|am obiis% Pfgs gefglgps pfb
bvz|bssgae ac gecidmmdpa|w nbebs) mdgeiw ofbmadpp|dopdeps)
pfb|blw |b`rogen lapf pfb |bo|rgpmbep de` pfb dopgdpgae ac
gecidmmdpa|w obiis% _pb|ag s d|b pfrs lbebcgogdi ge oaep|aiigen
gecidmmdpgae dssaogdpb` ~gpf O\_ ~gpf de` ~gpfarp edsdi
zaiwzasgs&24'
%
Cr|pfb|ma|b) ds pfbw `a eap gefglgp pfb bzgpfbigdi obii nbebs
gmza|pdep ca| geedpb gmmregpw) oa|pgoaspb|ag s mdw bbe drn-
mbep pfb geedpb gmmreb |bszaesb lw geo|bdsgen pfb bvz|bs-
sgae ac PI\s ae pfb bzgpfbigdi sr|cdob de` befdeogen pfb z|a-
`ropgae ac gps bccbopa|s srof ds oaiibopges) oamzibmbep de`
dorpb-zfdsb z|apbges) dmaen apfb|s&2
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6 Dipb|edpgb pfb|dzw ca| Zasp-B__ O\_
`bbiazmbep ac swspbmgo sg b bccbops% Fa~bb|) pfb sdcbpw ac
g||gndpgae ~gpf :%2 mn ac lr`bsaeg b LG@ fds lbbe oaecg|mb
lw ^|gnfp ~fa sfa~b` ea bccbop ae pfb FZD dvgs ds `bpb|-
mgeb lw mbdsr|bs ac sb|rm oa|pgsai de` |bszaesb pa DOPF
spgmridpgae ge d smdii n|arz ac zdpgbeps&27'
%
_fa|p-pb|m oar|sbs ac a|di) pazgodi de` GS depglgapgos d|b |boam-
mbe`b` ca| dorpb bvdob|ldpgaes ac swmzpams8 Ma b|dpb |boam-
mbe`dpgae) ~bdk bg`beob ldsb` ae p|gdis ac depglgapgo pfb|dzw
ca| dorpb ldopb|gdi sgersgpgs de` ldopb|gaianw ac O\_%
\dpgaedib8Ea spr`gbs ac bccbopgbebss ge O\_ de` |gsk ac sg b
bccbops ac depglgapgos de` `bbiazmbep ac |bsgspdeob%
A|di depglgapgos8 Lw `bcgegpgae) ge`gg rdis ~gpf \O\_ `a eap
|bszae` pa a|di depglgapgos% Ngbe pfbg| idok ac z|abe bccgodow
ge pfb iaen-pb|m mdednbmbep ac zdpgbeps ~gpf of|aego `gsbdsb
de` pfb zapbepgdi ca| `bbiazmbep ac |bsgspdeob) pfbw sfari`
z|aldliw lb |bsb|b` ca| bvdob|ldpgaes ~gpf sfa|p-pb|m oar|sbs&3:)34'
% Od|b mrsp lb pdkbe pa sbibop de depglgapgo ~gpf oab|dnb
ca| pfasb zdpfanbes bvzbopb` ge \O\_% Oaesg`b|dpgae sfari`
lb ngbe pa alpdgegen be`asoazgodiiw nrg`b` oripr|bs ac pfb
sgers odgpgbs dp pfb pgmb ac bdirdpgae ds pfgs mdw fbiz nrg b
sbibopgae ac depglgapgo a| g`bepgcw ge`gg`rdis ~gpf |bsgspdep
a|ndegsms%
Eblrigxdpgae ac pazgodi depglgapgos fds d iaen fgspa|w ge pfb
mdednbmbep ac zdpgbeps ~gpf owspgo cgl|asgs% Fa~bb|) edsdi
eblrigsdpgae fds eap lbbe ds sroobsscri ge \O\_% Ge d \OP
oamzd|gen sdigeb ~gpf pal|dmwoge d`mgegspb|b` LG@ ca|
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7/30/2019 Treatment alternatives for chronic rhinosinusitis persisting after ESS:What to do when antibiotics,steroids and surg
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@bs|agsgb|s de` Kgipw 7
D_D `bsbesgpgxdpgae8 ^bdk |boammbe`dpgae) ma`b|dpb bg-
`beob%
\dpgaedib8D_D `bsbesgpgxdpgae fds lbbe `aormbepb` bccbopgb
ge |b`rogen edsdi zaiwzs% _roobssbs fdb lbbe maspiw |bza|pb`
lw bvzb|gbeob n|arzs de` pfb|b gs d |gsk ac d b|sb |bdopgaes
ge rebvzb|gbeob` z|dopgpgaeb|s a| ~fb|b eae-oamzigdeob gs de
gssrb%
D_D `bsbesgpgxdpgae fds lbbe |bza|pb` lw sbb|di n|arzs ds
|b`rogen edsdi zaiwzs&>2'
% Pfb mb ofdegs m a c do pga e gs
rekea~e% Fa~bb|) pfb|dzw mrsp lb pdkbe `dgiw de` mdw
ebb` pa lb |b-gegpgdpb` gc pfb zdpgbep mgssbs d `dgiw `asb%
Gep|dbears gmmreanialrige &GSGN'8Azpgae) ~bdk bg beob%
\dpgaedib8Reoaep|aiib` p|gdi ac GSGN ca| zasp-B__ fds sfa~e
lbebcgps ge d sbibopb` zazridpgae ~gpf zasp-B__ `gsbdsb% Oasp
ac pfb|dzw de` |gsks c|am rsb ac d liaa`- b|gb z|a`rop srn-
nbsp oaesg`b|gen gps rsb aeiw ge srlhbops eap |bszae`gen pa
apfb| pfb|dzgbs%
Oidssgodi oammae d|gdlib gmmreanialrige `bcgogbeow gs aood-
sgaediiw dssaogdpb` ~gpf |bor||bep a| |bc|dopa|w sgersgpgs) de`
~gii lb `bpbopb` lw ia~ sb|rm GnN a| GnN-srloidss ibbis%
Fa~bb|) d spr`w lw Ofbb bp di% `bso|glb` dipb|b` obiirid|
gmmreb |bszaesbs ge ge`gg`rdis ~gpf |bc|dopa|w O\_ ~gpf
ea|mdi GnN ibbis ~fa |bszae`b` pa d sgv-maepf p|gdi ~gpf
GSGN&>3'
% Pfb|b gs pfrs igppib bg`beob pa srzza|p pfb rsb ac
gep|dbears gmmreanialriges ge pfgs sbppgen) de` pfgs pfb|d-
zbrpgo dzz|adof sfari` aeiw lb oaesg`b|b` ge pfb masp |bc|do-
pa|w ac odsbs%
_r|nb|w ds d sp|dpbnw ca| zasp-B__ `gsbdsb8 Azpgae) ~bdk bg-
`beob%
Pfb `bogsgae pa |b-azb|dpb d zdpgbep ~gpf sgers `gsbdsb gs obe-
pb|b` z|geogzdi iw ae pfb `bmaesp|dpgae ac d swmzpamdp go
alsp|ropgae pa sgers `|dgednb a| pfb z|bsbeob ac sgnegcgodep `gs-
bdsb iad&>>'
% D mdvgm pa nrg b pfb sr|nbae gs pfdp pfb zdpgbep
ode ebb| p|riw lb `bbmb` d cdgir|b ac pfb|dzw repgi dii alsp|ro-
pgaes pa `|dgednb de` bepgidpgae &a| g||gndpgae' fdb lbbe oa|-
|bopb % Ge pfb sgersbs pfgs mrsp lb pbmzb|b` lw pfb oigegogdes
hr`nmbep) bvzb|gbeob) de` oamca|p ibbi%
DIPB\EDPGSB PFB\DZGB_
Eap |boammbe`b`) ~bdk bg`beob%
\dpgaedib8^fgib samb |bsrips d|b gepb|bspgen) pfbw mrsp lb
oaesg`b|b` bvzb|gmbepdi repgi mbofdegsm ac dopgae z|azasb`
pfb|dzgbs srzza|pb` lw d` gpgaedi oigegodi p|gdis ~gii lb |btrg|b`
z|ga| pa dew |boammbe dpgae%
Ermb|ars pfb|dzgbs bvgsp `bzbe gen rzae pfb sp|bdm ac dipb|-
edpgb mb`gogeb pfdp gs oaesripb`% _amb d|b bvzb|gmbepgen
~gpf g||gndpgae d` gpgbs) geoir`gen pbd p|bb agi) ds gp fds lbbe
`bso|glb` ds zassbssgen nb|mgog`b) crengog`b) de` depgsbzpgo
z|azb|pgbs% D zapbepgdi gssrb ~fbe dzziwgen agi-ldsb` z|a`rops
pa pfb sgeaedsdi odgpgbs gs pfb zassglgigpw ac iren oaepdmged-
pgae de` d |bsripdep igzag` zebrmaegd%
Apfb| dipb|edpgb mb`gogebs geoir`b dorzreopr|b) ~fasb zb|-
ca|mdeob gs lbigbb` pa fbiz pa ldideob cirg og|oridpgae de` pa
diibgdpb sgeaedsdi oaenbspgae% D fambazdpf mdw srnnbsp pdk-
gen sgi god de` Kdig lgof|amgorm `dgiw ca| pfb swmzpams ac
sgersgpgs% Mbde~fgib) ge gg rdis ~fa rsb d|amdpfb|dzw ~ari`
oaesg`b| gefdigen pfb d|amds ac brodiwzprs) idbe`b|) ibmae
de` pbd p|bb agis mgvb ge d la~i ac lagigen ~dpb| ge a|`b| pa
dppdge |bigbc c|am sgeaedsdi swmzpams% Eaeb ac pfbsb pfb|dzgbs
fdb dew z|abe lbebcgp) lrp zfwsgogdes p|bdpgen zdpgbeps ~fa
d|b rsgen pfbsb dipb|edpgb pfb|dzgbs sfari` beoar|dnb sfd|gen
ac pfgs geca|mdpgae sa pfdp d gob ode lb ngbe gc pfb|b dzzbd|s
pa lb d oibd| fbdipf pf|bdp c|am pfb sbibopb` pfb|dzw) de` pa
lbppb| re`b|spde` zapbepgdi oaecare gen cdopa|s pa mb`godiiw
z|bso|glb` pfb|dzw%
Depgsbzpgos
E-ofia|apdr|geb &EOP') de avg dep z|a`rob` lw spgmridpb`
n|deriaowpbs) fds lbbe z|bgarsiw `bmaesp|dpb` pa zassbss d
ldopb|gog`di bccbop dp d|gars oaeobep|dpgaes ge gp|a% EOP fds
lbbe sroobsscriiw rsb` ge de g||gndpgae sairpgae ca| pfb p|bdp-
mbep ac sgers gecbopgae ge gmmreaoamz|amgsb` zdpgbeps% D
4" sairpgae rsb ge de reoaep|aiib ) z|aszbopgb oafa|p odrsb`
d `bo|bdsb ge mroasdi b`bmd ) gmz|ab` aic do pgae ) de`
`bo|bdsb` edsdi alsp|ropgae ~fgib lbgen ~bii paib|dpb`% Apfb|
edpr|di z|a`rops pfdp d|b |bcb||b` pa ds fdgen depgsbzpgo z|az-
b|pgbs geoir`b pbd p|bb agi) n|dzbc|rgp sbb` bvp|dop) de` brodiwz-
prs agi%
_gib| bvp|dop
Pfb|b oaepgerbs pa bvgsp ge`gg`rdis ~fa z|amapb pfb rsb ac
edsdi sz|dws de` apfb| z|a`rops oaepdgegen sgib| ds pfb edpr|di
depglgapgo de` p|bdpmbep ca| sgers gecbopgaes% Fa~bb|) pfgs
mbpdi fds lbbe `bmaesp|dpb` pa lb pavgo % Gp gs `g ccgorip pa
be`a|sb d z|a`rop pfdp fds rez|abe depgmgo|algdi trdigpgbs)
wbp zidobs pfb fbdipf ac dew oaesrmb| dp reebobssd|w |gsk%
Ebrp|dobrpgodis8 Z|algapgos
Z|algapgos d|b oammaeiw |bnd|`b` ds c|gbe`iw a| naa` ldopb-
|gd) ~fasb oaesrmzpgae gs pfarnfp pa z|ag`b fbdipf lbebcgp
ca| d zapbepg di ermlb| ac d gimbeps geo ir`gen s gers gp gs %
Pdlib 4% Zdpfazfwsgaianw ac zasp-B__ `gsbdsb%
Ldopb|gdi z|bsbeob Wbs Wbs
Pf< gecidmmdpgae Wbs Wbs
Ldopb|gdi lgacgims Wbs Wbs
Crendi z|bsbeob Wbs Ea
_rzb|depgnbe Wbs 1
Eae-FGS gmmreb bcgogbeow Wbs 1
\bszg|dpa|w diib|nw Ea 1@bcbops ge geedpb gmmregpw Wbs 1
Nbebpgo cdopa|s Wbs 1
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7/30/2019 Treatment alternatives for chronic rhinosinusitis persisting after ESS:What to do when antibiotics,steroids and surg
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4: Dipb|edpgb pfb|dzw ca| Zasp-B__ O\_
Pwzgodiiw) d z|algapgo oaesgsps ac d sp|dge ac Idopaldogiirs
szbogbs% Ge dipb|edpgb mb`gogeb) pfb pfarnfp lbfge` pfbg| rsb
spbms c|am pfb lbigbc pfdp pfbg| oaesrmzpgae fbizs pa sp|benpf-
be pfb gmmreb swspbm% Pfb|b gs samb lbigbc pfdp z|algapgos
mdw fdb d z|apbopgb bccbop dndgesp pfb `bbiazmbep ac dspf-
md de` diib|ngo |fgegpgs ca| ofgi`|be p|bdpb` ~gpf depglgapgos
`r|gen pfbg| cg|sp wbd| ac igcb% Ea |bsbd|of or||bepiw bvgsps ge
O\_ pa srzza|p pfbg| rsb%
Mgo|alb bvp|dops
Pfbsb dnbeps d|b ibss oammaeiw bmziawb` ge pfb p|bdpmbep ac
sgersgpgs% Ge d `arlib-lige` zidobla-oaep|aiib` Nb|mde spr`w
ac zasp-azb|dpgb of|aego sgersgpgs) de drpaiwsdpb ac
Bepb|aoaoors cbodigsldopb|gdb ac frmde a|gnge ~ds rsb` ds pfb
p|bdpmbep&6
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7/30/2019 Treatment alternatives for chronic rhinosinusitis persisting after ESS:What to do when antibiotics,steroids and surg
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@bs|agsgb|s de` Kgipw 44
ge pfb zidobla n|arz) de` pfdp |bidzsb paak sgnegcgodepiw iaenb|
pa aoor| zasp-azb|dpgbiw ge pfb b|rm-p|bdpb` n|arz% Pfbw
lbigbb pfbsb n|arz `gccb|beobs d|b |bidpb` pa gmmreb-ma`gcw-
gen ofd|dopb|gspgos ac pfgs p|bdpmbep% Ge de bd|igb| mripgobepb|)
|de`amgxb` arlib-lige` zidobla-oaep|aiib` spr`w rsgen d ldo-
pb|gdi iwsdpb ca| pfb p|bdpmbep ac zdpgbeps ~gpf O\_) rsb ac pfb
spr`w `|rn ~ds dssaogdpb` ~gpf d sgnegcgodep gmz|abmbep ge
pfb sgeaedsdi swmzpams c|am pfb cg|sp pa sgvpf maepf ac alsb|-
dpgae ca| pfb p|bdpmbep n|arz&6?'
%
Mgo|alb bvp|dops
Pfbsb dnbeps d|b ibss oammaeiw bmziawb` ge pfb p|bdpmbep ac
sgersgpgs% Ge d `arlib-lige` zidobla-oaep|aiib` Nb|mde spr`w ac
zasp-azb|dpgb of|aego sgersgpgs) de drpaiwsdpb ac Bepb|aoaoors
cbodigs ldopb|gdb ac frmde a|gnge ~ds rsb` ds pfb p|bdpmbep &66'
fds ib` pa gepb|bsp ge sp|dpbngbs pd|nbpgen oaep|ai ac
pfb lgacgim mdp|gv lw ofbmgodi a| mbofdegodi mbdes% Pfb|b
d|b ermb|ars zapbepgdi ~dws pa b|d`godpb d ldopb|gdi lgacgim%
Pfbsb geoir`b bepgidpgae ac pfb sgers odgpw) kgiigen ac pfb
zdpfanbego ldopb|gd) gepb|cb|gen ~gpf pfb tra|rm sbesgen ac
lgacgims) de` gepb|cb|gen ~gpf pfb lgacgim sp|ropr|b) bgpfb|
mbofdegodiiw a| ofbmgodiiw&>7'
%
Pa `dpb) depg-lgacgim sp|dpbngbs fdb aeiw lbbe pbspb` rsgen ge-
gp|a ma`bis lrp pfbsb accb| gep|gnrgen gesgnfps gepa bccbopgb-
ebss ac oaebepgaedi pfb|dzgbs% Ge de ge-gp|a ma`bi) ~b fdb
sfa~e pfdp _% dr|brs ge lgacgim `a eap |bszae` pa depglgapgos
pfbw d|b sbesgpgb pa dp oaeobep|dpgaes pfdp ode lb dppdgeb` a|di-
iw&6:'
% Oaeobep|dpgaes 4:::v pfb MGO d|b |btrg|b` pa bccbop d
sgnegcgodep |b`ropgae) srnnbspgen pfdp pazgodi pfb|dzgbs ~gpf
depglgapgos ~gii ebb` pa lb |b-bdirdpb`% _gmzib g||gndpgae ~gpf
sdigeb fds ea bccbop ae ldopb|gdi lgacgims&6:'
% Pfgs gs eap
befdeob` ~gpf pfb d``gpgae ac pal|dmwoge &6:mn!i') avwowoige
&6:mn!i') a| p|goiasde &de depgsbzpgo') lrp |b`ropgae ge ldopb|gdi
iad` gs eapb` ~gpf d oamlgedpgae ac ogp|go dog` &d odiogrm
sbtrbspb|gen dnbep' de` d x~gppb|gaego sr|cdopdep &d `bpb|nbep'%
Lgacgim |bmadi gs befdeob` lw rsgen d fw`|a`bl|g`b|) &d
`bgob ca| zrisdpgib g||gndpgae' ca| dzzigodpgae) de` geo|bdsbs pfb
bccbop sweb|ngspgodiiw% \bobepiw) pfb depglgapgo mrza|goge fds
lbbe srnnbspb` ds de bccbopgb depg lgacgim dnbep&64'
lrp fds
eap re`b|naeb pbspgen ge d oigegodi p|gdi sbppgen%
^fgib algarsiw z|amgsgen) pfbsb eabi pfb|dzbrpgo dzz|adof-
bs fdb wbp pa lb p|desidpb` gepa pfb|dzgbs ca| oigegodi z|dopgob%
^fgib pfb rsb ac g||gndpgaes ~gpf d `bpb|nbep srof ds ldlw
sfdmzaa fdb lbbe srnnbspb`) pfgs de` apfb| pfb|dzgbs fdb
eap lbbe srlhbopb` pa oigegodi p|gdis pa `bpb|mgeb sdcbpw de`
bccgodow%
Depg GI-2 maeaoiaedi depgla`gbs8Pd|nbpgen ge`gg`rdi owpakgeb
~gpf gep|dbearsiw gehbopb` maeaoiaedi depgla`gbs gs lbgen
`aeb sroobsscriiw ge apfb| gecidmmdpa|w `gsbdsbs% De depgla`w
pa GI-2 fds re`b|naeb p|gdis ge frmdes de` gp gs bccbopgb ge
|b`rogen sgxb ac edsdi zaiwzs&60'
% Gp gs eap oammb|ogdiiw ddgi-
dlib dp pfgs pgmb%
Zfapapfb|dzw8 Rip|dgaibp &RS' ignfp dzzigb` pa pfb edsdi zds-
sdnbs fds lbbe sroobsscriiw rsb` ca| pfb p|bdpmbep ac diib|ngo
|fgegpgs&62'
% Ge aeb spr`w) gp ~ds disa sfa~e pfdp RS bvzasr|b
geo|bdsb` basgeazfgi de` P obii dzazpasgs ge d `asb-`bzbe`bep
~dw&63'
% Gp mdw cge` d |aib ge pfb mdednbmbep ca| zasp-B__
|bor||beobs%
Sdoogebs8Depg-_pdzfwiaooaodi a| apfb| doogebs mdw bbeprdiiw
lb ddgidlib de` mdw zidw d |aib ge befdeogen mroasdi gmmr-
egpw%
Zfd|mdoanbebpgos8Ds ge`gg`rdi srsobzpglgigpw cdopa|s lboamb
lbppb| ofd|dopb|gxb` pf|arnf nbebpgo spr`gbs) z|b`gopa|s ac
sbb|gpw de` |bszaesb pa pfb|dzw ~gii fazbcriiw lb `bbiazb`%
Ge pfb crpr|b) pfb zfwsgogde ~gii fazbcriiw fdb ddgidlib d
`gdneaspgo pbsp diia~gen fgm!fb| pa g`bepgcw pfb cdopa|s |bszae-
sglib ca| pfb `bbiazmbep ac d zd|pgorid| zdpgbeps `gsbdsb de`
pa z|b`gop |bszaesb pa zapbepgdi pfb|dzgbs) diia~gen pfbm pa pd|-
nbp pfb `gsbdsb ma|b |dzg`iw de` bccbopgbiw lw sbibopgen dzz|a-
z|gdpb pfb|dzw%
GMZ\ASGEN ZDPGBEP _DPG_CDOPGAE ^GPF ZDPGBEP
OBEPB\B@ MDEDNBMBEP
Pfb gmza|pdeob ac bspdligsfgen d sgnegcgodep de` aenagen pfb|d-
zbrpgo |bidpgaesfgz ~gpf pfbsb zdpgbeps gs zd|dmarep% Pfbsb
ge`gg`rdis d|b dccigopb` ~gpf d `gsbdsb) ~fgof fds sgnegcgodep
gmzdop ae pfbg| zfwsgodi de` bmapgaedi spdpb ac fbdipf) ~gpf dii
ac gps dppbe`dep oamzigodpgaes ca| fdmzb|gen ~a|k) cdmgiw) de`
saogdi igcb% Pfb zfwsgogde sfari` getrg|b gepa pfbsb sa ds pa
dppbmzp pa pdgia| pfb|dzw dzz|az|gdpbiw% @rb pa pfb aenagen
edpr|b ac pfb `gsbdsb) d oamzibpb |bmgssgae ~gpf ea mb`god-
pgae a| pfb|dzw gs reigkbiw% Bbe ge pfb ~bii-mdednb` zdpgbep)
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7/30/2019 Treatment alternatives for chronic rhinosinusitis persisting after ESS:What to do when antibiotics,steroids and surg
10/12
4< Dipb|edpgb pfb|dzw ca| Zasp-B__ O\_
bvdob|ldpgaes mdw lb bvzbopb` pfrs pfb zdpgbep mrsp pfbe lb
oaresbib` ds pa ~fdp oaesgsps |bdigspgo bvzbopdpgaes de` pfb|d-
zbrpgo alhbopgbs mrprdiiw dn|bb` rzae%
Pfb ddgidlgigpw ac geca|mdpgae ae pfb Gepb|ebp mdkbs gp de
geo|bdsgeniw c|btrbep mb`godi |bcb|beob ca| ge`gg`rdis ~gpf
O\_% Pfb fbdipf od|b z|dopgpgaeb| mrsp lb d~d|b pfdp zdpgbeps
`a doobss pfbsb sgpbs de` d|b acpbe oaecrsb` lw pfb geca|mdpgae
de` !a| pfb|dzgbs z|bsbepb`) ~fgof mdw oaecigop ~gpf pfb
d`gob pfb z|dopgpgaeb| accb|s% Rsb ac dipb|edpgb mb`godpgaes gs
disa d oaeob|e ds oripr|di p|d`gpgaes mdw geo|bdsb d |bigdeob ae
p|d`gpgaedi pfb|dzgbs de` mdw d|w dooa|`gen pa lbigbcs ge d
ngbe oarep|w a| |bngae% Pfb zfwsgogde sfari` szbogcgodiiw
getrg|b gepa pfbg| rsb) de` dppbmzp pa zb|srd`b pfb zdpgbep pa
zr|srb pfbsb ge oaehreopgae ~gpf spde`d|` pfb|dzw%
Besr|gen oamzigdeob ~gpf pfb|dzw gs aeb ac pfb lgnnbsp ofdi-
ibenbs pfb zfwsgogde cdobs) de` dssbssmbep ac oamzigdeob
sfari` lb zd|p ac bdof gsgp%
OAEOIR_GAE_
\dpgaedi mdednbmbep ac sbb|b gsbdsb
_bb|b sgers `gsbdsb re|bszaesgb pa gepbesb mb`godi mdednb-
mbep de` sr|nb|w |bmdges de begnmd pa pfb oigegogde%
Mdednbmbep |bmdges id|nbiw ldsb` ae oigegodi bvzb|gbeob de`
eabi oaeobzps ndgeb` gd eb~ gesgnfps ae pfb zdpfazfwsgaianw
ac O\_% Pd|nbpgen gecidmmdpgae |bmdges d mdgespdw ac pfb|d-
zw) lrp eb~ care` |boanegpgae ac pfb |aib ac ldopb|gd ge
of|aegogpw ac pfgs `gsa|`b| |btrg|b nggen oaesg`b|dpgae pa szb-
ogcgo pfb|dzw) ~fgof mdw `gccb| c|am pfb oaebepgaedi sfa|p
oar|sbs ac ~g`b szbop|rm depglgapgos rsb` ge dorpb ldopb|gdi|fgeasgsergspgs%
@bszgpb pfb sbb|gpw de` geo|bdsgen c|btrbeow ac |bc|dopa|w |fg-
easgersgpgs) igmgpb` N|d`b G bg`beob bvgsps pa srzza|p pfb
mb`godi pfb|dzgbs oammaeiw rsb` ge gps mdednbmbep%
_bibopgae dmaen ddgidlib azpgaes ~gii pfrs |btrg|b lapf
kea~ib`nb ac pfb zdpfazfwsgaianw ac pfb `gsbdsb de` ac pfb
mbdes ac dopgae ac bdof pfb|dzw%
Ngbe pfb mripgzib oigegodi z|bsbepdpgaes de` pfb d|gdlib edp-
r|di bairpgae gp gs z|aldlib pfdp d ngbe zdpgbep mdw |btrg|b
`gccb|bep pfb|dzgbs dp `gccb|bep spdnbs ge pfbg| `gsbdsb z|aobss%
Pfb ofdiibenb ca| pfb oigegogde |bmdges pa `bpb|mgeb pfb spdnb
ac `gsbdsb de` sbibop dmaen pfb|dzbrpgo azpgaes% Pfrs dsprpb
oigegodi hr`nmbep ~gii oaepgerb pa zidw de gmza|pdep |aib ge pfb
mdednbmbep ac pfgs zdpgbep zazridpgae%
Ge pfb dlsbeob ac spde`d|`gxb` `bcgegpgaes de` ac oigegodi p|gdis)
pfb oigegogde gs spgii cdob` ~gpf d lb~gi`b|gen sb|gbs ac dipb|ed-
pgbs% Pfb|b gs de geo|bdsgen |boanegpgae ac pfb gmza|pdeob ac
pazgodi pfb|dzgbs ge pfb of|aego mdednbmbep ac pfgs `gsa|`b|)
lrp oigegodi |bsbd|of ge pfgs d|bd gs spgii ge gps gecdeow% Ge a|`b|
pa dag` |bpr|egen pa pfb b|d ac bd|iw 47::s b|d ac zdpbep mb`g-
ogebs ~gpf resrlspdepgdpb` oidgms) eb~ dnbeps sfari` lb
dssbssb` z|aszbopgbiw ge ~bii-`bsgneb` p|gdis ~gpf dzz|az|gdpb
oaep|ais pa `bpb|mgeb pfbg| bccbopgbebss de` sdcbpw z|acgib
z|ga| pa pfbg| d`azpgae%
\BCB\BEOB_4% Nigkigof \B) Mbpsae \% Pfb fbdipf gmzdop ac of|aego sgersgpgs ge
zdpgbeps sbbkgen apaid|wenaiango od|b% Apaid|wenai Fbd` Ebok _r|n
4772; 44?8 4:0-74:%
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7/30/2019 Treatment alternatives for chronic rhinosinusitis persisting after ESS:What to do when antibiotics,steroids and surg
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@bs|agsgb|s de` Kgipw 4?
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7/30/2019 Treatment alternatives for chronic rhinosinusitis persisting after ESS:What to do when antibiotics,steroids and surg
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40 Dipb|edpgb pfb|dzw ca| Zasp-B__ O\_
32% Ma|gwdmd F) Wdedng K) Afpa|g E) Crkdmg M Bdirdpgae ac be`a-
soazgo sgers sr|nb|w ca| of|aego sgersgpgs8 zasp-azb|dpgb b|w-
pf|amwoge pfb|dzw% \fgeaianw% 4772; ??8 433-4>:%
33% Ob|ge D) Kdim A) _de`krii Z) Ige lb|n _ Aeb-wbd| ia~-`asb b|w-
pf|amwoge p|bdpmbep ac zb|sgspbep of|aego sgersgpgs dcpb| sgers
sr|nb|w8 oigegodi arpoamb de` bccbops ae mroaogigd|w zd|dmbpb|s
de` edsdi egp|go avg`b% Apaid|wenai Fbd` Ebok _r|n%