Rhinosinusitis is primarily managed medically with antibiotics and nasal steroids. Surgery is reserved for cases that fail maximal medical therapy. The goals of treatment are to reduce symptoms, prevent recurrence and complications. For chronic rhinosinusitis, intranasal corticosteroids are the mainstay of treatment, targeting intrinsic mucosal inflammation. Surgery establishes drainage pathways and restores sinus ventilation and clearance when medical therapy is insufficient.

1. Management of
Rhinosinusitis
Dr. Yash Agrawal

2. ‘themainstayofmanagementof
rhinosinusitisis
MEDICAL THERAPY’

3. • Most cases resolve <10 days
• Incidence of complications : very low
• AIMS OF TREATMENT :
To reduce duration/ severity of illness
To prevent recurrence and complications
Reducing symptom severity alone
Acute rhinosinusitis

5. • ANTIBIOTICS
‘current evidence supports restricting antibiotic usage in uncomplicated ARS’
• Short course of narrow-spectrum antibiotics
• No role in prevention of complications
• Bacterial etiology :
• Gold standard : maxillary sinus aspirate
• Complicated cases: culture-directed antibiotics

6. • INCS can be prescribed in ARS : short-
term resolutions in all trials
• Isotonic saline> hypertonic saline
[less adverse effects; similar efficacy]
• Systemic steroids : in complicated
cases to reduce cerebral edema
• Antihistaminics- Loratadine,
Levocitrizine
Correct application for nasal drops.
(a) Head back position. (b) Head
down position.

7. ‘The treatment of chronic rhinosinusitis is
primarily MEDICAL, with surgery reserved for
those who fail a trial of maximal medical therapy’.
Chronic Rhinosinusitis

8. Medical management
GOALS :

9. EPOS 2020

11. • If patient have bleeding, pain, tissue loss and other organ
involvement
• D/D
• Vasculitides
• Cystic fibrosis
• sarcoidosis
• cilial motility disorders
• Mx- Systemic Management
Secondary Diffuse CRS

12. Primary Diffuse CRS

13. INTRANASAL CORTICOSTEROIDS
• Proven efficacy : in both CRSwNP/CRSsP :
• Improve overall symptom scores
• Decrease polyp size
• Decreased post-surgical recurrence of polyps
• excellent safety profile :
• Low systemic bioavailability
• Safe for long-term use
• S/E: Epistaxis, Headache
• Combination with oxymetazoline provide better improvement of
nasal blockage, smell and polyp size
Targetingintrinsicmucosalinflammation

14. • Various INCS
• Fluticasone Furoate (0.5%)
• Fluticasone Propionate (<1%)
• Mometasone Furoate(<0.1%)
• Ciclesonide Aqueous
• Budesonide (34%)
• Triamcinolone Acetonide (46%)
• Flunisolide (49%)
• Methods
• Drops/ Sprays
• Irrigation
• Yamik Sinus Catheter device
• Maxillary antrostomy sinus tube
• Mucosal Atomized device

15. ‘POST-SURGICAL EFFICACY
>>>
PRE-SURGICAL EFFICACY’

16. SYSTEMIC CORTICOSTEROIDS
• CRSsNP : NO studies
• CRSwNP
• Each course : 14–21 days [the lifespan of a tissue eosinophil]
• accumulative dose : less than 290–1000 mg
• maximum : 30–40 mg daily

17. IMMUNOMODULATORY ANTIBIOTICS
• Macrolides :roxithromycin, Clarithromycin
• Long-term : ANTI INFLAMMATORY EFFECT
• Pathway : neutrophil-mediated inflammation (IL-8)
• CRSsNP with normal IgE level
• Doxycycline: CRSwNP subgroup
[more sustained effect than methylprednisolone]
• Fluoroquinolone- Levofloxacin, Ciprofloxacin
• Amoxicillin+Clavulanate- No significant difference
• Cefuroxime Axetil

18. LEUKOTRIENE RECEPTOR ANTAGONISTS
• Monteleukast: Adjunct to corticosteroid
• In patient with CRSwNP and asthma and AR
• Beneficial
• sneezing
• Facial pain

19. NOVEL Immunoregulation
• Agents
• Omalizumab (anti-igE) – Decrease symptom and polyp size
• Mepolizumab (anti-IL-5)-
• Dupilumab (Anti IL-4)

22. • Saline irrigation : removal of mucus, infected crusts and pro-
inflammatory agents.
• When used with xylitol, sodium hyaluronate and xyloglucan
enhances activity of innate antimicrobial in secretion.
• Nasal irrigation with isotonic saline or ringer’s lactate is an effective
treatment for CRS.
• Irrigation alone comparable benefit with irrigation +INCS
Improvingmucociliaryclearance

23. MUCOACTIVE AGENTS
• Amphiphatic molecules : reduce mucus adhesiveness
• Both mucoactive and antimicrobial properties
• Cationic [max]/ anionic/ zwitter-ionic
• not a direct therapy : useful for treating crusting, thick mucus
and chronic bacterial mucosal colonization
• Agents: detergent, Paints, Soil wetting agents
combination of PEG-80 sorbitan laurate,
cocamidopropyl betaine and sodium
trideceth sulfate (‘Johnson & Johnson Baby
Shampoo’) has been shown to have both
antibiofilm forming properties at 1%
solution and clinical efficacy in managing
refractory CRS patients

24. • Photodynamic Therapy:
• Use photosensitizer and activated by light and form ROS which destroy cells
that have absorbed the photosensitizer
• Manuka Honey:
• Contain Methylglycol which have biocidal and antibiofilm property.
• Crenotherapy -Thermal Water(Bromic-iodic) nasal spray/inhalation-
Some patients have better results

25. ‘Failureisdefinedbypatient-focusedoutcomesrather
thanevidenceofmucosalinflammation.’
Assessment of response

26. OTHER PARAMETERS :
• the need for more than two courses of systemic treatment per year
• SNOT-22 provided unique information predictive of surgical outcomes.
• NOSE system :
• Nasal Obstruction
• Systemic Medication
• Endoscopy
• Persistent evidence on either endoscopy or CT of active mucosal inflammation is
associated with a high rate of relapse even in the asymptomatic patient

28. ‘Thosepatients thatfailto derivesufficientbenefitfrom pre-surgical
medicaltreatmentand fulfillthediagnosticcriteriafor CRS,in whoman
alternative diagnosis is not found, and who have confirmation of mucosal
diseaseon CT, should be consideredfor surgery.’
Opting for surgery

29. DISCOVERYOFSINUSDRAINAGEPATHWAYSBYMESSERKLINGERCHANGEDTHECOURSEOF
TREATMENTOFRHINOSINUSITIS.
Surgical management

31. Pre-op and anesthesia
• LMA > intubation – Lighter GA, Less vasodilation and less
bleeding
• 30 degrees head-up : less venous congestion
• Topical vasoconstriction : co-phenylcaine
• lignocaine 5% + phenylephrine 0.5%
• Infiltration: 2% lignocaine + 1:80,000 adrenaline
• Site:
• superior to anterior attachment of the middle turbinate
• the anterior end of middle turbinate
• Frontal process of maxilla and nasal septum
• Blood pressure: map around 60 mmHg : hypotensive anesthesia
Moffat’ssolution
Cocaine+adrenaline+/-
sodiumbicarbonate
solution
Preparation

32. • Inhalational agents : peripheral vasodilation: hence TIVA
• TIVA : continuous infusion propofol : action of GABA
• Risk of awake anaesthesia so use of bispectoral monitoring is recommended
• We can use sevoflurane with remifentanil to provide good surgical field.
• Remefentanil : suppresses respiration: allows LMV
• Safeguard : no muscle relaxation : quick response to inadequate anesthesia
• Adjunctive : beta-blockers + clonidine: enhance a clear field
GeneralAnesthetic technique:TIVA

33. ADVANTAGES
• Does not induce generalized
vasodilatation
• Increased circulating
catecholamines improve the
surgical field [by continuing to
act on the prearteriolar and
precapillary sphincters.]
DISADVANTAGES
• Patient anxiety and sudden patient
movements
• Meticulous anesthesia
• Aspiration of blood and saline
washes
• Teaching of residents can be more
difficult
LOCALANESTHESIA

34. Intranasal Packing
• A Merocele piece ls In the sphenoethmoldal
recess (1), another is In the middle meatus (2),
and another ls In the region of the axilllary flap (3)

35. Additionalmanoeuvres:infiltrationofpterygopalatine
fossa
DIRECT INFILTRATION OF
SPHENOPALATINE
FORAMEN
• Just under the post end
of middle turbinate
• Less effective
THROUGH GREATER
PALATINE CANAL
INFILTRATION
• Well-defined
landmarks
• Proven efficacy
Main blood supply : maxillary artery + terminal branches

36. • Foramen location
• Canal orientation
• Particulars of the needle
Needle was introduced into the greater palatine
canal (black arrow) of the left hard palate. The
second molar tooth is marked with a white arrow

37. Endoscopic sinus surgery
FESS- Functional Endoscopic Sinus Surgery is often a
non-invasive / minimal invasive surgical procedure
that discloses sinus air cells and sinus ostia by having
an endoscope. It restores the paranasal sinus
function by re-establishing the physiologic pattern
of ventilation & mucocilliary clearance

39. • Posterior-anterior
• Revision cases after loss of
conventional landmarks
• the novel landmark :
Fovea ethmoidalis
WIGAND’S APPROACH
• Anterior to posterior
MESSERKLINGER’S
Approaches

40. Uncinemctomy
ANATOMY

42. THE SWING DOOR TECHNIQUE :
removal of vertical part
• Reverse cutting forceps or backbiting forceps or sickle knife
were used in this technique.
• Free edge of uncinate identified with ball probe
• Inferior free margin overlying the maxillary ostium is cut
first & then incision is made in the superior margin just
under the axilla of middle turbinate to form a flap and
uncinate which is hinged on the anterior margin & can be
moved with an elevator or ball probe.
• This is followed by submucosal removal of the horizontal
process of the uncinate.
• More Prone for NLD Injury

44. THE SWING DOOR TECHNIQUE :
Removal of horizontal part

45. THE TRADITIONAL TECHNIQUE
• Uncinectomy is performed via an incision with either the sharp end
of freer elevator or a sickle knife
• The incision should be placed at most anterior portion of uncinate
process which is softer on palpation in comparison to firmer
lacrimal bone where also NLD located.
• Then by using blakeshly forceps the free uncinate edge is removed.
• More prone for orbital fat prolapse.

46. • 10%
• Recurrent cases : mucus circulates into it from natural ostium
• If found surgically : should be combined with the natural ostium
Posteriorfontanelle

47. • Natural size : 5*5 mm
• ARGUMENT AGAINST :
• NO dilution [stimulates ciliary clearance]
• Direct dump for ethmoid secretions
Middle meatusantrostomy

48. Initial identification of the natural ostium- anterior & inferior within
the middle meatus. Ostium usually at the same level as the inferior
margin of the middle turbinate,anterior to ethmoid bulla
Opening is further enlarged posteriorly to the posterior fontanelle
with backward-biting punch forceps & anteriorly with upturned
Blakesley-Wilde ethmoid forceps
Antrostomy should be placed just above the inferior turbinate & not
more anterior than the anterior end of the middle turbinate
Polypoid tissue, diseased mucosa , mucous plug should be removed

50. • Grading the sinus
Theseverelydiseasedmaxillary sinus

51. • Traditional complication rate : 75%
• Branches of infra-orbital nerve : ASAN/MSAN
• New landmarks : mid-pupillary line*floor of nose
• Complication: Cheek swelling and pain, Facial tingling and
numbness, Paresthesia and numbness of upper lip and teeth
Caninefossatrephination
vs

53. • Lowering the ostium to the floor of nasal cavity
• Ant 2 cm of inf turbinate : intact to preserve NLD
Megaantrostomy
• Inferior turbinate is
crushed with curved
artery forceps about
2.5 cm behind head
of turbinate and cut
with endoscopic
scissors up to lateral
nasal wall

54. Make
mucosal
incision as
outlined
Osteotome
used to
remove bone
of lateral wall
Backbiter used
to enlarge
antrostomy
under residual
IT
Mucosal flap
replaced over
expose bone
to improve
healing

55. • The basal lamella of MT separates ethmoid
labyrinth to two distinct anatomical and
physiologic compartment (Anterior and
Posterior)
• Finding the natural ostium
• Mini-ESS : 3-4 mm of anterio/inferior edge
of bulla is retained. ‘FINALL DRAINAGE
PATHWAY’ leading the secretions to
nasopharynx
• Through-cut instruments are preferred over
Blakesley foreceps
• When removing bulla superiorly , it is
important to recognize the anterior
ethmoidal artery.
• Located in suprabullar recess or can sit within
anterior wall of bulla
• AEA located anterior to superior attachment of
ground lamella
ANTERIOIRETHMOIDECTOMY
THEBULLAETHMOIDALIS
Final common drainage pathway (black arrow). This also
indicates the drainage pathway of maxillary sinus. The white
arrow indicates the drainage pathway of the frontal and
anteroinferior ethmoldal cells along the anterior face of buIla
ethmoldalls (BE). This portion of the BE forms the
posterosuperior part of the final common drainage pathway

56. The ball-probe (black arrow) is slid
medial to the anterior face of the
bulla ethmoidalis
The anteriorface of the bulla is
fractured, creating an edge for the
microdebrider.

57. ANTERIORETHMOIDALARTERY
Branch of : ophthalmic artery
Across roof of ethmoids
[antero-medially]
Ethmoid sulcus
[anteriorly along cribriform plate]
Grove along inner surface of nasal bone
[supplies upper part of septum/lateral nasal wall]
Appears on ext surface
through notch between nasal bone and upper
lateral cartilage
ORBIT
NOSE
[ORBITO-
CRANIAL
CANAL]
CRANIAL CAVITY
NOSE
EXTERNAL
SURFACE OF
NOSE

58. A cadaveric image taken of the left fovea ethmoidalis
demonstrating the anterior ethmoidal artery (AEA) and nerve
(AEN) leaving the orbit and traveling In a 45-degree angle from
lateral to medial along the skull base. This artery can be seen
giving off the anterior falcine artery (AFA) as it approaches the
lateral wall of the olfactory fossa (L. wall OF). M. Orbital wall,
medial orb.
Behind the upward
continuation of bulla
ethmoidalis/ frontal
recess
Breach : blindness

59. Breachingthegroundlamella

60. • Identify horizontal ground lamella.
• Enter Superior meatus through ground lamella and enter inferomedial
quadrant.
• Enter posterior ethmoidal cell.
• Limits: Superior limit correspond to roof of maxillary sinus or sphenoid
sinus opening medially.
• Cell above the solid bony rim of posterior choanae should be sphenoid
sinus cells.
• Optic nerve (Posterosuperior) may bulge into posterior sphenoiethmoidal
cell : vulnerable during surgery during attempts to enter sphenoid
‘through’ onodi cell(Pneumatized posterior ethmoidal air cell) and it will
create horizontal septa in sphenoid sinus.
Posteriorethmoidectomy

61. Pneumatises over top of the sphenoid : Pushes sphenoid inferiorly
The bony posterior choanae (broken white arrow) are
seen. At the point where a complete bony posterior
choana is identified, the sinus directly above this bony
choanae should be the sphenold sinus. The horizontal
septation (white arrow) separates the sphenold from
the Onodi cell

63. Management of CONCHA BULLOSA
• Incise the anterior face of concha bullosa
vertically.
• A pair of 5 mm endoscopic scissors is
used to continue the incision along
inferior of middle turbinate to the lateral
insertion of MT to lateral nasal wall.
• Continue superior incision posteriorly as
high as possible.
• Lateral lamella of turbinate with residual
upward continuation resected

64. • Medial to superior turbinate : 83% cases
• Sphenoethmoidal recess can be inspected through
middle meatus by gently moving superior turbinate
laterally .
• Prefer to open sphenoid through posterior ethmoid
rather then passing the instrument and endoscope
medial to middle turbinate.
• The lower third to half of superior turbinate is removed.
• Landmarks
• 12 mm above bony rim of choana
• Junction of upper 2/3rd and inferior1/3 of superior
turbinate
• Anterior face of sphenoid is removed upto skull base
and laterally to lamina papyracea.
Sphenoidotomy

65. The sphenoid ostium (SO) is first opened inferiorly (black arrow 1) then laterally
(black arrow 2). This should afford a clear view Into the sphenold sinus and the
remaining anterior face of the sphenold can be removed up toward the optic
tubercle (OT) but usually stopping short of the tubercle to lessen the potential
risk to the optic nerve.
(b) A cadaveric image demonstrating tedtnique for sphenoidotomy.

66. • 2 major philosophies for non-addressal to the region
• MIST : minimally invasive sinus technique : clearance of
maxillary sinus and associated spaces will lead to clearance of
the frontal recess area : drainage
• The sole indication for frontal sinusotomy : frontal headache
and pain
FRONTALRECESSANDSINUS
Poor evidence and back-up arguments

67. 3 difficulties with frontal sinus surgery
• Medial is thinnest skull base (Lateral Lamella)
• Lateral is orbit (lamina papyracea)
• Posterior is anterior ethmoidal artery (just behind attachment of bulla
to skull base)

68. Important : all or none approach
‘The frontal recess is either left entirely alone or all the cells are removed
from the recess with visualization of the frontal ostium.’
• Narrow A-P diameter of the frontal ostium
• SAFC obstructing the ostium
• Poorly pneumatised agger nasi cell
• Osteitis in the region of the ostium
• Scarring of frontal recess
• Extensive disease : distortion of landmarks/ bleeding
• Loss of landmarks
Gradingthedifficultapproaches

70. • Principle of surgery-
• To relieve obstruction that may lead to
inflammatory changes
• Mucosa preservation is important
• Choose least invasive procedure
• Surgery depends on previous surgery,
extent of disease, burden of disease
• Simple fess with minimal manipulation of
frontal recess if patient have
comorbidities.

71. • Classically : 30/45/70 degree endoscopes
• Degree of difficulty increases with angulation
• Increases with bloody field
• The anterior wall of the ethmoid bulla is a good landmark
in finding the frontal recess as its anterior wall will lead
you up to the frontal recess
endoscopy

72. • Emerging and as yet
controversial
• Most evidence : non-inferior to
FESS
• Can maintain patency of the
sinus ostia
• 80.5% : 6 months
• 85.1% : 1 year
• 91.6% : 2 years.
• High cost : single-use equipment
ballooon sinuplasty

73. • Incision : 8 mm above axilla / horizontal
for 8mm/ vertically down/ posteriorly till
root
• Elevation of mucoperichondrial flap
• Vertical upper part of middle turbinate
removed
• REMOVAL OF ANTERIOR WALL
OF AGGER NASI
• Drainage pathway traced and cleared
• Reposition of the flap
Axillary flap technique

77. Draf Procedures

79. • Draf 1 Indication-
• Failure of conservative surgery
• First time surgery
• No risk factor (Aspirin intolerance, asthma)
• Revision after incomplete ethmoidectomy
• Draf 2A Indication
• Serious complication of acute sinusitis
• Medial muco-pyocele
• Benign Tumor
• Good quality mucosa
• Draf 2B Indication
• All type 2A indication with resulting 2A smaller

80. • Draf 3 indication (Modified endoscopic Lothrop procedure)
• Difficult revision surgery
• Kartagener syndrome
• Frontal Osteoma Grade 1 and 2
• Frontal sinus trauma ( to close csf leak)
• Cranionasal resection (for anterior cranial fossa tumor)
• Inverted papilloma extending into frontal sinus
• Large frontal mucocele extending beyond mid pupillary line
• CRS with nasal polyp, asthma, AERD

81. Osteoplastic Flap Procedure +/- Fat Obliteration
• To manage chronic frontal sinus disease refractory to
frontoethmoidectomy
• Indication
• Large osteomas
• Inverted papilloma with significant lateral extension
• Malignant tumours
• Far lateral mucoceles in a well-pneumatized sinus
• Failed endoscopic (MELP and medical therapy) procedure for CRS and extensive
frontal bone osteomyeilitis
• Extensive neo-osteogenesis of frontal recess (Failed ESS, facial fracture, Frontal bone
osteomyelitis)- Obliteration done
• Underdeveloped sinus (AP diameter<8mm)- Obliteration done
• Frontal sinus fracture (ant and post table)

82. (1) Elevated galea-periosteum; (2) pathologically altered
mucosa frontal sinus; (3) drill holes

83. (4) bony flap hinged on periosteum (anterior wall of the frontal
sinus); (5) preserved fascia; (6) cartilage; (7) transplanted fat
with fibrin glue; (8) fibrin glue; (9) resorbable sponge; (10)
rubber finger packs.

84. Above and below approaches
• Endonasal procedure(MELP) +External Procedure(OPF/Trephination)
• Indication (Disease inaccessible by endoscopy)
• Inverted papilloma with lateral attachment
• Medially based osteoma
• Neo-osteogenesis of frontal recess
• Posterior table CSF leak
• Encephalocele

85. • In chronic frontal sinusitis,1 cm parasagitally on the line joining the
medial ends of two eyebrows
• Aspiration/ irrigation followed by fluoresecein dye
• Aspiration of clear fluid should alert the surgeon : CSF
• Indication- Where frontal sinus outflow tract is difficult to detect
Mini-Trephination of the frontal sinus

87. • In acute frontal sinusitis cases which are refractory to medical
management
• A small incision (1-1.5 cm) made below medial end of eyebrow and
supraorbital rim down through periosteum
• Periosteum elevated
• Drill to make small window(At junction of floor and anterior wall of frontal
sinus)
• Sinus irrigated
• Drain placed in situ

88. External frontoethmoidectomy
• A curvilinear incision made between
nasion and medial canthus.
• Indication-
• To access anterior ethmoidal artery
• Drainage of periorbital abscess
• To trephine floor of frontal sinus

89. Cranialization of Frontal Sinus
• Midfrontobasal Craniotomy (Coronal Incision)
• Posterior wall and floor of sinus removed
• Mucosa of frontal sinus outflow tract is inverted
into nasal cavity and seals with fascia/pericranium
with fibrin glue
• Dead space filled with fat/pericranial vascularized
flap
• Indication-
• Refractory chronic frontal sinusitis
• Extensive fracture of posterior table of frontal bone
• Osteomyeilitis

90. Complications
Minor : Major:
Orbital- Orbital -
orbital emphysema Orbital hematoma
orbital ecchymosis Optic nerve injury
Nasolacrimal Duct Injury(epiphora) CSF fistual
Disturbance in olfaction Brain laceration
Dental pain/lip pain or numbness Haemorrhage
Ethmoid arteries
Internal carotid artery
Cavernous sinus fistula
Sphenopalatine artery

91. THE SURGICAL FIELD
Boezaart and van der Merwe grading
system for bleeding during endoscopic
sinus surgery
Abort procedure @ 5

92. The Wormald grading system
for bleeding during
endoscopic sinus surgery
Abort procedure @
8-10

93. • Epistaxis
• Anterior ethmoid artery-
• Posterior nasal artery [branch of SPA]: vertical branch / main branch
inferiorly
• Mx- Bipolar cauterization or clipping of small vessel
• Nasal Packing with epinephrine and decongestant
• Damage to carotid artery
• dehiscent in 5-8% of patients
• 2 ways
• the natural ostium of the sphenoid sinus is very small
• if the intersinus septum of the sphenoid is attached to the anterior face of the
carotid artery
• Mx- Packing with crushed muscle and epinephrine pledget
• Endovascular Intervention to prevent delayed pseudo aneurysm and carotid
dissection

94. • Orbital injury
• From the very first incision with sickle knife during uncinectomy (traditional)
• No intervention is usually needed
• Muscle resection : little can be done
• Optic nerve damge
• Sphenoidotomy attempt too superolateral
• Superolateral wall of sphenoid [inside] :12% dehiscent
• While encountering septations
• Orbital Hematoma-
• Arterial or venous
• Mx- Lateral Canthotomy or Cantholysis or medial wall decompression
• If artery lumen seen in nasal cavity – try to hold vessel and clip it and medial
• If artery retracted into orbit – External ethmoidectomy to hold artery

95. • Cerebrospinal fluid leak
• 0.5% of the surgical cases
• Highest risk : area surrounding the vertical lamella of the
cribriform plate, so during frontal sinusotomy avoid to probe
medially as vertical/lateral lamella is very thin
• Can usually be repaired without any long-term morbidity

96. Corticosteroids and saline irrigations
Antibiotics/ leukotriene antagonists/ monoclonal antibodies as deemed fit
Post-surgical medical treatment

97.  At the end of op :- Removal of all bone fragments .
- Resection of devitalized mucosa .
 Post operative medications :
- Nasal saline irrigations .
- Nasal steroid sprays .
- Systemic steroids .
-Antibiotics .
 Post operative follow up :
- In office - day 6 , 13 .
- endoscopic resection of devitalized mucosa & bone .
- endoscopic lysis of synechia
- weekly for 6-8 weeks .
- every 1-2 month for 1st year .

98. ‘Outcomes ofFESS surgery inpatients withCRSwNP andCRSsNP
remainexcellent wheremedicalmanagementhas failed,however
there islittle evidence forendoscopicsinussurgeryover medical
managementasa primarytreatment.’
Access for topical therapies is critical as a goal of
surgery for CRS patients, and thus allows a patient
to switch from relying on systemic therapies to
local treatments.
Conclusions

99. THANK YOU