9
Table 4. CRS Disease States That Warrant Consideration for
Expedited Sinus Surgery
CRS disease
state Description
Medical therapy
response Surgery rationale
Osteitis Bony thickening
of the sinus walls
and partitions. e
histopatholog y of
osteitis in CRS is
likely a process of
neo-osteogenesis and
bone remodeling and
is more common in
patients having revision
sinus surgery. e
etiolog y is unknown,
and it is unclear if
bony remodeling and
thickening are the cause
or the result of chronic
inflammation. Multiple
grading scales exist
based on CT imaging.
No medical treatment
exists for paranasal
sinus osteitis at this
time.
Surgery can remove
the osteitic bone
that contributes to
sinonasal obstruction.
Sinus surgery can also
immediately decrease
the progression
of disease to help
facilitate topical
medical treatments
that better control the
inflammatory process.
Allergic
mucin
A subtype of CRSwNP
in patients with
thick eosinophilic
mucin contained in
the sinuses, which
may also contain
noninvasive fungal
hyphae, particularly
in allergic fungal
rhinosinusitis where
type 1 hypersensitivity
to fungi exists.
Medical therapy
(prolonged high dose
oral steroids, topical
steroids) carries
significant risks.
Although medications
can reduce edema or
polyps to a degree,
they are insufficient
at enabling effective
mucociliary clearance
of the thick sticky
mucin.
Surgical intervention
is considered first-
line treatment and
is recommended in
multiple consensus
statements, due to
its ability to clear
the mucin, improve
sinonasal outflow
tract dimensions, and
facilitate mucociliary
clearance and
topical medication
application.
Fungal ball A collection of
noninvasive fungal
debris that collects
within a sinus
and can lead to an
inflammatory mucosal
reaction and sinus
outflow obstruction,
leading to mucostasis
and bacterial
superinfection.
No medical therapy
to completely
eradicate fungal
ball and bacterial
superinfection
currently exists.
Surgical intervention
should be "gold-
standard" treatment
to remove the fungal
debris and reestablish
sinus drainage
pathway to facilitate
topical irrigations and
mucociliary clearance.
(cont'd)
