Chronic rhinosinusitis can be refractory and has detrimental effects not only on symptoms, but also on work absences, work productivity, annual productivity costs, and disease-specific quality of life measures. The pathophysiology of chronic rhinosinusitis continues to evolve. There is evidence that it is driven by various inflammatory pathways and host factors and is not merely an infectious problem, although pathogens, including bacterial biofilms, may certainly contribute to this inflammatory cascade and to treatment resistance. Given this, medical management should be tailored to the specific comorbidities and problems in an individual patient. In addition to treating acute exacerbations of chronic rhinosinusitis with amoxicillin-clavulanate, second or third generation cephalosporins, or fluoroquinolones, one must consider if nasal polyps are present, when symptoms and disease severity correlate to mucosal eosinophilia, and there is the best evidence for intranasal corticosteroids and saline irrigation. Asthma worsens severity of chronic rhinosinusitis and it is felt to be mediated by increased leukotrienes, when leukotriene antagonists may be utilized. Cystic fibrosis has a genetic defect and increased mucin, which are potential treatment targets with dornase alfa showing efficacy. Other comorbidities that may impact treatment include allergies, ciliary dyskinesia, immunodeficiency, and possibly allergic fungal rhinosinusitis.
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