Revision Sinus Surgery

188	Benjamin Bleier, James N. Palmer, and Bradford A. Woodworth

22

Fig. 22.1  (continued) b Intraoperative computed tomography (CT) scan and real-time updating of image-guidance was performed to confirm that the mucocele was completely marsupialized (c)

Recurrent Mucoceles

189

■The overall goal of revision mucocele surgery includes complete adjacent sinusotomy followed by wide-field marsupialization of the cyst wall to minimize the risk of scarring and entrapment of residual secretory mucosa.

If significant intraorbital or intracranial extension is present, utilization of MRI and image-guidance technologies is advocated. An open approach including craniotomy may be required in select cases [18]. If the technology is available, intraoperative CT scanning with real-time update of computer-aided systems is valuable for difficult cases, especially when the confines of the mucocele are more difficult to visualize (Fig. 22.1).

Frontal Sinus Mucoceles

Adequate drainage of frontal mucoceles to establish longterm patency requires a thorough knowledge of frontal recess anatomy and its variants. All air cells encroaching on the frontal sinus outflow tract, such as agger nasi cells anterolaterally or suprabullar cells posteriorly, are removed in their entirety to increase the chance of longterm frontal patency.

■A common set-up for recurrence is a reliance on im- age-guidance technology in the absence of technical skill and a comprehensive understanding of frontal recess anatomy.

Evacuating a frontal sinus mucocele using image-guid- ance-based suction without performing a complete frontal recess dissection invites a recurrence (Fig. 22.2). All endoscopic frontal recess dissections are more easily performed with 45 or 70 4-mm nasal endoscopes for visualization. If there is little osteoneogenesis present, the frontal recess should be dissected with frontal sinus hand instruments in an attempt to drain the mucocele into the nose. Careful attention is paid to preserving the mucosa surrounding the outflow tract to help increase long-term patency. In cases with abundant osteoneogenesis, a 70 diamond burr is helpful during the dissection. When the drill is needed or in the case of small frontal openings, an intraoperative decision must be made to extend the operation to a Draf IIB or Draf III (modified endoscopic Lothrop) procedure. If the patient has a recurrent mucocele in the presence of a prior osteoplastic flap with obliteration, a Draf III is an option to unobliterate the frontal sinuses. Stenting after endoscopic frontal sinusotomy is of controversial benefit and is often left to surgeon prefer-

Fig. 22.2  Frontal sinus mucocele. Triplanar CT imaging and endoscopic view following complete frontal sinusotomy for a recurrent frontal sinus mucocele. The prior surgeons did not fully resect the uncinate process or adequately address the frontal recess

190	Benjamin Bleier, James N. Palmer, and Bradford A. Woodworth

ence [9]. If stenting is used, it should be made from a soft, conformable material such as silastic and removed within 2–4 weeks to prevent bacterial biofilm formation on the stent itself, as this might create a nidus for inflammation.

Maxillary Sinus Mucoceles

■Mucoceles recurring in the maxillary sinus are treated with a partial (modified) endoscopic medial maxillectomy (Fig. 22.3) [19].

A middle meatal antrostomy is revised first, if necessary, with complete removal of the uncinate process. Using the turbinate scissors and through-biting forceps, an incision is carried through the anterior one-third of the inferior turbinate to the inferior portion of the maxillary antrostomy, directing the cut posterior to the distal end of the nasolacrimal duct (Hasner’s valve). The anterior portion of the medial maxillary wall is then incised using the down-biting forceps to make the anterior cut. Using turbinate scissors, an inferior cut along the junction of the nasal floor and floor of the maxillary sinus is taken back flush with the posterior maxillary wall, followed by

posterior cuts to remove the medial maxillary wall and inferior turbinate. The entire cavity is then inspected with 45, 70 and 120 rigid endoscopes. Meticulous preservation of mucosa is attempted in all cases. The modified endoscopic medial maxillectomy permits wide marsupialization of the maxillary sinus to decrease the probability of recurrence and optimizes distribution of postoperative topical medications and mechanical irrigations.

Patients with a prior history of Caldwell-Luc operations typically had their maxillary mucosa stripped, which may result in a contracted, hypoplastic maxillary sinus with multiple recurrent loculated mucoceles within the sinus. Facial trauma patients may also develop laterally located mucoceles within the maxillary sinus. In these instances, a modified endoscopic medial maxillectomy can be performed in conjunction with a CaldwellLuc procedure to effectively drain and marsupialize these lateral mucoceles.

Ethmoid and Sphenoid Sinus Mucoceles

Recurrent ethmoid mucoceles are approached utilizing a complete ethmoidectomy with removal of the anteroinfe-

22

Fig. 22.3  Maxillary sinus mucocele. A patient with a history of massive facial trauma and multiple recurrent mucoceles. An inferiorly based left maxillary sinus mucocele is marsupialized with a modified medial maxillectomy

Recurrent Mucoceles

rior and medial aspects of the mucocele. Recurrent sphenoid mucoceles may be approached via either a transnasal/transseptal approach or a traditional transethmoid approach (Fig. 22.4). In both instances, locating the natural ostium of the sphenoid is the preferred entry point into the sphenoid. Recurrent lesions may be secondary to significant scarring and/or prior pituitary surgery, and thus are likely to have altered anatomy. The superior turbinate is the most reliable landmark if still present. The inferior aspect of the superior turbinate is removed to identify the natural ostium and a wide sphenoidotomy is performed.

Postoperative Care

Postoperatively nasal saline irrigation and topical nasal steroids are critical in helping to clear the operative site of debris and maintain patent ostia. Packing is generally not required. In the setting of mucopyocele or positive intranasal cultures, patients are placed on a culture-directed antibiotic regimen. Patients are monitored and debrided postoperatively until healing and reestablishment of normal mucociliary clearance pathways are complete.

191

Tips and Pearls to Avoid Complications

1.Carefully reexamine the CT scan just prior to surgery.

2.Potential landmarks should be identified on the CT in patients who have distorted anatomy due to prior surgery.

3.When chronic infection and inflammation is present, a preoperative course of oral antibiotic and steroid therapy helps reduce tissue inflammation and vascularity.

4.Provide careful topical and infiltrative vasoconstriction, minimize mucosal trauma (especially to the nasal mucosa anteriorly in the nose), and limit dissection in the region of the sphenopalatine artery branches. If during surgery, bleeding persists so that it interferes with visualization, it is safer to stop the procedure and if necessary, return at a later time.

5.Identify medial orbital wall and skull base early on in the dissection.

6.Avoid trauma to the anterior ethmoid artery. Identify by imaging preoperatively to avoid mistaking the artery for a bony septae of an ethmoid cell and attempting resection. Supraorbital ethmoid muco-

Fig. 22.4  Sphenoid sinus mucocele. This large mucocele with significant skull-base erosion recurred following sphenoidotomy at an outside institution. A transnasal/transseptal approach was performed to completely open the face of the sphenoid sinus

192	Benjamin Bleier, James N. Palmer, and Bradford A. Woodworth

celes are particularly tricky as the artery often lies just posterior to this sinus.

7. Extruded orbital fat from a periorbital violation not only puts the orbit at risk, but can also

obstruct the frontal outflow tract in the area of the frontal recess. Use extreme care near dehiscent lamina and avoid powered instrumentation as much as possible in these areas.

8. Preserve mucosa within the frontal recess.

Outcomes

In 1989, Kennedy et al. [12] successfully drained 16 of 18 complicated frontal mucoceles endoscopically, many of which had eroded the posterior table, extended into the orbit, or had associated Pott’s puffy tumor. There were no mucocele recurrences after 42 months of follow-up. HarEl reported that 107 of 108 paranasal sinus mucoceles were successfully managed endoscopically with recurrence noted in only 1 patient (0.9%) [9]. This one recurrence was subsequently managed with an open procedure and obliteration. This case series had a median clinical follow-up of 4.6 years. Therefore, endoscopic drainage appears to be an effective technique with little morbidity in the proper hands. Mucocele recurrence rates with modern endoscopic techniques have been reported anywhere between 9 and 10%. However, given the scarcity, no larger series have been reported [9, 18].

Conclusion

	Sinonasal mucoceles represent benign, expansile lesions
	that most often occur in the frontal and ethmoid sinus
	and can result in local bony destruction. In the era of en-
	doscopic marsupialization complimented by high-reso-
	lution CT imaging, recurrences are rare. When they do
	occur, surgery should be directed toward creating a wide
	outflow tract with complete adjacent sinusotomy. In com-
	plex cases with significant orbital or intracranial involve-
22	ment, open approaches may be required.

References

1.Arrue P, Thorn Kany M, Serrano E, et al. (1998) Mucoceles of the paranasal sinuses: Uncommon location. J Laryngol Otol 112:840–844

2.Batsakis JG (1980) Tumours of the Head and Neck. Williams and Wilkins, Baltimore

3.Brook I, Frazier EH (2001) The microbiology of mucopyocele. Laryngoscope 111:1771–1773

4.Delfini R, Missori P, Ianetti G, Ciappetta P, Cantore G (1993) Mucoceles of the paranasal sinuses with intracranial and intraorbital extension: report of 28 cases. Neurosurgery 32:901–906

5.al-Dousary S, al-Kaharashi S (1996) Maxillary sinus mucopyocele in children: a case report and review of literature. Int J Pediatr Otol 36:53–60

6.Garston JB (1968) Frontal sinus mucocele. Proc R Soc Med 61:549–551

7.Guttenplan MD, Wetmore RF (1989) Paranasal sinus mucoceles in cystic fibrosis. Clin Pediatr 28:429–430

8.Hardy JM, Montgomery WW (1976) Osteoplastic frontal sinusotomy: an analysis of 250 operations. Ann Otol Rhinol Laryngol 85:523–532

9.Har-El G (2000) Endoscopic management of 108 sinus mucoceles. Laryngoscope 111:2131–2143

10.Har-El G, Dimaio (2000) Histologic and physiologic studies of marsupialized sinus mucoceles. J Otolaryngol 29:195–198

11.Howarth WG (1921) Mucocele and pyocele of the nasal accessory sinuses. Lancet 2:744–746

12.Kennedy DW Josephson JS, Zinreich SJ, Mattox DE, Goldsmith MM (1989) Endoscopic sinus surgery for mucoceles: a viable alternative. Laryngoscope 99:885–895

13.Lloyd G, Lund VJ, Savy L, Howard D (2000) Optimum imaging for mucoceles. J Laryngol Otol 114:233–236

14.Lund VJ, (1991) Fronto-ethmoidal mucoceles: a histopathologic analysis. J Laryngol Otol 105:921–923

15.Lund VJ, Harvey W, Meghji S, Harris M (1988) Prostaglandin synthesis in the pathogenesis of fronto-ethmoidal mucoceles. Acta Otolaryngol 106:145–151

16.Lund VJ, Henderson B, Song Y (1993) Involvement of cytokines and vascular adhesion receptors in the pathology of fronto-ethmoidal mucoceles. Acta Otolaryngol 113:540–546

17.Rubin JS, Lund VJ, Salmon B (1986) Frontoethmoidectomy in the treatment of mucoceles. A neglected operation. Arch Otolaryngol Head Neck Surg 112:434–436

18.Weitzel EK, Hollier LH, Calzada G, Manolidis S (2002) Single stage management of complex fronto-orbital mucoceles. J Craniofac Surg 13:739–745

19.Woodworth BA, Parker RO, Schlosser RJ (2006) Modified endoscopic medial maxillectomy for chronic maxillary sinusitis. Am J Rhinol 20:317–319

Chapter  23	23
Allergy and the Patient Requiring
Revision Sinus Surgery

Li-Xing Man and Berrylin J. Ferguson

 Core Messages

■Allergic rhinitis is an IgE-mediated response to allergens including pollens, fungi, animal danders, insects, and dust mites.

■The role of allergic rhinitis in the pathogenesis of chronic rhinosinusitis is poorly understood, but the association is strong.

■Persistent sinonasal symptoms after endoscopic sinus surgery may indicate the need for management of an underlying allergy. Evaluation of allergy is therefore an important component in the evaluation of the patient considering revision sinus surgery.

■Typical symptoms of allergic rhinitis include nasal congestion, itching, sneezing, rhinorrhea, and postnasal discharge.

■Pharmacotherapy for allergic rhinitis should be targeted toward the specific symptom profile of the individual patient. Immunotherapy can benefit patients who fail to achieve symptom relief with environmental controls and pharmacotherapy, or who have perennial symptoms.

 

Introduction

Evaluation of allergy is an integral part of the assessment of all patients with sinonasal complaints. Allergic rhinitis affects 10–40% of the population worldwide [30]. In the largest and most comprehensive national survey to date, approximately 14% of the adult population in the United States has been diagnosed with allergic rhinitis [28]. In terms of overall economic burden of illness in the United States, allergic rhinitis ranks fifth overall, with an estimated twofold increase in medication costs and physician visits, 3.5 million lost workdays, and 2 million lost schooldays [11, 12, 22].

Contents

Introduction  . . . . . . . . . . . . . . . . .   193

Allergy and the Pathogenesis of Chronic

Rhinosinusitis  . . . . . . . . . . . . . . . . .   193

Allergic Rhinitis  . . . . . . . . . . . . . . .	.   194
Diagnosis  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	.  194
In-Vitro Screens  . . . . . . . . . . . . . .	.   195
Skin Testing  . . . . . . . . . . . . . . . .	195
Medical Therapy for Allergic Rhinitis  . . . . .	.   195
Conclusion  . . . . . . . . . . . . . . . . .	.   197

This chapter explores the role of allergy in chronic rhinosinusitis and reviews the diagnosis and treatment of allergic rhinitis in the patient undergoing revision sinus surgery.

Allergy and the Pathogenesis of Chronic Rhinosinusitis

Allergic rhinitis is a symptomatic nasal disorder characterized by IgE-mediated inflammation of nasal membranes triggered by exposure to an allergen [1]. Diagnosing allergic rhinitis in patients with chronic rhinosinusitis is difficult due to shared symptoms such as nasal congestion and rhinorrhea. Atopy, a state in which elevated levels of IgE antibodies to allergens can be detected by skin-prick, or specific IgE to antigens, can be determined objectively; however, atopic individuals may not have clinical manifestations of allergic rhinitis [18, 27]. In addition, only a subset of patients with rhinitis symptoms has disease attributable to atopy [18, 27, 35].

The role of allergic rhinitis in the pathogenesis of chronic rhinosinusitis is unclear. It has been hypothesized that allergen-mediated nasal mucosal inflammation may obstruct the sinus ostia, leading to poor sinus

194

drainage and ventilation, mucus retention, and bacterial growth, but the evidence remains unconvincing [2]. The estimated prevalence of allergy in patients undergoing endoscopic sinus surgery ranges from 20 to 84% [6, 8, 13, 19, 23, 26, 27, 31, 32]. Few studies, however, tested all patients for atopy using in vivo assays (typically skin-prick tests) or in vitro assays for serum IgE antibody to allergens (Table 23.1). Some studies suggest that atopic patients have more severe disease when assessed by computed tomography scan appearance and have less improvement in symptoms and quality of life after endoscopic sinus surgery [3, 6, 14, 15, 23]. Other studies found no association between atopy and either preoperative severity of sinus disease or postoperative symptomatic improvement [19, 25–27, 31, 32].

Few studies have explored the role of allergy in the patient requiring revision sinus surgery. Several analyses have noted no difference in the rate of revision endoscopic sinus surgery between allergic and nonallergic patients [19, 25, 27]. One series demonstrated a reduction in prescription antihistamine use after revision endoscopic sinus surgery that was not statistically significant [4]. Another study of patients undergoing revision sinus surgery showed a nonsignificant trend toward allergic patients being more likely to require further surgical management [25].

The persistence of sinonasal symptoms in patients with allergy after endoscopic sinus surgery may reflect the need for more intensive or specific allergy management [19]. In a review of 190 consecutive patients with

Li-Xing Man and Berrylin J. Ferguson

chronic rhinosinusitis refractory to medical management and who subsequently underwent endoscopic sinus surgery, none had received preoperative immunotherapy, but 84% tested positive for inhalant allergies [8]. Evaluation of allergy is an integral part in the assessment of all patients considering revision sinus surgery.

Allergic Rhinitis

Diagnosis

■The diagnosis of allergic rhinitis is suggested by a history of typical symptoms and confirmed by skin or blood testing for allergies. Symptoms of allergic rhinitis include:

1.Nasal congestion.

2.Fatigue.

3.Postnasal discharge.

4.Rhinorrhea.

5.Sneezing.

Many of these symptoms are typical of chronic rhinosinusitis. The diagnosis of allergic rhinitis is more likely if the patient can relate a history in which symptoms resolve in different localities and recur with a return to the home or local environment. Patients with seasonal allergic rhinitis have often already made the diagnosis on their own, but those with perennial allergic rhinitis are often unaware that they have an allergy.

		Study	Number of	Number tested		Prevalence	Method of diagnosis for allergy
			patients	for allergy (%)		of allergy
		Newman et al. [23]	104	95	(91.3%)	20.0%	In vitro testing
		Robinson et al. [27]	193	193	(100.%)	30.1%	Skin or in vitro testinga
		Smith et al. [31]	119	NA		34.5%	Patient history
		Sobol et al. [32]	393	NA		34.6%	Skin testing
		Dursun et al. [6]	130	67	(51.5%)	36.2%	Skin testing and history
	23
		Marks et al. [19]	115	0		54.5%	Self-reported on survey
		Ramadan et al. [26]	141	NA		54.6%	Patient historyb
		Kennedy [13]	120	NA		57.5%	Skin or in vitro testing
		Emanuel and Shah [8]	190	190	(100.%)	83.7%	Skin or in vitro testing

a Skin testing of 10% and in vitro testing of 90% of patients (Wormald 2007, personal communication) b Study population comprised children aged 3–13 years

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195

■Allergy testing is valuable in the management of patients with chronic nasal symptoms for two reasons:

formed initially and additional IDTs within the subgroups are performed if the respective mix is positive. There is a

1.Allergy testing can identify allergens that the pawide selection of prick-testing devices. The Multitest II tient did not previously suspect so that environdevice is one of the most popular, most reproducible, and

mental controls can be directed.

2.Allergy testing provides the basis for formulation of allergen vials for immunotherapy.

■Immunotherapy is the only treatment modality that has the potential to cure the patient with allergic rhinitis. Indications for immunotherapy include patients who:

1.Fail to achieve relief from targeted pharmacotherapy.

2.Have symptoms over half of the year so immunotherapy becomes a cost-effective alternative.

In-vitro (blood) testing and skin testing are the two major forms of allergy testing. There are multiple in-vitro tests available for allergy testing including, but not limited to, radioallergosorbent test (RAST), modified RAST, and the Pharmacia CAP System. There are two types of skin testing for allergy: intradermal dilutional testing (IDT) and prick testing. A serum total IgE level is not an adequate screen for allergy, as it can often be within normal limits and yet the patient will have significant specific IgE-me- diated hypersensitivity to a few antigens.

In-Vitro Screens

A mini-allergy screen of six antigens using RAST batteries of one grass (Timothy), one weed (common ragweed), one tree (oak), two molds (Alternaria and Helmithosporium), and one dust mite (Dermatophagoides pteronyssinus) – with epidermals (i.e., cat, horse, etc., added if indicated by history – has a predictive value of 75%. If the testing battery is expanded to a total of nine antigens by including a second grass (Bermuda), an additional tree (mountain cedar), and an additional mold (Cladosporium), the predictive value increases to 95% compared to a 13-antigen screen [16]. The population for this study comprised patients living in southwest Texas. Practitioners in other locales should tailor the antigens to the most prevalent and likely allergens in their particular region. Pollen maps, available from many of the testing companies, can help guide the selection of these antigens.

Skin Testing

IDT, also known as skin endpoint titration, is the most sensitive allergy test and is able to establish a safe starting dose for immunotherapy. Usually a screen using dust mite, cat, dog, mold mix, tree mix, and grass mix is per-

fastest to apply. A negative Multitest using 14 antigens plus histamine and glycerin controls indicates that significant inhalant allergy is unlikely. A positive Multitest may require additional in vitro or IDT testing [17].

■The simplest screen for allergies involves either an in-vitro allergen screen of 6–9 allergens or a Multitest II prick test. As they are most often associated with chronic rhinosinusitis, the allergen screen should be focused on perennial allergens:

1. Dust mite.

2. Cockroach.

3. Molds.

4. Cat (if applicable).

The patient probably does not have inhalant allergy if the screen is negative. If the screen is positive, the patient may be allergic to multiple other allergens and may require further, more detailed investigation.

Medical Therapy for Allergic Rhinitis

It is essential to control the symptoms of rhinitis in the allergic patient requiring revision sinus surgery. Management of allergic rhinitis in the patient considering revision sinus surgery has four components: allergen avoidance, pharmacotherapy, immunotherapy, and surgery.

The ideal treatment of allergic rhinitis is avoidance of allergens that provoke symptoms. Common environmental agents that trigger IgE-mediated allergic rhinitis symptoms include dust mites, pollens, molds, animal danders, and insect allergens [7]. In very specific circumstances, environmental control can be as effective as pharmacologic therapy [9]. For example, a pet linked to a patient’s allergy can be removed from the home. There is evidence that a home-based, total environmental control program benefits patients with dust mite and cockroach sensitivity [21, 24, 29]. Other interventions, such as avoidance of the outdoors, keeping windows closed, and air conditioning during peak pollen seasons are often more difficult to achieve. Avoidance of all offending allergens is unrealistic for many patients [20].

When environmental controls are impractical or incompletely effective, pharmacotherapy is introduced. A wide variety of medications is available for the treatment of allergic rhinitis. The choice of pharmacologic agent is tailored to the individual patient’s symptoms. Medications and their relative efficacy toward specific symptoms are outlined in Table 23.2.

196

■Medications effective for treating allergic rhinitis include:

1.Topical and systemic steroids.

2.Topical and oral antihistamines.

3.Topical and oral decongestants.

4.Leukotriene receptor modulators.

5.Mast cell stabilizers.

6.Anticholinergics.

7.Saline nasal washes.

8.Anti-IgE.

Nasal steroid sprays provide the most comprehensive relief of allergic rhinitis symptoms with the least amount of morbidity and are recommended as first-line therapy [5, 9]. Nasal steroid sprays are distinct from the other classes of pharmacotherapy since they control all of the major nasal symptoms of allergic rhinitis: sneezing, rhinorrhea, itching, and congestion. In a meta-analysis of 16 randomized trials, nasal steroid sprays were significantly better than oral antihistamines at relieving nasal symptoms [33]. Nasal steroid sprays may begin to take effect within 12 h after dosing, but efficacy may not be maximal until 1–2 weeks after initiation of therapy. Patients should always be educated in directing the steroid spray away from the septum and toward the lateral wall of the nose to minimize septal excoriation, bleeding, and the very rare complication of septal perforation.

Azelastine is a topical antihistamine nasal spray that has a symptom relief profile similar to that of nasal steroid sprays. Onset of action is within a day. Its use is limited by a bad taste appreciated by approximately 30% of users, and a slight sedation potential.

Oral antihistamines can be divided into sedating and nonsedating drugs. Fexofenadine, loratadine, and desloratadine at recommended doses do not cause sedation and

Li-Xing Man and Berrylin J. Ferguson

are effective for nasal itching and sneezing symptoms, but have little impact on nasal congestion. For this reason, antihistamines are often paired with a decongestant. Sedating antihistamines are available over-the-counter and have anticholinergic properties, which thickens nasal secretions and may over-dry the nose in some patients. The utility of oral antihistamines in patients with chronic rhinosinusitis is limited due to the failure of antihistamines to significantly reduce congestion.

Topical decongestants may be used for short periods of time to decongest the nose and to optimize drainage. Prolonged use can lead to rebound swelling. This may be diminished with concurrent use of a topical nasal steroid spray [10]. Most practitioners do not recommend longterm use of oral decongestants because of the side effects of tachycardia, tremors, and insomnia.

The leukotriene receptor antagonist montelukast is moderately effective in relieving symptoms of rhinorrhea, congestion, sneezing, and nasal itching. Overall, it is less effective than nasal steroid sprays [34]. Certain patients, however, may respond markedly to montelukast.

The cromone cromolyn is available over-the-counter as a nasal spray. The efficacy data for this product are inconsistent and the effects on nasal symptoms are modest.

It is often difficult to predict which pharmacologic therapy will be the most effective, but initial treatment should be directed according to symptom profile. The senior author currently practices a cost-effective method whereby samples of several classes of pharmacologic agents are given to the patient to try serially. Prescriptions are filled only if the drug is found to provide relief. This reduces the number of prescriptions and frequency of clinic visits. Patients who have incomplete relief with monotherapy may require combination therapy with several classes of drugs.

		Table 23.2  Medications and their relative efficacy in allergic rhinitis
		Medication	Congestion	Sneezing	Rhinorrhea	Nasal itching	Eye symptoms
		Nasal steroid	+++	+++	+++	+++	+
		Antihistamine
23			+/–	++	++	++	++
		Sedating
		Nonsedating	+/–	++	–	++	++
		Decongestant	+++	–	–	–	–
		Leukotriene receptor antagonist	++	+	+	+	+
		Mast cell stabilizer	+	+	+	+	+/–
		Ipratropium	–	–	+++	–	–

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Allergen immunotherapy is the only treatment modality with the potential for disease modification. Immunotherapy should be considered in patients who continue to have significant symptoms despite pharmacotherapy, who require systemic corticosteroids, or who have comorbid conditions such as asthma [7]. Typical candidates for immunotherapy have severe seasonal symptoms that return or worsen each year, or perennial symptoms. Subcutaneous allergen immunotherapy typically consists of weekly doses of a solution containing the culpable allergens that are gradually increased to an optimal maintenance dose. Immunotherapy can be stopped after 1 year if there are no noticeable improvements.

Patients who continue to have residual nasal congestion after endoscopic sinus surgery should be evaluated for turbinate hypertrophy. In patients who have chronic hypertrophy of the inferior turbinate with nasal symptoms refractory to pharmacotherapy, surgery to reduce the inferior turbinate may be a useful treatment option. Several inferior turbinate reduction techniques have been described.

Conclusion

Allergic rhinitis is a common comorbidity in patients with chronic rhinosinusitis. Many patients who continue to have symptoms of rhinosinusitis despite endoscopic sinus surgery have not been adequately evaluated and treated for allergic rhinitis. The diagnosis of allergic rhinitis is based on history, and on in vitro or skin allergy testing. Optimal therapy of allergic rhinitis includes the identification and elimination of allergen exposure. Pharmacotherapy should be targeted toward allergic symptoms. Immunotherapy can be utilized in patients who failed to achieve adequate symptom relief with environmental controls and pharmacotherapy, or who have perennial symptoms. Inferior turbinate reduction can provide relief from nasal congestions in patients with chronic turbinate hypertrophy.

References

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2.Bachert C, Vignola AM, Gevaert P, et al. (2004) Allergic rhinitis, rhinosinusitis, and asthma: one airway disease. Immunol Allergy Clin North Am 24:19–43

3.Berrettini S, Carabelli A, Sellari-Franceschini S, et al. (1999) Perennial allergic rhinitis and chronic sinusitis: correlation with rhinologic risk factors. Allergy 54:242–248

4.Bhattacharyya N (2004) Clinical outcomes after revision endoscopic sinus surgery. Arch Otolaryngol Head Neck Surg 130:975–978

5.Bousquet J, Van Cauwenberge P, Khaltaev N (2001) Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol 108:S147–S334

6.Dursun E, Korkmaz H, Eryilmaz A, et al. (2003) Clinical predictors of long-term success after endoscopic sinus surgery. Otolaryngol Head Neck Surg 129:526–531

7.Dykewicz MS, Fineman S, Skoner DP, et al. (1998) Diagnosis and management of rhinitis: complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma and Immunology. American Academy of Allergy, Asthma, and Immunology. Ann Allergy Asthma Immunol 81:478–518

8.Emanuel IA, Shah SB (2000) Chronic rhinosinusitis: allergy and sinus computed tomography relationships. Otolaryngol Head Neck Surg 123:687–691

9.Ferguson BJ (1997) Allergic rhinitis. Options for pharmacotherapy and immunotherapy. Postgrad Med 101:117– 120, 123–116, 131

10.Ferguson BJ, Paramaesvaran S, Rubinstein E (2001) A study of the effect of nasal steroid sprays in perennial allergic rhinitis patients with rhinitis medicamentosa. Otolaryngol Head Neck Surg 125:253–260

11.Goetzel RZ, Long SR, Ozminkowski RJ, et al. (2004) Health, absence, disability, and presenteeism cost estimates of certain physical and mental health conditions affecting U.S. employers. J Occup Environ Med 46:398–412

12.Kay GG (2000) The effects of antihistamines on cognition and performance. J Allergy Clin Immunol 105:S622–S627

13.Kennedy DW (1992) Prognostic factors, outcomes and staging in ethmoid sinus surgery. Laryngoscope 102:1–18

14.Kountakis SE, Arango P, Bradley D, et al. (2004) Molecular and cellular staging for the severity of chronic rhinosinusitis. Laryngoscope 114:1895–1905

15.Krouse JH (2000) Computed tomography stage, allergy testing, and quality of life in patients with sinusitis. Otolaryngol Head Neck Surg 123:389–392

16.Lehr AJ, Mabry RL, Mabry CS (1997) The screening RAST: is it a valid concept? Otolaryngol Head Neck Surg 117:54–55

17.Levine JL, Mabry RL, Mabry CS (1998) Comparison of Multi-Test device skin testing and modified RAST results. Otolaryngol Head Neck Surg 118:797–799

18.Lilja G, Wickman M (1998) Allergy–atopy–hypersensitiv- ity – a matter of definition. Allergy 53:1011–1012

19.Marks SC, Shamsa F (1997) Evaluation of prognostic factors in endoscopic sinus surgery. Am J Rhinol 11:187–191