CRS should be initially targeted with maximal medical therapy (e.g., a 3 month course of a macrolide antibiotic, douche, and topical steroid), with surgical treatment being reserved for cases refractory to medical therapy. The presence of nasal polyps is not a poor prognostic factor for the efficacy of CRS therapy, either surgical or medical.

Nasal nitric oxide, which is easily measured, provides a valuable non-invasive objective measure of the response of CRS to therapy. Topical nasal corticosteroids may be needed to reduce the contribution of nasal epithelial nitric oxide and allow that emanating from the sinuses to be measured.

The effects of rhinosinusitis treatment upon asthma are disputed.The first randomised prospective study of surgical compared with medical therapy of chronic rhinosinusitis in 90 patients with and without nasal polyps was previously reported. Asthma symptoms, control, forced expiratory volume in one second (FEV1), peak flow, exhaled nitric oxide, medication use and hospitalisation at 6 and 12 months from the start of the study were also monitored. This paper reports these results in 43 of those patients with concomitant asthma.Both medical and surgical treatment of chronic rhinosinusitis were associated with subjective and objective improvements in asthma. Overall asthma control improved significantly following both treatment modalities, but was better maintained after medical therapy, where improvement could also be demonstrated in the subgroup with nasal polyps. Medicine was superior to surgery with respect to a decrease in exhaled nitric oxide and increase in FEV1 in the polyp patients. Two patients noted worsening of asthma post-operatively.Improvement in upper airway symptoms, as assessed using a visual analogue scale, correlated with improvement in asthma symptoms and control. Treatment of chronic rhinosinusitis, medical or surgical, benefits concomitant asthma; that associated with nasal polyposis benefits more from medical therapy.KEYWORDS: Asthma, chronic rhinosinusitis, endoscopic sinus surgery, exhaled nitric oxide, forced expiratory volume in one second, nasal polyps R hinosinusitis coexisted with asthma in 34% of patients in one study [1]. Radiological studies have shown abnormal sinus radiographs in 53% [2,3] and mucosal thickening on sinus computed tomography (CT) scans in 74% [4] of patients with asthma. Recently, .84% of CT scans were found to be abnormal in severe asthma, with a correlation between the extent of CT changes, sputum eosinophilia and pulmonary function [5].A number of authors have investigated the effect of surgical treatment of rhinosinusitis upon asthma, with improvement [6-8], worsening [9, 10] and equivocal effect [11,12] being reported. Only two studies of medical chronic rhinosinusitis (CRS) treatment exist, one included four medical patients [13], whereas the other considered CRS with polyposis alone and was nonrandomised [14]. MATERIALS AND METHODSPatients were recruited over 2 yrs from the Rhinology Clinics of the Royal National Throat, Nose and Ear Hospital (London, UK). The study was approved by the Ethics Committee of the Royal Free Hospital (London, UK). After application of exclusion criteria, the study was discussed with 327 consecutive patients with a primary diagnosis of CRS. Of these, 90 patients who agreed to the process of randomisation were finally included and were randomised equally into the medical and surgical groups. The study design and flow chart showing the course of the study are presented in figures 1 and 2, respectively. Diagnosis of CRS was based on the criteria described by the Staging and Therapy Group [15]. The criteria for diagnosis of...

The findings are consistent with a subgroup of nasal polyps/asthma patients in whom leukotriene receptor antagonists are effective. This is not related to aspirin sensitivity. Further placebo-controlled studies need to be undertaken.

Improving the quality of the surgical field and providing a bloodless FESS in children is attainable with TIVA. TIVA using a combination of remifentanil and propofol is superior to BA, even with the use of additional potent hypotensive agents such as esmolol. Both techniques are safe and effective in inducing controlled hypotension in children at a target mean arterial blood pressure of 50 mm Hg.

Both maximal medical and surgical therapy of CRS improves the quality of life of CRS patients, providing further evidence that chronic rhinosinusitis should be targeted with maximal medical therapy in the first instance, with surgical treatment being reserved for cases refractory to medical therapy. The presence of nasal polyps does not imply any negative effect on the quality of life after CRS therapy, either medical or surgical.

In the presence of a clinically diagnosed CSF leakage, topical fluorescein is a very easy, sensitive, safe, and highly accurate tool in the intraoperative localization of the site and extent of CSF fistulas, and should be considered a viable noninvasive alternative to intrathecal fluorescein. We also recommend its use as a simple and quick outpatient clinic test for preoperative diagnosis of CSF rhinorrhea. It can be used postoperatively as well when there is a doubt of recurrence of the CSF leak.

Recurrent nasolacrimal duct obstruction after primary endoscopic DCR is mainly due to reclosure of the nasolacrimal stoma with synechia and fashioning of the small misplaced bony window. Mitomycin C does not increase the success rate of revision endoscopic DCR. It is a safe procedure and may be of value only in patients inaccessible to strict follow-up because it induces a better healing profile in terms of mucosal recovery, wound healing, and less need for debridement sessions.