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Chronic Rhinosinusitis: Pathogenesis and Medical Management

2007 Edition, May 8, 2007

Complete Document

Detail Summary

Active, Most Current

Additional Comments:
ISBN: 978-0-8493-4052-9
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Product Details:

  • Revision: 2007 Edition, May 8, 2007
  • Published Date: May 8, 2007
  • Status: Active, Most Current
  • Document Language: English
  • Published By: CRC Press (CRC)
  • Page Count: 377
  • ANSI Approved: No
  • DoD Adopted: No

Description / Abstract:


When Marcel Dekker, Inc., first contacted us about publishing a monograph on chronic rhinosinusitis, we were excited. It seemed that the timing was good for writing a book for clinicians focusing on medical management of this condition. In the interim, our publisher's name changed (it is now Informa Healthcare USA, Inc.) but our mission remained the same. A decision was made to invite experts across the globe and embrace the discipline broadly beginning with its clinical appearance, health care impacts, pathologic features, and emerging concepts regarding pathogenesis, and ending with its clinical management. A content list was prepared, authors were contacted, and we began working. Upon receiving all contributions, and after careful editing and some revisions, we have compiled a comprehensive review and state-of-the-art update on classification, pathophysiology, and management options for chronic rhinosinusitis. More than ever before, this exercise taught us how little we know, and how much still needs investigation. It also inspired us to search deeper for answers and novel insights into a condition that deserves more attention and better treatments.

To say chronic rhinosinusitis is complex is merely to acknowledge its heterogeneity and unknown causes. Research in this field has lagged behind other areas, such as asthma, owing in part to the fact that, although it is common, it rarely results in hospitalization or mortality. These facts are offset by the sheer magnitude of the problem. Allergists/immunologists devote 20% to 30% of their practice time caring for patients with rhinosinusitis (1), and this percentage is even higher for otolaryngologists.

At first glance, we seem to have advanced only modestly from the description of chronic rhinosinusitis offered by Noah Fabricant in 1942, or from Max Samter in 1961. Fabricant wrote:

Repeated acute infections eventually lead to chronic infections of the nasal cavity and in the associated nasal sinuses. The changes in the individual layers of the mucous membranes vary considerably according to the severity and the duration of the infection. In chronic inflammatory processes the fundamental pathologic change is one of cellular proliferation. ... The epithelium is definitely thickened, and the degree of thickening is more pronounced in chronic nasal infection than in acute inflammatory processes or in allergy. The basement membrane is also markedly thickened. ... While the lymphocyte is the predominating cell, there are often large numbers of neutrophiles, monocytes, histiocytes, plasma cells, fibroblasts and a few eosinophils (2). Max Samter described nasal polyp formation, discussing the involvement of polymorphonuclear cells, mast cells, and eosinophils in polyps, and the peculiar phenotype of "nasal polyps which form in middle-aged, nonallergic persons that experience acute exacerbation of hyperplastic changes of the nasal mucous membrane in response to small doses of acetylsalicylic acid" (3). He speculated that "a systematic search might uncover at least one enzyme systemwhichmight be inhibited in vitro by this drug." Yet we are certainly making progress. And, in retrospect, the "gaps" in our knowledge base that may have once looked small now appear as vast expanses of information dealing with inflammatory pathways, cytokines, chemokines, growth factors, and enzymes that collectively orchestrate both acute and chronic inflammation and the tissue remodeling that accompanies or follows it.

This monograph highlights several concepts that have emerged or crystallized over the past decade. First is the greater appreciation for the role of eosinophilic (Th2-type) inflammation as a central feature not just in nasal polyps but more broadly in chronic rhinosinusitis. This observation, made by Harlin, Gleich, and colleagues (4) in 1988, continues to be a focal point for studies of chronic rhinosinusitis pathogenesis. The second is the observation that specific pathogens, such as colonizing fungi or, in the case of nasal polyposis, Staphylococcus aureus, may be a driving stimulus for chronic rhinosinusitis inflammation. The third is a growing appreciation for the importance of the innate host defense molecules in maintaining normal sinus health. Innate factors in nasal mucus were studied by Kaliner in the early 1990s (5). However, the science of host/microbial interactions expanded greatly over the past decade and is now poised to address critical questions about the role of defective innate immunity in human diseases such as chronic rhinosinusitis.

There has been an evolving consensus that the different phenotypes of chronic rhinosinusitis, namely chronic rhinosinusitis without nasal polyps, chronic rhinosinusitis with nasal polyps, and allergic fungal rhinosinusitis, represent distinct clinical syndromes and pathologic processes. Although this remains controversial, it provides an important framework for investigations and therapeutic interventions, and was adopted for use in this monograph. It is encouraging that interest in chronic rhinosinusitis is increasing. This is evidenced by several excellent consensus reports published over the past three years and increased funding for research from the National Institutes of Health over the past decade. The contributors to this monograph were carefully selected to showcase their involvement in these important initiatives. The authors wish to thank the many contributors to this monograph whose unselfish contributions reflect their true passion for what they do. We thank our spouses and families for their forbearance during those many weekends when "the book" took priority over other duties. And we especially thank Ms. Sandra Beberman from Informa who first approached us with the idea for the monograph, and who patiently guided us through every step of the process. We reached this point in large part owing to her patience and encouragement.

We and our co-authors hope our goal of producing a monograph that improves the lives of patients with chronic rhinosinusitis will be realized. If that happens, even in some small way, our efforts will not have been in vain.