When FESS fails: The inflammatory load hypothesis in refractory chronic rhinosinusitis

Ahmed Bassiouni, Yuresh Naidoo, Peter Wormald

    Research output: Contribution to journalArticlepeer-review

    76 Citations (Scopus)


    Through recent advances in research, our understanding of chronic rhinosinusitis (CRS) has evolved to consider it as an inflammatory condition of the mucosa brought about by multiple factors. However, surgical management is still ruled by the classical concepts of functional endoscopic sinus surgery (FESS), which emphasizes the importance of ostial obstruction and sinus ventilation. These concepts fail to provide sufficient explanation for the presence of a subset of patients with refractory CRS who fail to respond to conventional FESS. Recent outcome studies have shown that high-grade mucosal inflammation often results in a poor outcome and that this patient group may show improved results with more radical surgery. This review examines the "inflammatory load hypothesis" as a possible explanation. We hypothesize that the grade of the inflammation is the most important predictor of long-term outcomes. Surgery, therefore, has a significant role not only in reestablishing ventilation, but also with removing the inflammatory load in the affected sinuses. We suspect that in these severely diseased patients, a more radical removal of local proinflammatory factors during surgery may improve patient outcomes.

    Original languageEnglish
    Pages (from-to)460-466
    Number of pages7
    Issue number2
    Publication statusPublished - Feb 2012


    • Chronic rhinosinusitis
    • eosinophilic chronic rhinosinusitis
    • functional endoscopic sinus surgery
    • inflammatory load hypothesis
    • Level of Evidence: 2-1
    • mucosal inflammatory load
    • radical endoscopic sinus surgery
    • radical sinus surgery
    • refractory chronic rhinosinusitis


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