The treatment of chronic sinusitis: a controversial issue.

The persistence of sinusitis after upper respiratory tract infection is influenced by a range of aetiological factors such as anatomical variation which may be surgically corrected, mucociliary abnormalities and immune deficiency. The latter is more common than previously realised, encompassing IgG subclass deficiency, reduced opsonization and Fc gamma receptor polymorphism. This has therapeutic implications, with the possibility of IgG replacement therapy and vaccination. CT scanning suggests that the age of the patient and anatomical abnormalities are important aetiological factors in chronic rhinosinusitis. Only when medical therapy fails, is surgery considered. Although a range of surgical procedures are available, an endoscopic approach may be directed at the ostiomeatal complex and is generally very conservative. Scanning is a prerequisite to this surgery, demonstrating both the extent of disease and the anatomy but requires careful interpretation. Furthermore, an endoscopic technique can be employed for a number of other sinus conditions though this should only be undertaken by an experienced surgeon. A long-term prospective study of children undergoing radical sinus surgery for neoplasia strongly suggests that concerns that surgery in the middle meatus might disturb subsequent facial development are unfounded.