Topical steroids are commonly prescribed as a component of first-line treatment in CRS. They are recommended as monotherapy or adjunctive to oral antibiotics in acute rhinosinusitis [51]. It is rare to see a CRS patient scheduled for ESS who is naïve to topical nasal corticosteroids. There is no contraindication to continuation of nasal spray preoperatively in the context of positive objective and/or subjective results. Table 23.2 lists some commonly prescribed nasal steroids in the adult population [52–59].

In chronic rhinosinusitis with nasal polyposis, topical corticosteroids have been shown in multiple studies to be beneficial in improving patient symptoms, reducing polyp size, and preventing polyp recurrence after surgery. Results are more pronounced in patients with previous ESS [60, 61]. Although there are few studies regarding the use of topical corticosteroids in patients with CRSsNP, there is ample information showing symptomatic improvement in this population as well [62, 63]. The response may be greater with direct application of the corticosteroid via cannulation of the sinuses or nasal irrigation compared to drops or sprays. Off-label drops (prednisolone, dexamethasone, ciprofloxacin/dexamethasone) may be useful in limiting the need for postoperative oral steroids and reducing risk of ostial stenosis in patients undergoing revision endoscopic sinus surgery at high risk for ostial obstruction [64]. Challenging patients with eosinophilic chronic rhinosinusitis (tissue eosinophil >10 eosinophils/HPF) may specifically benefit from budesonide and betamethasone irrigations postoperatively [65].

The timing of postoperative topical steroids depends on multiple factors such as endoscopic appearance of the dissected sinuses, debridement status, and patient compliance. Ideally, topical steroids may be more effective when initiated after the first debridement 1–2 weeks postoperatively when there is more mucosal surface area for distribution. Common local adverse effects such as ulceration and epistaxis can be prevented by teaching patients proper technique of spraying and irrigating away from the nasal septum.

A detailed discussion of the management of allergic disease in the CRS patient is outlined in Chap. 10. Nonetheless, treatment of allergic and immunologic aspects of CRS is key in overall management preoperatively and postoperatively. Dedicated treatment of chronic allergic rhinitis should include accurate diagnosis with skin or in vitro testing, address environmental contributors, and trial of appropriate pharmacotherapy. There are multiple options for pharmacotherapy regardless of the surgical phase of the patient. Topical options include nasal corticosteroids, antihistamines, and anticholinergics. Decongestants can serve as temporary adjuncts especially during acute exacerbations. Oral antihistamines and leukotriene receptor antagonist also provide benefit in select patients. Intranasal corticosteroids may be more effective than topical antihistamines, but combination therapy of both produces significantly greater benefit than monotherapy with either class or oral antihistamines [66–68]. Patients with a history of positive response to topical and oral treatment of their allergic disease should continue their treatment in the context of planned ESS continuing in the postoperative period. If a patient has aspirin-exacerbated airway disease (AERD), postoperative aspirin desensitization should be considered as this is associated with improved symptoms, better olfaction, and lower recurrence rates relative to AERD patients that do not undergo aspirin desensitization [69, 70]. Postoperative immunotherapy in patients with allergic rhinitis has also been associated with decreased need for revision surgery and reduced usage of intranasal and oral steroids [71].

Patients with nasal polyposis and asthma tend to exhibit marked local production of immunoglobulin E (IgE). Human monoclonal anti-IgE antibody, omalizumab, utilizes this feature as a novel target. This antibody binds circulating IgE and prevents binding of available IgE to the IgE receptor. Omalizumab is approved for moderate-to-severe asthma in the United States; further, results in clinical study of patients with CRSwNP and comorbid asthma are encouraging. Gevaert et al. reported a decrease in total nasal endoscopic scores and radiologic improvement in disease load in subjects who received 4–8 subcutaneous injections of omalizumab [72]. Though this study was not conducted in the perioperative phase, given the challenging sinonasal disease exhibited by this phenotype, omalizumab may be a promising adjunct for future perioperative medical care in this cohort of CRSwNP with comorbid asthma.

The use of nasal saline irrigation alone or as an adjunct to other medical therapies is an important postoperative practice. Nasal saline irrigation can be instrumental in mobilizing crusts and blood clots, moisturizing biodegradable dressing, and removing antigens which may contribute to postoperative edema. The body of literature regarding postoperative nasal irrigation consists of heterogenous studies but favors an overall benefit. A Cochrane review by Harvey et al. reported eight randomized trials with different experimental regimens which compared isotonic nasal saline to placebo, no treatment, and hypertonic saline [73]. Large volume saline irrigation (>240 ml daily) is recommended over saline mist alone or low volume irrigation [74]. Lactated Ringer’s may play a role in postoperative sinonasal toilet, and it has been shown to result to better symptom improvement relative to normal or hypertonic saline [75]. Patients are typically instructed to start irrigation 24–48 h after surgery.

Unlike skin wounds that are immediately accessible for necessary dressing changes and suture removal, the paranasal sinuses require endoscopic-guided care to promote postoperative healing and limit complications. Clinical experience and available evidence suggest that debridement in 1 week is useful in removing crusts and clot and any residual biomaterials and nasal dressing that may promote synechiae and ostial stenosis [33]. Additional debridements are performed dependent on patient outcome and surgeon preference.

Perioperative care in CRS patient can be a complex undertaking due to the different subtypes and plurality of contributing etiologies. Preoperative antibiotics are an option but not a universal practice given the lack of clear benefit. Available evidence favors nasal saline irrigation commencing within 1–2 days postoperatively, use of perioperative intranasal corticosteroids, and debridement within a week of surgery. A short postoperative course of macrolide or penicillin antibiotic may alleviate patient symptoms and improve objective outcomes as well. Potent corticosteroid irrigation such as budesonide suspension in saline is an off-label option in patients with moderate to severe CRS, especially in the setting of polyposis. Aspirin desensitization should be considered in postoperative AERD patients. Patients with comorbid asthma and refractory CRSwNP should be considered for omalizumab treatment. Ongoing investigations are underway to identify novel therapeutic approaches, including other monoclonal antibodies and immune modulators that may modify various components of both innate and adaptive immunity in the CRS patient.