Current controversies in endoscopic sinus surgery

Treatment of chronic rhinosinusitis (CRS), especially polypoid, represents a great medical challenge as there are  still no reliable methods providing satisfactory long-term outcomes. Besides promising results of newly developed
medical treatments, new algorithms for phenotype-specific treatment are to be established by medical society.
Poorly understood mechanisms of CRS development, multifactorial nature of the disease, and the tendency of CRS  to form “dif fic ult-to -treat ” inflammation t yp es c ontribute to the treatment c omplexit y, with surgic al methods still playing
a crucial role. Endoscopic sinus surgery is accepted worldwide as a gold standard of surgical treatment of different  CRS forms but approaches and surgical techniques differ greatly among specialists: some follow minimally invasive
techniques, others perform classic functional methods, while a group of surgeons tends to carry out extended  operations with maximal resection of anatomical structures in order to create a single cavity. Additionally, great  difference exists in surgical techniques, surgical instruments to be used, opinions on whether uncinate process should  be removed or not for maxillary sinus approach, what size of sinus ostium is optimal and which approach to frontal  sinus is more appropriate. One of the most challenging problems in rhinology is refractory forms of frontal sinusitis,
in which various methods of surgical treatment frequently fail. Moreover, every new surgery frequently makes next  treatment more difficult, making the decision-making process on a more appropriate approach especially hard.  One of the novel promising methods of surgical treatment of severe frontal sinusitis is endoscopic extended frontal  sinus drill-out procedure (Draf 3). There is increasing evidence that this kind of surgery gives reliable long-term  results. However, this method has several limitations including technical issues, need for an image guidance and
a high qualification of the endoscopic sinus surgeon. Alternative to this technique is open frontal sinus surgery with  sinus cavity obliteration, however, it also still carries a number of limitations. This literature review describes recent
opinions on different aspects of chronic rhinosinusitis including basic trends and concepts of surgical treatment,  their benefits and limitations, and associated problems and controversies.
Key words: endoscopic sinus surgery, extended sinus surgery, chronic rhinosinusitis, frontal sinus obliteration,  recalcitrant frontal sinusitis
Conflicts of interest. The authors have no conflicts of interest to declare.