To the Editor..
To the Editor:
I was dismayed to read the recommendations for investigating and treating “sinusitis” by Druce and Slavin in the October 199 I issue of THE JOURNAL OF ALLERGY AND CI.IN-
We welcome the opportunity to respond to Dr. Knight’s comments. Dr. Knight quotes his own article’ to conclude that the pathology of chronic sinusitis is chronic inflammation. We know of no good evidence in the literature to substantiate this. The term “chronic inflammation“ refers to a nonspecific pathologic appearance. We believe it is necessary to go a step further and determine the cause 01’ the inflammation to provide adequate therapy for patients.’ Dr. Knight postulates that “hyperreactivitl to various stimuli perpetuates continuing symptoms. Again. we arc not aware of any data in the literature to support this concept and are unclear as to which stimuli he refers to. It 1s mlsleading to liken the heterogeneous symptoms ot chronic sinusitis to a “late-phase” allergic reaction. smce the latter is a defined pathologic response to an antigemc challenge. The blind prescription of corticosteroids without an understanding of the etiology of the patient’s smusitis can hardly be described as a safe therapy. Many of the refractor? patients referred to us have failed such a program. We do not recommend surgical evaluation until the optimum medical program has been found to be ineffective. unless thcrc is an indicated imperative need for surgery. such as unilateral polyps, or intolerable symptoms. Such a progrdm might include a short course of oral steroids. but prolonged systemic steroids have no place in the management ol this localized disease. Dr. Knight does his patients a dtaservicc by denying them the well-documented advantdpcs of polypectomy andior functional endoscopic \urger! :’ The tests that Dr. Knight criticizes are wasteful and cx-pensive only if they are used inappropriatel). .rhis is why we and other physicians have advocated the ux of a clrmcal trial ol’ maximal medical therapy before resorting to further investigations.’ The physical finding of pale mucosal swelling is insensitive. diagnostically, and would bc consldcrcd by most investigators to be associated with Jlcrglc htimulation, and not sinusitis. Dr. Knight states that rhe presence of air-fluid levels makes no difference to the treatment and that sinuses drain well with prednisone. We would be interested to see Dr. Knight’s data to support thrs. E\:an\ ct al.“ clearly demonstrated a striking correlation between the presence of air-fluid levels and the recover! 01 bacteria Iron1 maxillary sinus aspirates. We certainly do not advocate the USC01 antibiotics unlc\\ we observe evidence of infection, that IS. pub In the nareb or nasopharynx. It should also be added th