الفهرس 
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Abstract
Chronic rhinosinusitis (CRS) is a common disease with significant morbidity and health care cost. Although the medical and surgical treatments for CRS have improved markedly over the past few decades, a subset of patients remains quite resistant to all forms of therapy. Such patients end up being over-treated and subjected to numerous unsuccessful surgeries. The optimal treatment for these patients (an entity referred to as refractory or recalcitrant sinusitis) (RCRS) is complex and challenging.
One of the proposed theories in pathogenesis of recalcitrant CRS is formation of bacterial biofilm on the mucous membrane of paranasal sinuses. Biofilms are a complex organized community of germs that adhere to the mucosal surface and surrounded by a self-produced extensive extra cellular polymeric substance called (glycocalyx) which is composed primarily of polysaccharides. Bacterial biofilms have two microbiological characteristic: first, they are difficult to detect and culture using routine conventional methods and second, they are 10-1000 time resistant to current antimicrobial therapy when compared with genetically identical planktonic bacteria.
The benefit from saline irrigations to the management of RCRS includes the mechanical removal of infectious and allergenic material, decrease of mucosal edema, improvement of the mucociliary function, and thinning of mucus secretions. Usually, saline rinses are prescribed in combination with other means of topical therapy.
Recent advances in the understanding of the pathogenesis of RCRS have led to some promising therapeutic developments, particularly in respect to topical treatments. Despite improvements in therapy, RCRS remains a challenging condition to manage.