Management of the small percentage of chronic rhinosinusitis (CRS) patients who continue to be symptomatic after appropriate functional endoscopic sinus procedure (FESS) is challenging and complex. This group of patients, often referred to refractory CRS, is increasingly seen in tertiary academic centers as FESS becomes popular procedure in otolaryngology. We have been involved in treating these patients over the last five years and would like to share briefly our experience and protocol algorithm.