When are we operating for chronic rhinosinusitis? A systematic review of maximal medical therapy protocols prior to endoscopic sinus surgery

Surgery for chronic rhinosinusitis with nasal polyps: An update

This update aimed to evaluate surgical indications in the management of chronic rhinosinusitis with nasal polyps (CRSwNP). It was conducted and reported according to the criteria stipulated by the Synthesis Without Meta-analysis (SwiM) guidelines. From the PubMed-National Library of Medicine database, 1098 articles were identified for the period 2006-2021 using the key words "nasal polyps" and "surgery". After screening and analysis, 39 publications were selected. The efficacy of surgery on functional improvement in CRSwNP, measured by the specific quality-of-life score SNOT-22, is established, and improvement in olfactory function is expected in 50% of patients. The rate of surgical revision is at least 10-15% at 4 years, but the disease can be controlled for several years, with the interval between primary surgery and symptomatic recurrence exceeding 10 years in some cases. The criteria for surgery are not clearly defined in the literature. However, several authors consider failure of ≥ 8 weeks' well-conducted local medical treatment and use of more than 2 courses of systemic corticosteroids as a reliable indication. No studies or meta-analyses are currently available to determine the superiority of one surgical technique over another.

Orally administered Chinese herbal therapy to assist post-surgical recovery for chronic rhinosinusitis-A systematic review and meta-analysis

This systematic review and meta-analysis aims to: assess the effectiveness and safety of orally administered Chinese herbal medicines (CHMs) as adjuncts to the post-surgical management of chronic rhinosinusitis (CRS); inform clinicians of the current evidence; identify the best available evidence; and suggest directions for further research. Randomised controlled trials (RCTs) were identified from searches of nine databases plus clinical trial registries. Participants were adults and/or children diagnosed with sinusitis or rhinosinusitis, with or without nasal polyps, who had received surgery. Interventions were CHMs used orally following surgery for CRS as additions to conventional post-surgical management. Controls received conventional post-surgical management without CHMs. Studies reported results for Sino-Nasal Outcome Test (SNOT), visual analogue scales (VAS), Lund-Mackay computed tomography score (LM), Lund-Kennedy endoscopic score (LK), mucociliary transport time (MTT), mucociliary transport rate (MTR), mucociliary clearance (MC) or quality of life (QoL). Twenty-one RCTs were included. All used oral CHMs following functional endoscopic sinus surgery (FESS). The pooled results showed no significant difference between groups for SNOT-20 at the end of treatment (EoT) but there was a significant difference at follow up (FU) in favour of additional CHMs. The VAS for total nasal symptoms (VAS-TNS) showed greater improvements in the CHM groups at EoT and FU. Only FU data were reported for LM which showed greater improvement in the CHM groups. LK showed greater improvements at EoT and FU. The measures of mucociliary transport (MTT, MTR, and MC) each showed significantly greater improvement at EoT in the group that received additional CHMs. No study reported QoL. Adverse events were not serious, but reporting was incomplete. The meta-analyses suggested the addition of oral CHMs to conventional management following FESS may improve recovery. However, most studies were not blinded, and substantial heterogeneity was evident in some meta-analyses. Blinded studies are required to further investigate the roles of oral CHMs in post-surgical recovery. Systematic review registration number: The protocol was registered in PROSPERO (CRD42019119586).

Surgical management of rhinosinusitis for the allergist-immunologist

Chronic rhinosinusitis (CRS) is a common chronic inflammatory disease characterized by inflammation of the sinus, with or without nasal passage inflammation, occurring for more than 12 weeks at a time. CRS has historically been classified in 2 categories: CRS without nasal polyps or CRS with nasal polyps (25%-30% of cases). The mainstay of treatment for CRS with or without nasal polyps is medical management, and options may include a combination of saline irrigation, nasal steroids, allergy medications, antibiotics, oral steroids, and treatment with targeted monoclonal antibodies. Unfortunately, up to 60% of patents report symptoms refractory to maximal medical therapy. As such, a combined approach of surgery and medical therapy may be offered. Endoscopic sinus surgery for CRS is approached in a stepwise fashion, ranging from the simplest technique, such as polyp removal, to more expanded approaches that open the paranasal sinuses and allow gravity-dependent drainage. This review article provides a review and in-depth explanation of various surgical approaches for CRS, including the indications, techniques, and respective outcomes for each one.

State of the Art Medical Management of Nasal Polyps

BACKGROUND

Chronic rhinosinusitis with nasal polyposis (CRSwNP) is an inflammatory disease with a treatment goal of controlling symptoms and limiting disease burden. While endoscopic sinus surgery is effective for removing polyps and aerating sinuses, proper medical management remains necessary for reducing inflammation and limiting polyp recurrence.

OBJECTIVE

This article aims to summarize the literature regarding medical treatment of chronic rhinosinusitis with nasal polyposis, with a specific focus on developments in the past 5 years.

METHODOLOGY

We conducted a literature review using PubMed to identify studies assessing medical treatment strategies for patients with CRSwNP. Articles focusing on chronic rhinosinusitis without nasal polyposis were excluded unless specifically stated. Surgical treatment and biologic therapies for CRSwNP will be covered in subsequent chapters and are therefore not included.

RESULTS

Intranasal saline irrigations and topical steroids are mainstays of CRSwNP treatment in the pre-surgical, post-surgical, and maintenance phases of the disease. Alternative steroid delivery methods and adjunctive treatments with antibiotics, anti-leukotrienes, and other topical therapies have been investigated and may benefit certain patient populations, but convincing evidence does not exist to warrant addition of these treatments to the standard of care for CRSwNP.

CONCLUSIONS

Topical steroid therapy is clearly effective for CRSwNP, and recent studies demonstrate the safety and efficacy of high-dose nasal steroid rinses. Alternate delivery methods for local steroids may be useful for patients who are not responding to or who are noncompliant with conventional intranasal corticosteroid sprays and rinses. Future studies are needed to clarify if oral or topical antibiotics, oral anti-leukotrienes, or other novel therapies are significantly effective in decreasing symptoms and improving the quality of life in patients with CRSwNP.

Current and Emerging Treatment Options in Sinus and Nasal Diseases: Surgical Challenges and Therapeutic Perspectives

Chronic rhinosinusitis (CRS), one of the most prevalent health problems worldwide, is defined as a chronic inflammation of the nasal and paranasal sinuses mucosa persisting for more than 12 weeks [...].

Endoscopic sinus surgery with medical therapy versus medical therapy for chronic rhinosinusitis with nasal polyps: a multicentre, randomised, controlled trial

BACKGROUND

Endoscopic sinus surgery (ESS) is a common operation for patients with chronic rhinosinusitis with nasal polyps (CRSwNP) when medical therapy alone is insufficient. No randomised controlled trials on the efficacy of ESS have been published. We aimed to assess the efficacy of ESS plus medical therapy versus medical therapy alone in patients with CRSwNP.

METHODS

We performed an open-label, multicentre, pragmatic, randomised, controlled trial in three tertiary care centres and 12 secondary care centres in 11 cities in the Netherlands (Almere, Amstelveen, Amsterdam, Blaricum, Den Haag, Deventer, Haarlem, Hoofddorp, Hoorn, Leiderdorp, and Rotterdam). Adults (aged ≥18 years) with CRSwNP and an indication for ESS were randomly assigned (1:1) using block randomisation (block sizes of six), stratified by study centre, to receive either ESS plus medical therapy or medical therapy. ESS was performed according to local practice, although anterior ethmoidectomy was mandatory. Medical therapy was prescribed at the patient's otorhinolaryngologist's discretion, and could be, but was not limited to, nasal corticosteroids, nasal rinsing, systemic corticosteroids, or systemic antibiotics. The primary outcome was disease-specific health-related quality of life (HRQoL) at 12 months of follow up, measured with the validated Sinonasal Outcome Test 22 (SNOT-22; where each item is scored from 0 to 5, where 0 indicated no problems and 5 indicates problems as bad as can be, with a total score of 0-110 points), and the minimal clinically important difference of the SNOT-22 is 9·0 points. Primary and safety analyses were performed on an intention-to-treat (ITT) basis. The ITT population comprised all patients who were randomly assigned to treatment according to their randomisation group and without any protocol violation. This study is registered with the Netherlands Trial Register, NTR4978, and is ongoing.

FINDINGS

Between Feb 15, 2015, and Aug 27, 2019, 371 patients were screened for eligibility, of whom 238 were eligible, willing to participate, and randomly assigned to ESS plus medical therapy (n=121) or medical therapy (n=117) and 234 were included in the baseline ITT population (n=118 ESS plus medical therapy; n=116 medical therapy). 142 (61%) of 234 patients at baseline were men and 92 (39%) were women, and the mean age was 50·4 years (SD 12·7). 206 participants were analysed at 12 months for the primary outcome (n=103 in the ESS plus medical therapy group; n=103 in the medical therapy group). At 12 months follow-up, the mean SNOT-22 score in the ESS plus medical therapy group was 27·9 (SD 20·2; n=103) and in the medical therapy group was 31·1 (20·4; n=103), with an adjusted mean difference of -4·9 (95% CI -9·4 to -0·4), favouring ESS plus medical therapy. Adverse events were similar between the groups. The most common adverse events were minor epistaxis or gastrointestinal problems. No treatment-related deaths occurred, but one patient died due to congestive heart failure.

INTERPRETATION

ESS plus medical therapy is more efficacious than medical therapy alone in patients with CRSwNP, although the minimal clinically important difference was not met. Long-term follow-up data are needed to determine whether the effect persists. The current results are a basis for further development of evidence-based guidelines.

FUNDING

The Netherlands Organisation for Health Research and Development (ZonMw).

Treatment options for chronic rhinosinusitis with nasal polyps

Background: The management of chronic rhinosinusitis with nasal polyps (CRSwNP) is evolving, with an emphasis on treating the underlying type 2 inflammation. Objective: The objective was to summarize the updated evidence-based medical and surgical treatment recommendations for CRSwNP, including the position of biologics in the treatment algorithm. Methods: This review compared and contrasted the therapeutic recommendations presented by the European Position Paper on Rhinosinusitis and Nasal Polyps 2020 and the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis 2021. Results: The long-term use of intranasal corticosteroids and the short-term use of oral corticosteroids are strongly recommended, whereas corticosteroid-eluting implants are considered an option. Although the use of saline solution rinses is recommended, there is uncertainty as to whether irrigation is more effective than sprays. Oral aspirin (ASA) desensitization, followed by ASA ≥ 300 mg daily for patients with ASA-exacerbated respiratory disease may be considered. In general, the use of antifungal agents offers no benefit and potential harm. Although the use of oral antibiotics for an acute exacerbation is still debated, oral and topical antibiotics are discouraged for subacute or chronic use. Antileukotrienes are inferior to intranasal corticosteroids and are unlikely to provide added benefit when used concomitantly. It is unlikely that the benefit of oral antihistamines and decongestants outweigh the potential harm. Dupilumab is recommended for severe CRSwNP when consensus-determined criteria are met. Omalizumab may be an option with concomitant poorly controlled asthma. Mepolizumab and reslizumab may be used, particularly in patients with concomitant uncontrolled asthma. In allergic fungal rhinosinusitis, oral and topical antifungals, antileukotrienes, allergen immunotherapy, and omalizumab are therapeutic options. Although surgical intervention is recognized to be of benefit for CRSwNP, there are no evidence-based criteria to indicate when maximum medical treatment has failed. Conclusion: An evidence-based CRSwNP treatment algorithm for when to recommend surgery and/or initiate or discontinue biologics to maximize quality of life and cost-effectiveness is still lacking.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Multiomic analysis identifies natural intrapatient temporal variability and changes in response to systemic corticosteroid therapy in chronic rhinosinusitis

INTRODUCTION

The pathophysiology and temporal dynamics of affected tissues in chronic rhinosinusitis (CRS) remain poorly understood. Here, we present a multiomics-based time-series assessment of nasal polyp biopsies from three patients with CRS, assessing natural variability over time and local response to systemic corticosteroid therapy.

METHODS

Polyp tissue biopsies were collected at three time points over two consecutive weeks. Patients were prescribed prednisone (30 mg daily) for 1 week between Collections 2 and 3. Polyp transcriptome, proteome, and microbiota were assessed via RNAseq, SWATH mass spectrometry, and 16S ribosomal RNA and ITS2 amplicon sequencing. Baseline interpatient variability, natural intrapatient variability over time, and local response to systemic corticosteroids, were investigated.

RESULTS

Overall, the highly abundant transcripts and proteins were associated with pathways involved in inflammation, FAS, cadherin, integrin, Wnt, apoptosis, and cytoskeletal signaling, as well as coagulation and B- and T-cell activation. Transcripts and proteins that naturally varied over time included those involved with inflammation- and epithelial-mesenchymal transition-related pathways, and a number of common candidate target biomarkers of CRS. Ten transcripts responded significantly to corticosteroid therapy, including downregulation of TNF, CCL20, and GSDMA, and upregulation of OVGP1, and PCDHGB1. Members of the bacterial genus Streptococcus positively correlated with immunoglobulin proteins IGKC and IGHG1.

CONCLUSIONS

Understanding natural dynamics of CRS-associated tissues is essential to provide baseline context for all studies on putative biomarkers, mechanisms, and subtypes of CRS. These data further our understanding of the natural dynamics within nasal polypoid tissue, as well as local changes in response to systemic corticosteroid therapy.

Chronic rhinosinusitis in eosinophilic granulomatosis with polyangiitis: clinical presentation and antineutrophil cytoplasmic antibodies

BACKGROUND

In this study we aim to describe presenting characteristics and identify prognostic factors for disease resolution in patients with chronic rhinosinusitis (CRS) in the setting of eosinophilic granulomatosis with polyangiitis (EGPA).

METHODS

Patients evaluated at a tertiary care center with diagnoses of EGPA and CRS were identified. Descriptive statistics were obtained. Univariate analysis was used to search for prognostic factors associated with higher Lund-Mackay score at presentation and disease resolution.

RESULTS

Forty-four patients were included with a mean age of 52.7 (standard deviation, 14) years. Twenty-one patients (47.7%) were female, all had a diagnosis of asthma, and 36 (83.7%) had eosinophils >10%. Common presenting symptoms for CRS included nasal discharge (87.9%) followed by nasal congestion (83.9%) and facial pain and pressure (83.8%). Medical management of CRS included systemic corticosteroids (93.2%) and systemic antibiotics (75%). Surgical intervention occurred in 29 patients (67%). Nine patients (20.5%) had resolution of sinus symptoms, including 4 with imaging confirmation. Fourteen patients (31.8%) had continued CRS, but with improved symptoms, whereas 9 patients (20.5%) had continued CRS with no improvement in symptoms. Eleven patients (25%) were lost to follow-up and 4 (9.1%) died. Univariate analysis did not show antineutrophil cytoplasmic antibody positivity, presence of peripheral eosinophilia, gender, age, or absence of systemic therapy to be predictive of higher Lund-Mackay score at presentation or predictive of disease resolution.

CONCLUSION

CRS in patients with EGPA is often refractory to medical and surgical management. Treatment of these patients should occur in a multidisciplinary setting.

Treatment Outcomes in Chronic Rhinosinusitis Refractory to Maximal Medical Therapy: A Prospective Observational Study Under Real-World Conditions

This investigation explored the outcomes of 4 standardized treatments in patients with refractory chronic rhinosinusitis (CRS), despite recent maximal medical therapy (MMT). In a prospective observational study, we compared continued nasal steroids and irrigation (cNSI), repeated MMT (rMMT), pulsed nasal steroid inhalation (PSI), and endoscopic sinus surgery (ESS). Between November 2015 and March 2016, patients with symptomatic CRS despite having received MMT during the year prior to symptom reoccurrence were offered 1 of 4 standardized treatments. Reflecting real-world conditions, patients selected their treatment option following physician counseling. Sino-Nasal Outcome Test-22 (SNOT-22) scores were obtained before treatment, at the end of treatment, and at 2 months and 1 year following treatment. The mean (± standard deviation [SD]) duration since last MMT was 144 (±36 days). Of the 130 patients, 52 selected cNSI, 16 PSI, 19 rMMT, and 43 ESS. Mean SNOT-22 scores before treatment did not significantly differ between treatments (P = .99). Overall, SNOT-22 scores decreased from 38 ± 2 before treatment to 20 ± 2 after 1 year (P < .001), with a higher reduction for patients having CRS with nasal polyps than for those without nasal polyps (35 ± 2 to 15 ± 2 vs 41 ± 3 to 25 ± 4, respectively; both P < .001). Overall, no difference between the 3 medical treatments was observed (all P > .2). Post-treatment scores following ESS (19 ± 2) were significantly lower than for each of the 3 medical treatments (cNSI 26 ± 2, P = .004; PSI 27 ± 3, P = .026; rMMT 28 ± 3, P = .008). At 1 year following ESS, 26 of 31 patients were asymptomatic and did not require additional systemic steroids, compared to 25 of 50 patients following medical treatment (P = .002). The investigated standardized treatments significantly improved SNOT-22 scores in patients with refractory CRS under real-world conditions. Both patients having CRS with and those without nasal polyps showed significant improvement in SNOT-22 scores, although a less profound effect was found among the latter group. Patients who selected ESS were less symptomatic during the first follow-up year than patients who selected medical treatment alone. Patients with refractory CRS did not benefit from an additional course of MMT in comparison to those who were treated only with cNSI.

Should nasal biopsy inevitably be performed for classifying granulomatosis with polyangiitis in patients with rhinosinusitis? A retrospective chart review study

Nasal biopsy is the essential method for differentiating and diagnosing granulomatosis with polyangiitis (GPA) in patients with chronic rhinosinusitis. Nevertheless, in the real clinical settings, there are several cases unable for nasal biopsy. Hence, in this study, we investigated initial clinical manifestations and laboratory factors which could be helpful for diagnosing GPA in cases unable for nasal biopsy performance. We retrospectively reviewed the medical records of 45 patients with GPA. Twenty-five patients exhibited chronic rhinosinusitis, among which 16 patients underwent nasal biopsy. We applied the 2007 European Medicines Agency algorithm for the classification of GPA, the 2012 Chapel Hill Consensus Conferences Nomenclature of Vasculitis and the 2017 American College of Rheumatology/European League Against Rheumatism provisional classification criteria for GPA to them for reclassifying GPA. Among six patients without granuloma on nasal biopsy, three patients with only antineutrophil cytoplasmic antibody (ANCA) and chronic rhinosinusitis could be classified as GPA due to proteinase 3 (PR3)-ANCA (or cytoplasmic (C)-ANCA) positivity. Among nine patients without nasal biopsy, three patients with only chronic rhinosinusitis could be classified as GPA due to GPA-specific lung lesions. When we excluded an item of granuloma in ten GPA patients with granuloma on nasal biopsy, four patients without ANCAs could be classified as GPA due to GPA-specific lung lesions and cartilaginous involvement. In conclusion, PR3-ANCA (or C-ANCA) positivity, GPA-specific lung lesions and cartilaginous involvement could help physicians in charge make a final diagnosis of GPA in cases unable for nasal biopsy.

Preoperative Management of Chronic Rhinosinusitis Prior to Office Balloon Sinus Dilation: A 2011-2014 MarketScan® Analysis

Background

In-office balloon sinus dilation (BSD) has recently gained popularity as a surgical treatment option for chronic rhinosinusitis (CRS). However, utilization, indications, and practice patterns surrounding in-office BSD remain unclear.

Objective

The purpose of this study was to use a large national administrative database to assess preoperative management of CRS prior to in-office BSD.

Methods

Patients undergoing standalone in-office BSD from 2011 to 2014 were identified on MarketScan and compared to a control group undergoing functional endoscopic sinus surgery (FESS). Visits to the otolaryngologist, number of computed tomography (CT) scans, number of antibiotic and steroid prescriptions, and duration of time from first visit to procedure were compared.

Results

When compared to the FESS group, the in-office BSD group overall had fewer office visits (2.0 vs 2.2), CT scans (1.0 vs 1.1), prescriptions for antibiotics (2.0 vs 2.2), prescriptions for systemic steroids (1.5 vs 1.8), and topical steroids (1.4 vs 1.5) in the preoperative period. They also had a shorter mean duration of time between first visit and CT scan (17.5 vs 21.4 days) as well as between first visit and procedure (55.0 vs 67.8 days). All of these findings were statistically significant.

Conclusion

In-office BSD for CRS was overall associated with less intense management in the preoperative period when compared to FESS. Such differences may reflect ongoing shifts in practice patterns and need to be further investigated.

Diseases of the nasal cavity

Despite garnering minimal attention from the medical community overall, olfaction is indisputably critical in the manner in which we as humans interact with our surrounding environment. As the initial anatomical structure in the olfactory pathway, the nasal airway plays a crucial role in the transmission and perception of olfactory stimuli. The goal of this chapter is to provide a comprehensive overview of olfactory disturbances as it pertains to the sinonasal airway. This comprises an in-depth discussion of clinically relevant nasal olfactory anatomy and physiology, classification systems of olfactory disturbance, as well as the various etiologies and pathophysiologic mechanisms giving rise to this important disease entity. A systematic clinical approach to the diagnosis and clinical workup of olfactory disturbances is also provided in addition to an extensive review of the medical and surgical therapeutic modalities currently available.

Resection versus preservation of the middle turbinate in surgery for chronic rhinosinusitis with nasal polyposis: a randomized controlled trial

Background

Chronic rhinosinusitis (CRS) affects up to 16% of the population. When medical treatment fails, endoscopic sinus surgery (ESS) is considered. The value of resecting the middle turbinate to optimize surgical outcomes has been hypothesized but remains controversial and unproven. Whether the middle turbinate should be left in place or resected is controversial. Our objective is to determine if middle turbinectomy improves objective surgical outcomes after ESS.

Methods

Sixteen patients (15 men, 15 primary surgery) undergoing bilateral complete ESS for CRS with nasal polyposis were recruited. Nasal cavities were randomized so that middle turbinectomy was performed on one side while the middle turbinate was preserved on the other. Each participant acted as their own control. Nasal cavities were compared using Perioperative Sinus Endoscopy (POSE) and Lund-Kennedy (LKES) scores pre-operatively, and at 1, 3 and 6 months after ESS. Results were analyzed using Wilcoxon signed-rank test.

Results

Pre-operatively, the POSE (12.4 ± 2.9 vs 12.8 ± 2.6, p = 0.33, for the preserved side and the resected side, respectively) and LKES (5.0 ± 1.0 vs 4.8 ± 1.2, p = 0.33) scores were similar between sides. During follow up, resection was associated with more crusting at 1 month following ESS (1.0 ± 0.7 vs 0.4 ± 0.6, p = 0.02). There was a small, but statistically significant, difference between the nasal cavities at 3 months, where the resected side showed better endoscopic appearance (2.0 ± 2.2 vs 3.4 ± 2.8, p = 0.01). No difference was found at 6 months. Frontal sinus scores were similar between sides at 6 months (0.7 ± 0.5 vs 0.7 ± 0.5, p = 1.00).

Conclusion

Our results show no sustained objective endoscopic benefit of routine middle turbinectomy, at least within the first six postoperative months, in patients undergoing primary ESS for CRS with polyposis.

Trial registration

NCT, NCT02855931. Registered 16 August 2016.

Appropriateness Criteria for Surgery in the Management of Adult Recurrent Acute Rhinosinusitis

OBJECTIVES/HYPOTHESIS

Endoscopic sinus surgery (ESS) is frequently performed for recurrent acute rhinosinusitis (RARS). Appropriate indications for surgery among patients with RARS have not yet been rigorously determined. The objective of this study was to define appropriateness criteria for ESS in the management of adult RARS.

STUDY DESIGN

Application of RAND-UCLA appropriateness methodology.

METHODS

A panel of nine multidisciplinary experts in RARS was formed to evaluate RARS scenarios generated from current evidence. The panel completed two rounds of a modified Delphi-ranking process and a teleconference.

RESULTS

A total of 32 clinical scenarios were ranked in each round. For adult patients with RARS, ESS can appropriately be offered as a treatment option when patients experience ≥ four annual episodes, and there is confirmation of at least one episode via computed tomography or nasal endoscopy, and the patient and clinician jointly participate in shared decision making, and the patient has either failed a trial of topical nasal steroids or experienced RARS-related productivity loss.

CONCLUSIONS

This study has defined appropriateness criteria for ESS as a management option for adult patients with RARS. These criteria are intended to represent a minimum threshold for which ESS should be considered in the treatment of RARS and do not suggest that all patients who meet these criteria should undergo surgery. These criteria may serve as a baseline set of indications for ESS in patients with RARS.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:37-44, 2019.

Precision medicine: why surgeons deviate from "appropriateness criteria" in the management of chronic rhinosinusitis and effects on outcomes

BACKGROUND

In uncomplicated chronic rhinosinusitis (CRS), a consensus regarding appropriate medical therapy (AMT) before surgical intervention has been published in the form of "appropriateness criteria" for endoscopic sinus surgery (ESS). We sought to determine why tertiary surgeons may deviate from the suggested criteria and evaluated whether those deviations result in change in outcomes.

METHODS

Patients with uncomplicated CRS were prospectively enrolled over the course of 1 year. The 22-item Sino-Nasal Outcomes Test (SNOT-22), a general health outcome out of 100, and a physician form, indicating management pathway and decision making, was completed at each visit over a 6-month follow-up period. A descriptive analysis was used to quantify reasons for veering from the "appropriateness criteria," and repeated linear regression modeling was used to measure whether compliance impacted SNOT-22, general health, and Lund-Kennedy (LK) scores over the period of study.

RESULTS

One hundred fifty-five patients were enrolled. Sixty-eight percent followed the appropriate management pathway based on their presentation and the suggested criteria. Disparate reasons were documented for deviation in the other 32%, and, despite establishing several predictive categories, "other" was the most common reason, with various explanations well documented. SNOT-22, general health, and LK scores were not statistically impacted by compliancy status (p > 0.05).

CONCLUSION

The suggested "appropriateness criteria" predict a management pathway for the majority of CRS patients. However, in a tertiary sinus center, surgeons may deviate from that model with a significant minority of their patients, for multiple reasons, without causing a change in outcomes.

Evaluating Surgeon-Specific Performance for Endoscopic Sinus Surgery

Importance

Several identified factors have raised questions concerning the quality of care for endoscopic sinus surgery (ESS), including the presence of large geographic variation in the rates and extent of surgery, poorly defined indications, and lack of ESS-specific quality metrics. Combined with the risk of major complications, ESS represents a high-value target for quality improvement.

Objective

To evaluate differences in surgeon-specific performance for ESS using a risk-adjusted, 5-year ESS revision rate as a quality metric.

Design, Setting, and Participants

This retrospective study used a population-based administrative database to study adults (≥18 years of age) with chronic rhinosinusitis (CRS) who underwent primary ESS in Alberta, Canada, between March 1, 2007, and March 1, 2010. The study period ended in 2015 to provide 5 years of follow-up.

Interventions

Endoscopic sinus surgery for CRS.

Main Outcomes and Measures

Primary outcomes were the 5-year observed and risk-adjusted ESS revision rate. Logistic regression was used to develop a risk adjustment model for the primary outcome.

Results

A total of 43 individual surgeons performed primary ESS in 2168 patients with CRS. Within 5 years after the primary ESS procedure, 239 patients underwent revision ESS, and the mean crude 5-year ESS revision rate was 10.6% (range, 2.4%-28.6%). After applying the risk adjustment model and 95% CI to each surgeon, 7 surgeons (16%) had lower-than-expected performance and 2 surgeons (5%) had higher-than-expected performance. Three variables had significant associations with surgeon-specific, 5-year ESS revision rates: presence of nasal polyps (odds ratio [OR], 2.07; 95% CI, 1.59-2.70), more annual systemic corticosteroid courses (OR, 1.33; 95% CI, 1.19-1.48), and concurrent septoplasty (OR, 0.70; 95% CI, 0.55-0.89).

Conclusions and Relevance

Evaluating surgeon-specific performance for ESS may provide information to assist in quality improvement. Although most surgeons had comparable risk-adjusted, 5-year ESS revision rates, 16% of surgeons had lower-than-expected performance, indicating a potential to improve quality of care. Future studies are needed to evaluate more surgeon-specific variables and validate a risk adjustment model to provide appropriate feedback for quality improvement.

Economics of Chronic Rhinosinusitis

PURPOSE OF REVIEW

The objective of this article is to provide an updated review of the economic burden of chronic rhinosinusitis (CRS) and discuss how both medical and surgical interventions impact direct and indirect costs related to CRS. By understanding the economics of CRS, clinicians may improve the patient-centeredness of their care and help distinguish between low and high value interventions.

RECENT FINDINGS

Direct costs related to CRS are primarily driven by outpatient physician visits, prescription medical therapy, and endoscopic sinus surgery (ESS). CRS produces large indirect costs and these costs often vary based on the severity of the patients CRS-specific QoL impairment. The overall direct cost related to CRS is estimated to range between $10 and $13 billion per year in the USA. The overall indirect cost related to CRS-related losses in work productivity is estimated to be in excess of $20 billion per year. In the appropriate patients with refractory CRS, ESS provides significant reductions in both direct and indirect costs; however, continued medical therapy alone may be a high value intervention in select patients who have lower severity in their baseline QoL and work productivity.

Examination of high-antibiotic users in a multi-institutional cohort of chronic rhinosinusitis patients

BACKGROUND

In addition to known concerns regarding antibiotic overuse, recent research indicates that excessive antibiotic use is associated with poorer long-term health. Given that rhinosinusitis is the leading condition accounting for antibiotic prescriptions in the ambulatory setting, we aimed to evaluate characteristics associated with greater antibiotic use in chronic rhinosinusitis (CRS).

METHODS

Adult CRS patients enrolled in a prospective, multi-institutional, observational cohort study evaluating treatment outcomes were included in this analysis. Study participants were asked to report the number of days out of the previous 90 days that systemic antibiotics were taken for sinus disease. Patient demographics, disease characteristics, and measures of disease severity were evaluated.

RESULTS

A total of 561 patients from 4 institutions were included in the analysis, with mean antibiotic use of 17.4 ± 22.4 out of the prior 90 days. No differences between antibiotic-use groups were found for objective measures of disease severity (computed tomography [CT], endoscopy, Brief Smell Identification Test [BSIT] scores), however, increased patient-reported symptom burden (22-item Sino-Nasal Outcome Test [SNOT-22], Rhinosinusitis Disability Index [RSDI]) was associated with more antibiotic use. Patients reporting the most antibiotic use were older (p = 0.004) but no ethnic or gender differences were seen. Comorbid diagnoses of allergy, asthma, diabetes, depression, or fibromyalgia were not associated with increased antibiotic use. In accordance with literature recommendations, CRS with nasal polyps (CRSwNP) patients were less likely to have used antibiotics. Endoscopic sinus surgery (ESS) significantly decreased antibiotic use.

CONCLUSION

Variability in antibiotic use in CRS appears to be driven by symptom burden, independent of objective measures of disease severity, patient demographics, and presence of comorbid disease. Clear guidelines are essential to define appropriate antibiotic use in CRS.

CHEER National Study of Chronic Rhinosinusitis Practice Patterns: Disease Comorbidities and Factors Associated with Surgery

Objectives (1) Describe national patterns of chronic rhinosinusitis (CRS) care across academic and community practices. (2) Determine the prevalence of comorbid disorders in CRS patients, including nasal polyposis, allergic rhinitis, asthma, and cystic fibrosis. (3) Identify demographic, clinical, and practice type factors associated with endoscopic sinus surgery (ESS). Study Design Multisite cross-sectional study. Setting Otolaryngology's national research network CHEER (Creating Healthcare Excellence through Education and Research). Subjects and Methods A total of 17,828 adult patients with CRS were identified, of which 10,434 were seen at community practices (59%, n = 8 sites) and 7394 at academic practices (41%, n = 10 sites). Multivariate logistic regression was used to evaluate the association between demographic, practice type, and clinical factors and the odds of a patient undergoing ESS. Results The average age was 50.4 years; 59.5% of patients were female; and 88.3% were Caucasian. The prevalence of comorbid diseases was as follows: allergic rhinitis (35.1%), nasal polyposis (13.3%), asthma (4.4%), and cystic fibrosis (0.2%). In addition, 24.8% of patients at academic centers underwent ESS, as compared with 12.3% at community sites. In multivariate analyses, nasal polyposis (odds ratio [OR], 4.28), cystic fibrosis (OR, 2.42), and academic site type (OR, 1.86) were associated with ESS ( P < .001), while adjusting for other factors. Conclusions We describe practice patterns of CRS care, as well as demographic and clinical factors associated with ESS. This is the first study of practice patterns in CRS utilizing the CHEER network and may be used to guide future research.

Evidence and evidence gaps in therapies of nasal obstruction and rhinosinusitis

Therapeutic decisions in otorhinolaryngology are based on clinical experience, surgical skills, and scientific evidence. Recently, evidence-based therapies have gained increased attention and importance due to their potential to improve the individual patient's treatment and their potential at the same time to reduce treatment costs. In clinical practice, it is almost impossible to stay ahead of the increasing mass of literature and on the other hand critically assess the presented data. A solid scientific and statistical knowledge as well as a significant amount of spare time are required to detect systematic bias and other errors in study designs, also with respect to assessing whether or not a study should be part of an individual therapeutic decision. Meta-analyses, reviews, and clinical guidelines are, therefore, of increasing importance for evidence-based therapy in clinical practice. This review is an update of the availability of external evidence for the treatment of nasal obstruction and rhinosinusitis. It becomes evident that both groups of diseases differ significantly in the availability of external evidence. Furthermore, it becomes obvious that surgical treatment options are normally based on evidence of significantly lower quality than medical treatment options.

Surgical therapy vs continued medical therapy for medically refractory chronic rhinosinusitis: a systematic review and meta-analysis

BACKGROUND

The currently accepted treatment paradigm of treating chronic rhinosinusitis (CRS) first with appropriate medical therapy (AMT) and then with surgery if patients are refractory to AMT, has been criticized for lack of evidence. The objective of this study was to reassess the literature and establish the highest level of evidence possible regarding further management of CRS patients refractory to AMT.

METHODS

This study was a systematic review (SR) with meta-analysis (MA). Adult CRS patients who received AMT and then underwent either medical or surgical therapy in moderate to high level prospective studies were included. Outcomes assessed were disease-specific quality of life (QOL), nasal endoscopy, health-state utility, missed work days, change in cardinal symptoms of CRS, economic impact, and adverse events.

RESULTS

A total of 970 manuscripts were identified; 6 studies were ultimately included in the SR with 5 included in the MA. Compared to continued medical therapy, endoscopic sinus surgery (ESS) significantly improved patient-based QOL scores (p < 0.00001) and nasal endoscopy scores (p < 0.00001). Difference in missed work days depended heavily on patient choice of intervention. Unpooled analysis showed improvements in olfaction, health utility scores, and cost-effectiveness.

CONCLUSION

On meta-analysis, for CRS patients refractory to AMT, ESS significantly improves objective endoscopic scoring outcomes vs continued medical therapy alone. In patients with refractory CRS who have significant reductions in baseline QOL, ESS results in significant improvements. Continued medical therapy appears to maintain outcomes in patients with less severe baseline QOL. Unpooled analysis demonstrates improvement in health utility, olfaction, and cost-effectiveness following ESS compared to continued medical therapy alone, in medically refractory CRS.

Chronic rhinosinusitis: the rationale for current treatments

INTRODUCTION

Chronic rhinosinusitis (CRS) is a broad clinical syndrome linked by mucosal inflammation. Primary treatment modalities are corticosteroids and antibiotics with surgery an option for failures, but the level of supporting evidence is generally low. The primary reason is that CRS is a symptom complex and not a specific disease. Areas covered: The primary treatment modalities for CRS are corticosteroids, antibiotics and surgery. Corticosteroids, which have very broad anti-inflammatory properties, also have the strongest evidence for efficacy. Antibiotics are likely effective in a subpopulation of patients but the various phenotypes and endotypes that make up CRS have thus far been poorly defined. Early surgery as well as biologics may also be more efficacious and cost effective in some phenotypes as well. Expert commentary: A better understanding of the inflammatory pathways that drive CRS will permit investigators to separate patient groups. This will allow for clinical trials that target specific subpopulations and more personalized therapy for CRS patients in the future.

Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis: a RAND/UCLA appropriateness study

BACKGROUND

Appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) are currently poorly defined. The lack of clear surgical indications for ESS likely contributes to the large geographic variation in surgical rates and contributes to reduced quality of care. The objective of this study was to define appropriateness criteria for ESS during management of adult patients with uncomplicated CRS.

METHODS

The RAND/UCLA appropriateness methodology was performed. An international, multidisciplinary panel of 10 experts in CRS was formed and completed 2 rounds of a modified Delphi ranking process along with a face-to-face meeting.

RESULTS

A total of 624 clinical scenarios were ranked, 312 scenarios each for CRS with and CRS without nasal polyps. For adult patients with uncomplicated CRS with nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus a short-course of systemic corticosteroid with a post-treatment total SNOT-22 score ≥ 20. For adult patients with uncomplicated CRS without nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus either a short-course of a broad spectrum/culture-directed systemic antibiotic or the use of a prolonged course of systemic low-dose anti-inflammatory antibiotic with a post-treatment total SNOT-22 score ≥ 20.

CONCLUSION

This study has developed and reported of list of appropriateness criteria to offer ESS as a treatment "option" during management of uncomplicated adult CRS. The extent or technique of ESS was not addressed in this study and will depend on surgeon and patient factors. Furthermore, these criteria are the minimal threshold to make ESS a treatment "option" and do not imply that all patients meeting these criteria require surgery. The decision to perform ESS should be made after an informed patient makes a preference-sensitive decision to proceed with surgery. Applying these appropriateness criteria for ESS may optimize patient selection, reduce the incidence of unwarranted surgery, and assist clinicians in providing high-quality, patient-centered care to patients with CRS.