Long-term outcomes of different endoscopic sinus surgery in recurrent chronic rhinosinusitis with nasal polyps and asthma

Abstract

Background: Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) and asthma have poorer outcomes after functional endoscopic sinus surgery (FESS) and higher recurrence rate. The aim of present study was to investigate the long-term clinical outcomes of extended surgical strategies for patients with recurrent CRSwNP and asthma.Methods: Eighty-one patients with CRSwNP and asthma were enrolled in this 5-year prospective study. They were randomly assigned to undergo FESS, radical endoscopic sinus surgery (RESS), or RESS+Draf 3 surgery. Disease severity and clinical outcomes were evaluated using symptoms scoring, endoscopic scoring system, computed tomography staging system, sinus-specific quality of life scores, tissue and peripheral blood eosinophil percentage, and pulmonary function tests. Baseline, 1-year, 3-year, and 5-year follow-up data were compared among the groups.Results: RESS and RESS+Draf 3 strategies yielded better short-term (1 year) outcomes than did FESS. FESS had a higher short-term recurrence rate, although recurrence rates were similarly high (95.6-96.1%) in all the groups at 5 years postoperatively. RESS and RESS+Draf 3 yielded a lower long-term revision surgery rate and a longer time to recurrence post-surgery than FESS, which was negatively correlated with tissue and peripheral blood eosinophil percentage. Conclusions:CRSwNP with asthma is a systemic disease that inevitably recurs. Radical surgery prolongs recurrence time and improves olfaction, rhinorrhea, and quality of life in the short-term. Combining Draf 3 with RESS did not yield better clinical outcomes than RESS alone; thus, although RESS alone appears to be the best option, these findings need to be confirmed in further studies involving more patients, longer follow-up duration and stricter standardized medication use especially the adequate steroid irrigations.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

“…In the presence of co‐morbid conditions such as asthma and nasal polyposis, the extent of surgery may influence rates of polyp recurrence. In patients with asthma and nasal polyposis, Zhang et al found that the addition of a Draf III frontal sinusotomy improved polyp recurrence rates in the first year after surgery compared to standard ESS (59% vs 89%); however, by year 3 there were no differences in polyp recurrence rate, with a 96% rate of polyp recurrence in both groups 2020 …”

Predictive Significance of Charcot-Leyden Crystal Protein in Nasal Secretions in Recurrent Chronic Rhinosinusitis with Nasal Polyps

“…Further investigations have revealed that a Th2-biased inflammation pattern underlying the eosinophilic infiltration is predominant among the Caucasian CRSwNP population in Western countries, whereas over 50% of CRSwNP patients in the Eastern countries present a Th1/Th17-skewed inflammation involving non-eosinophilic accumulation [20, 49-53]. CRSwNP still has a high propensity for recurrence regardless of significant improvement being facilitated by ESS intervention [13, 54-56]. Previous studies have reported that better surgical interventions or the long-term application of postoperative intranasal GCs may prevent or delay recurrence [7, 9, 13, 57].…”

“…CRSwNP still has a high propensity for recurrence regardless of significant improvement being facilitated by ESS intervention [13, 54-56]. Previous studies have reported that better surgical interventions or the long-term application of postoperative intranasal GCs may prevent or delay recurrence [7, 9, 13, 57]. To date, novel parameters and biomarkers, in addition to tissue and peripheral blood eosinophil counts and percentages, have been proposed as predictive factors for recurrence and are worth further investigating, including CLC [33, 34, 41, 58-61].…”

“…Moreover, an earlier onset of recurrence was found in the high CLC protein individuals when drafting the Kaplan-Meier curve only for patients with recurrence, suggesting that patients with high CLC protein levels needed stronger medical intervention to reverse or postpone the recurrence. According to our previous study, a more radical ESS procedure and/or additional systemic GC therapy might be a considerable option during postoperative treatment [13, 35]. However, a high CLC protein level is still an indicator of strong eosinophilic inflammation pattern, and recurrence in high CLC protein population might be inevitable in longer terms of follow-up.…”

“…First-line therapy includes the use of intranasal and/or oral corticosteroids, and endoscopic sinus surgery (ESS) is recommended when first-line therapy fails [1, 6-11]. However, recurrence appears in over 50% patients worldwide who have undergone ESS, including the most radical procedure, suggesting that persistent medical care is needed after ESS [6, 11-13].…”