Outcomes of complete vs targeted approaches to endoscopic sinus surgery

Abstract

Background Functional endoscopic sinus surgery (FESS) was historically predicated on targeted widening of narrow anatomic structures that caused post-obstructive persistent sinus inflammation. It is now clear that chronic rhinosinusitis (CRS) is a multi-factorial disease with subsets of patients which may require a more extensive surgical approach. This study compares quality-of-life (QOL) and disease severity outcomes after FESS based on the extent of surgical intervention. Methods Participants with CRS were prospectively enrolled into an on-going, multi-institutional, observational, cohort study. Surgical extent was determined by physician discretion. Participants undergoing bilateral frontal sinusotomy, ethmoidectomy, maxillary antrostomy, and sphenoidotomy were considered to have undergone ‘complete’ surgery, while all other participants were categorized as receiving ‘targeted’ surgery. Improvement was evaluated between surgical subgroups with at least 6-month follow-up using the 22-item Sinonasal Outcome Test (SNOT-22) and the Brief Smell Inventory Test (BSIT). Results 311 participants met inclusion criteria with 147 subjects undergoing complete surgery and 164 targeted surgery. A higher prevalence of asthma, ASA sensitivity, nasal polyposis, and a history of prior sinus surgery (p≤0.002) was present in participants undergoing complete surgery. Mean improvement in SNOT-22 (28.1[21.9] vs. 21.9[20.6];p=0.011) and BSIT (0.8[3.1] vs 0.2[2.4];p=0.005) was greater in subjects undergoing complete surgery. Regression models demonstrated a 5.9[2.5] greater relative mean improvement on SNOT-22 total scores with complete surgery over targeted approaches (p=0.016). Conclusions Complete surgery was an independent predictor of greater postoperative SNOT-22 score improvement, yet did not achieve clinical significance. Further study is needed to determine the optimal surgical extent.

Surgical Versus Medical Interventions in CRS and Nasal Polyps: Comparative Evidence Between Medical and Surgical Efficacy

“…They found the mean improvement in SNOT-22 (28.1 vs 21.9; p=0.011) and Brief Smell Inventory Test (B-SIT) (0.8 vs 0.2; p=0.005) was statistically greater in the group undergoing complete surgery, but was not clinically significant. [32]. It is likely that more extensive surgery allows better postoperative access for topical therapies and therefore better reduces the risk of recurrence (Fig.…”

Editorial

“…In another article, the Oregon group evaluate the outcomes of complete vs targeted approaches in functional endoscopic sinus surgery (FESS). 4 In this study, they report that the 22-item Sino-Nasal Outcome Test (SNOT-22) results were better in patients having complete as opposed to targeted FESS. However, because the disease burden was greater in the patient group undergoing complete FESS, the results are not surprising.…”

“…Yu et al 11 examine HO-1 expression in patients with both eosinophilic and non-eosinophilic polypoid disease; the expression was greater in the non-eosinophilic subset. Kim et al 12 evaluate the mechanism by which β-glucan, a known potent stimulator of the innate immune system found in the cell walls of fungi, stimulates the expression of MUC 4 and MUC 5 B, and show that it does so via the Toll-like receptor 4 (TLR4)-p38 mitogen-activated protein kinase (MAPK)-nuclear factor kappa-light-chainenhancer of activated B cells (NF-κB) signaling pathway. Chitin is also a major component of fungal spores and is thought to be an immune modulator.…”

Outcomes After Frontal Sinus Surgery

“…16 There may just be such a large effect size associated with addressing the other sinuses on QOL measures, that the differential impact of presence or absence of a frontal sinusotomy could be obfuscated on a QOL questionnaire. 17 Endoscopic data may be the key to determining the difference in the outcomes, but this is admittedly not a patient-centered outcome measure as this found to be different patients undergoing surgery with and without frontal sinusotomy. 17 …”

“…17 Endoscopic data may be the key to determining the difference in the outcomes, but this is admittedly not a patient-centered outcome measure as this found to be different patients undergoing surgery with and without frontal sinusotomy. 17 …”