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MUSC Otolaryngology - Head & Neck Surgery E-Update                 September 2016 
  Greetings Colleagues!

I hope you are findng our ENT E-Updates useful. These newsletters are designed to provide brief, practical, clinical updates in areas where we all struggle in managing our patients. Your feedback or questions about the E-Update articles, your patients, or any other ENT issue are always welcome. Write to us at entupdate@musc.edu - And please forward this E-Update to your colleagues who may also benefit from sharing the latest ENT topics. As always, your support is deeply appreciated.

Yours sincerely,
Paul R. Lambert, M.D.
Professor and Department Chair

Endoscopic Sinus Surgery: When and how much?
Rodney J. Schlosser, M.D. 
Endoscopic Lothrop cavity 2 years after ESS in patient with Aspirin Exacerbated Respiratory Disease (AERD/Samter's triad). Patient has not used oral steroids since surgery and asthma is under good control.
Endoscopic sinus surgery (ESS) has been performed routinely for the last 3 decades for patients failing medical therapy and numerous studies demonstrate improvement in sinus-specific quality of life (QOL), productivity and medication usage.1, 2 However, there is wide variability in how often ESS is performed around the US with the highest rates of ESS being performed in South Dakota at a rate over 3 times that of the lowest state, Vermont.3 A recent international panel examined when it is appropriate to offer ESS to a patient with CRS and recommended a certain minimal level of radiographic disease, sinonasal symptoms and failure of appropriate medical therapy.4 Despite this, otolaryngologists are often faced with patients who are surgical candidates, but decline surgery or want to defer it. In trying to inform our patients using the best data and perform shared decision making on their treatment options, a common question that arises is:
What happens if patients opt for continued medical treatment of their CRS rather than choosing ESS ?
We sought to begin answering that question when we collaborated with rhinologists from OHSU, Penn and Northwestern to complete a prospective study that compared patients who chose to undergo ESS with those who opted for continued medical management. Those that underwent ESS achieved greater improvements in sinus-specific QOL than a cohort that chose medical treatment.5 In fact, over 1/3 of patients who initially chose continued medical therapy crossed over to ESS within one year. Rudmik1 studied this question in the Canadian system in a different fashion. He followed 31 patients who failed medical therapy and were scheduled for ESS. In the 7 months while they were waiting for surgery, QOL and medication usage worsened. These outcomes improved after ESS was eventually performed. 
Most studies of ESS demonstrate that about 80% of patients achieve clinically important improvements in QOL, thus ESS is not universally successful and data supporting ESS as a treatment option must be weighed against data supporting continued medical therapy. It has been shown that CRS patients with low baseline QOL impairment as measured by SNOT22 scores below 30, typically report stable QOL with medical treatment. 6  Similarly, those with minor impairments in productivity are able to maintain their productivity with continued medical therapy. 7 Thus, while ESS is an effective treatment option, its greatest benefit appears to be in patients with moderate to severe sinus symptoms and those mild QOL impairments may not require ESS or benefit as much from it. Exactly what the threshold is to define optimal treatment remains to be determined.
Several large database studies from the UK and US have also examined the timing of ESS. Patients who had surgery within one year of being diagnosed with CRS had better long term outcomes with regard to sinus QOL and medication usage when compared to patients who deferred ESS for several years.8-10 In addition to the benefits of ESS upon sinus-specific outcomes, there are also benefits upon the lower airway. Our group recently examined patients with previously diagnosed asthma and found that ESS improves asthma-specific QOL and asthma control using validated outcome measures. Nearly 60% of patients achieved a minimal clinically important difference (MCID) in asthma QOL scores after undergoing ESS. CRS patients are also at risk for developing new onset asthma. Patients with CRS who defer ESS develop asthma at about 5% per year until they have ESS when this risk plateaus.8-10  
Thus, there is growing evidence to suggest that in patients who fail appropriate medical therapy and undergo ESS, early ESS provides more improvement in QOL, medication usage and may decrease development of new onset asthma when compared to delayed ESS. There are obvious limitations to the quality of this evidence, as they were non-controlled, epidemiologic studies with diagnostic criteria based upon database entry and it is unknown exactly which patients are most likely to receive benefit from early surgical treatment of the sinuses.

Once a patient elects to proceed with ESS, the next challenge for the surgeon often becomes:
How much surgery should be done?

There are widely varying philosophies regarding this question, extending all the way from balloon sinuplasty to complete turbinate resection and mucosal stripping. Unfortunately, evidence is weak to support any view due to numerous confounding factors, such as surgeon technique/experience, patient anatomy, disease severity, polyp status and perioperative medical therapies. DeConde et al11 examined this question in a prospective fashion collected from multiple surgeons and the entire spectrum of primary, revision, and polyp groups. He controlled for many confounders and found that patients who underwent complete ESS on all sinuses had better sinus-specific outcomes when compared to patients who underwent limited or targeted ESS. Extending this question to more aggressive frontal sinus surgery in polyp patients, Bassiouni et al12 found that patients who underwent endoscopic modified Lothrop after failing complete ESS had lower recurrence rates and less revision surgery than patients undergoing standard frontal sinusotomies. Whether this is due to improved delivery of topical steroids postoperatively or not and the impact upon patient reported outcomes are areas for further investigation. It should be noted that they did not examine the Lothrop performed as a primary procedure in polyp patients and reserved this for those that failed standard complete ESS. These conclusions should be limited only to the patients studied and recognize that they were treated by a very experienced surgeon.
In summary, shared decision making for patients with CRS should include the discussion that while ESS is successful, there are still approximately 20% of patients who do fail standard ESS. It is likely that patients with lower QOL impacts can be managed with continued medical therapy, thus avoiding ESS. Once patients fail appropriate, comprehensive medical therapy, have persistent moderate to severe symptoms and objective evidence of disease, the benefits of ESS are well established. Conclusions regarding the timing and extent of ESS must be tempered until higher level evidence is obtained, but preliminary data suggest that once patients choose to pursue ESS, there is benefit in timely, complete surgery, rather than continued medical management or delayed, limited ESS.  
  1. Smith TL, Kern R, Palmer JN, et al. Medical therapy vs surgery for chronic rhinosinusitis: a prospective, multi-institutional study with 1-year follow-up. International forum of allergy & rhinology. Jan 2013;3(1):4-9.
  2. Rudmik L, Mace J, Soler ZM, Smith TL. Long-term utility outcomes in patients undergoing endoscopic sinus surgery. Laryngoscope. Jan 2014;124(1):19-23.
  3. Rudmik L, Holy CE, Smith TL. Geographic variation of endoscopic sinus surgery in the united states. Laryngoscope. Apr 17 2015.
  4. Rudmik L, Soler ZM, Hopkins C, et al. Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis: a RAND/UCLA appropriateness study. Rhinology. Jun 2016;54(2):117-128.
  5. Smith KA, Smith TL, Mace JC, Rudmik L. Endoscopic sinus surgery compared to continued medical therapy for patients with refractory chronic rhinosinusitis. International forum of allergy & rhinology. Oct 2014;4(10):823-827.
  6. Steele TO, Rudmik L, Mace JC, DeConde AS, Alt JA, Smith TL. Patient-centered decision making: the role of the baseline SNOT-22 in predicting outcomes for medical management of chronic rhinosinusitis. International forum of allergy & rhinology. Jun 2016;6(6):590-596.
  7. Rudmik L, Soler ZM, Smith TL, Mace JC, Schlosser RJ, DeConde AS. Effect of Continued Medical Therapy on Productivity Costs for Refractory Chronic Rhinosinusitis. JAMA otolaryngology-- head & neck surgery. Nov 2015;141(11):969-973.
  8. Hopkins C, Rimmer J, Lund VJ. Does time to endoscopic sinus surgery impact outcomes in Chronic Rhinosinusitis? Prospective findings from the National Comparative Audit of Surgery for Nasal Polyposis and Chronic Rhinosinusitis. Rhinology. Mar 2015;53(1):10-17.
  9. Benninger MS, Sindwani R, Holy CE, Hopkins C. Early versus delayed endoscopic sinus surgery in patients with chronic rhinosinusitis: impact on health care utilization. Otolaryngol Head Neck Surg. Mar 2015;152(3):546-552.
  10. Benninger MS, Sindwani R, Holy CE, Hopkins C. Impact of medically recalcitrant chronic rhinosinusitis on incidence of asthma. International forum of allergy & rhinology. Feb 2016;6(2):124-129.
  11. DeConde AS, Suh JD, Mace JC, Alt JA, Smith TL. Outcomes of complete vs targeted approaches to endoscopic sinus surgery. International forum of allergy & rhinology. Apr 23 2015.
  12. Bassiouni A, Wormald PJ. Role of frontal sinus surgery in nasal polyp recurrence. Laryngoscope. Jan 2013;123(1):36-41.
Rodney J. Schlosser, M.D.

 Professor and Director, Rhinology & Sinus Surgery

M.D.: Mayo Clinic
Residency: University of Virginia
Fellowship: University of Pennsylvania
Special Interests: Adult and pediatric sinus and allergy disorders, CSF leaks, sinus tumors
Email: schlossr@musc.edu

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The Charleston Course: 7th Annual Otolaryngology Literature Update
July 14-16, 2017 

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