Chronic Rhinosinusitis Symptom Duration Does Not Affect ESS Outcomes

by Literature Review •

Do patients with chronic rhinosinusitis (CRS) with longer symptom duration have worse preoperative disease severity and/or quality of life (QOL), and does delayed surgical intervention influence outcomes of endoscopic sinus surgery (ESS)?

Bottom Line
Symptom duration was not associated with mean preoperative disease severity or QOL. Patients with long-term symptom duration reported the greatest mean postoperative QOL improvement, suggesting that delayed surgical intervention may not reduce QOL improvement following ESS.

Background: Current consensus guidelines recommend ESS as a treatment option for CRS patients who have persistent symptomatic burden and objective evidence of disease despite receiving appropriate medical management. Patients with worse sinus-specific QOL impairment are more likely to pursue ESS, while those with less symptomatic burden are more likely to continue medical therapy alone. The choice to delay ESS has never been considered inherently harmful, but recent studies have questioned whether the duration of persistent, symptomatic CRS impacts long-term outcomes.

Study design: Multicenter cohort study of 113 CRS patients observed over an average of 14.7 months between July 2012 and January 2016 following primary ESS.

Setting: Departments/Divisions of Otolaryngology–Head and Neck Surgery at the following: Oregon Health and Science University, Portland; University of Utah, Salt Lake City; Medical University of South Carolina, Charleston; Stanford University, Palo Alto, Calif.; University of Calgary, Alberta, Canada.

Synopsis: The final study cohort was re-categorized into symptom duration subgroups: short-term (32 at <12 months), middle-term (39 at 12–60 months), and long-term (42 at  >60 months). Brief Smell Identification Test (BSIT) scores were significantly worse in the long-term cohort compared to the middle-term cohort. There were no significant differences between participants with and without postoperative follow-up across demographic, comorbidity, and disease severity clinical measures, or across mean patient-reported outcome measure scores, with the exception of age at enrollment: Participants providing postoperative follow-up were significantly older on average. Within-subject mean improvements were highly significant for all three cohorts for all patient-reported outcome measures (PROMs) over time, except for the SNOT-22 rhinologic, extranasal rhinologic, and sleep domains, and the Rhinosinusitis Disability Index (RSDI) emotional domain. Long-term cohort patients reported significantly greater improvement across disease-specific PROMs and improved on SNOT-22 psychological dysfunction scores compared to the short-term cohort; improved significantly more on SNOT-22 ear/facial scores compared to the middle-term cohort; and improved significantly more on SNOT-22 total scores compared to both. Limitations included a potential bias toward more severe sinonasal disease at academic tertiary care centers; a potential for differential misclassification and/or recall bias; unmeasured confounding factors that may be responsible for observed associations; and sample size limitations.

Citation: Alt JA, Orlandi RR, Mace JC, Soler ZM, Smith TL. Does delaying endoscopic sinus surgery adversely impact quality-of-life outcomes? Laryngoscope. 2019;129:303–311.