Conflicting Evidence on Tobacco’s Effect on ESS Outcomes

But David Kennedy, MD, professor of rhinology at the University of Pennsylvania Medical Center and Veterans Administration Hospital in Philadelphia, puts a higher weight on the endoscopy readings. His goal is resolution of the disease and getting the mucosa to settle down and become stable; on the research side, his team studies the underlying persistent inflammation.

“We look primarily at the endoscopic outcomes, not just quality of life.”

—David Kennedy, MD

Dr. Kennedy said there are two things that are important in identifying outcome after ESS: the extent of disease and patients who continue to smoke. In a study (Laryngoscope. 1998;108(2):151-157) in which researchers enrolled 120 patients and followed them for eight years, Dr. Kennedy and his colleagues found that more smokers than nonsmokers needed revision surgery. Based on these findings and his personal experience, Dr. Kennedy said he refuses to do elective sinus surgery unless the patient has quit smoking for approximately six weeks prior to surgery. He will operate on smokers if there are complications of the sinusitis or a neoplasm.

“We look primarily at the endoscopic outcomes, not just quality of life,” Dr. Kennedy said, noting that persistent asymptomatic disease is common after ESS in smokers. “All patients feel better after ESS, so it probably doesn’t matter if all you’re looking for is symptom improvement in the short to medium-term follow-up period.”

Meanwhile, several studies have found that smokers do worse after ESS. For example, a study published in 2004 found that smoking was associated with statistically worse outcomes after ESS based on average SNOT-16 scores (Laryngoscope. 114(1):126-128). The smokers’ SNOT-16 scores averaged 27.5, versus 18.2 for the non-smokers. Passive smoke exposure in smokers increased the average SNOT-16 score to 30.6. The average SNOT-16 score in the ex-smoking nonsmokers was 22.1, and passive exposure in this group increased the average SNOT-16 score to 25.5.

A 2011 article in Rhinology (49(5):577-582) showed that smokers had worse post-operative outcomes than their nonsmoking counterparts, including nasal blockage, loss of smell, frontal headache, postnasal drip, muco-purulent rhinorrhea and watery rhinorrhea, over an observation period of two to nine years.

“The significance of [the 2011 Rhinology paper] is to underline that smoking may negatively influence the post-operative course in chronic rhinosinusitis in terms of higher risk of unresponsiveness to further treatment, leading to revision surgery,” said the study’s first author Antoni Krzeski, MD, PhD, a professor within the department of otolaryngology at Warsaw Medical University, Poland. “It is particularly important when discussing informed consent with the patient.”