Experts Debate Surgical Approaches To Sinus Disease

FESS results showed improvements over the years, Dr. Marple said. A 1990 study of 165 patients showed that patients reported subjective improvement after 10 months, but that endoscopic disease continued. In 1992, 97% of 120 patients reported subjective improvement in a symptom-based questionnaire, but, again, the disease persisted. In 1998, at a follow-up of eight years, 98% of 120 patients showed overall improvement, but revision surgery was needed in 18% of the patients.

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Figure. When medical management of chronic rhinosinusitis has failed, surgery may be a viable option for patients to obtain relief.

A 2004 randomized controlled trial-the only such study on the topic, Dr. Marple noted-measured success rates of endoscopic sinus surgery compared to continued medical treatment in 90 patients who failed initial treatment of chronic rhinosinusitis. The results were roughly equivalent for the two groups.

The outcome was a little bit numbing when you look at it from the standpoint of a surgeon, Dr. Marple said. When you look at the outcome at six months and you look at outcome at 12 months, there’s really no statistically significant difference.

One major advantage of FESS is that it can be tailored to the individual, Dr. Marple noted. But there is evidence that FESS can fail at holding down inflammation in CRS.

In chronic rhinosinusitis, the overwhelming data suggest that patients feel better after sinus surgery, Dr. Marple said. Persistence of some inflammation is present-and that raises the question: Are we really accomplishing what we set out to accomplish at the very beginning by simply opening and ventilating sinuses?

In a retrospective review of 188 patients, with follow-up at 12 to 168 months, recurrence occurred in 60% of the patients and revision surgery was required in 27% of the patients.

Studies have also found that ESS can provide beneficial systemic changes in patients with more severe disease, such as CRS with polyps, with studies showing beneficial effects on asthma and that surgery can limit cytokine expression.

Another Surgical Option: Sphenoidectomy

Jean Michel Klossek, MD, PhD, of the University Hospital Poitiers in France, said that a sphenoidectomy involving a total removal of the ethmoidal mucosa is a viable option for patients with chronic rhinosinusitis with polyps. He said that his center has performed the procedure on 35 to 50 such patients each year since 1985.

It’s only for chronic rhinosinusitis with polyps, which is very important, Dr. Klossek said. It’s not for chronic rhinonsinusitis without polyps.