A look at practice patterns over recent years shows that even as the prevalence of chronic rhinosinusitis (CRS) has remained essentially stable, the number of sinus surgeries has dipped a bit.
Explore This IssueApril 2019
In 2011, there were 1,384 patients with CRS per 100,000 people up to 65 years of age, according to a study published in 2017 (Int Forum Allergy Rhinol. 2017 Jun;7:600–608). By 2014, there were 1,514 CRS patients per 100,000. But, over the same period, the number of sinus surgeries has remained relatively flat—at 64 per 100,000 in 2011; 68 in 2012; 71 in 2013; and back down to 65 per 100,000 in 2014, according to the same 2017 study.
Data like these raise the question: Is sinus surgery, slowly but surely, on the way out?
In a discussion at the Triological Society Combined Sections Meeting, expert panelists, on the whole, said no. Sinus surgery, they said, is still an essential part of the care of patients, and some data support an expanded role for boosting quality of life.
But the face of surgery has been changing. After CPT coding changes made balloon sinuplasty a more attractive financial option, frequency of the procedure has skyrocketed, more than quadrupling, for example, among Medicare patients from 2011 to 2015 (Laryngoscope. 2018;128:1299-1303). Additionally, more and more procedures are being performed in-office, across all age groups, said Todd Kingdom, MD, professor of otolaryngology at the University of Colorado in Denver.
Biologics will play an important role for patients with CRS with type 2 inflammation, but certainly in the near term, algorithms will continue to include sinus surgery ahead of these medications, said Robert Kern, MD, chair of otolaryngology-head and neck surgery at Northwestern University in Chicago.
The precise role of biologics continues to take shape, he added. They have been studied only in patients with nasal polyps, but the patient pool for biologics is likely to shift. “Realistically, I think, going forward, biologics will not just be for polyps, and the presence or absence of polyps will not be the criteria. It will be other things. And not all polyp patients need a biologic,” he said.
Most younger patients with early-onset CRS tend to do well, but “it’s the older, late-onset sinusitis and asthma patients, irrespective of the polyps status, who tend to do very poorly,” Dr. Kern said. Commonly, this patient group will have type 2 hyperplastic inflammation contained within the ethmoid sinuses. “Those are patients who might really be the best candidates for a biologic.” Younger patients with the more severe form of CRS known as Samter’s triad also might be good candidates, he said.
Biologics are primarily directed against type 2 inflammation, and approximately 90% of patients with polyps have either a pure type 2 inflammation or a mixed version that includes type 2. But studies of polyp shrinkage with biologics have thus far yielded responses only in the 50% to 70% range (J Allergy Clin Immunol. 2013 Jan;131:110-6.e1; JAMA. 2016;315:469–479). While the results of more extensive studies are imminent, we will likely need to fine-tune the use of biologics, given the cost.
“Why isn’t it a 90 (percent response rate)? We don’t know,” Dr. Kern said, adding that the answer is now under study. “Do we need to give the drug longer? Are particular biologics more effective in particular subgroups (such as those with Samter’s)? We really still don’t know who should get which drug and for how long, or whether these drugs should be given instead of revision surgery or after revision surgery.”