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.
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.”
In a short period of time, the criteria for appropriate selection for FESS has really shifted from a focus pathway to more of a quality of life focus pathway. —Adam Zanation, MD
Invasive Fungal Rhinosinusitis
Stilianos Kountakis, MD, PhD, chairman of the otolaryngology department and director of neurorhinology-advanced sinus surgery fellowship at the Medical College of Georgia-Augusta University, underscored the continued essential role of surgery in the treatment of invasive fungal rhinosinusitis (FRS) which, when acute in immunocompromised patients, has a high mortality rate.
In these patients, identified by edema, ulcerations, and necrosis on endoscopy; sinus ossification and bone necrosis on CT; and fungal particles invading the mucosa with thrombosis, ischemia, and necrosis on biopsy, there is an urgent need for surgical debridement, Dr. Kountakis said. “It’s a question of minutes sometimes, and hours, instead of days,” he said. “All the necrotic debris and tissue has to be removed until we encounter bleeding tissue. Once we do that, the patients may have a chance.” Then, patients should receive anti-fungals to fight the disease, he said.
For the allergic version of FRS, a subclass accounting for approximately 10% of the surgical cases in the U.S. and usually involving young, immunocompetent people with a fungal atopy, endoscopic sinus surgery provides a definitive diagnosis, he said. Key to resolving the symptoms is removing all of the fungal and eosinophilic debris, followed by medical management to control the underlying disease.
Endoscopic Sinus Surgery
Adam Zanation, MD, professor of otolaryngology at the University of North Carolina, said that recent findings suggest that the role of endoscopic sinus surgery is likely to expand for certain patients.
A 2019 study published in The Laryngoscope proposed that criteria for appropriateness for surgery in the management of uncomplicated adult chronic rhinosinusitis should be minimum prior therapy; a Sino-Nasal Outcome Test (SNOT-22) score of 20 or higher; and a CT Lund-Mackay score of 1 or higher (Laryngoscope. 2019;12:37–44). “Several years ago, a CT Lund of 1 would likely not have meant surgery,” he said. “We’ve opened ourselves up to a broader range of patients we can help from a quality-of-life perspective.”
Studies have found that baseline CT scores don’t necessarily correlate with quality-of-life outcomes after FESS, he said. “In a short period of time, the criteria for appropriate selection for FESS [functional endoscopic sinus surgery] has really shifted from a focus pathway to more of a quality-of-life focus pathway,” he said.
But questions remain as to which type and what extent of FESS is best, he said. Data from a study of 311 patients with CRS suggests similar benefits for a complete versus a targeted approach, done according to physician discretion (Int Forum Allergy Rhinol. 2015;5:691-700). Those undergoing the complete procedure had a higher prevalence of asthma, aspirin sensitivity, nasal polyps, and history of prior surgery. While the overall SNOT score was higher for those undergoing a complete procedure, there was no difference in the number of patients showing improvement between the two groups, Dr. Zanation noted.
“Both FESS and extended endoscopic endonasal surgery have had and will continue to have expanding roles,” he said. “Research and innovation and outcomes and value studies will be key to protecting this growth.”
Thomas R. Collins is a freelance medical writer based in Florida.