Sleep Dysfunction a Strong Indicator of ESS Election for CRS

What are the prevalence, timing, and potential baseline clinical risk factors associated with patients with medically refractory chronic rhinosinusitis (CRS) electing to change from continued medical therapy (CMT) (with or without surgery) to endoscopic sinus surgery (ESS)?

Bottom Line: Baseline total SNOT-22 and endoscopy scores are associated with treatment crossover, but reported sleep dysfunction is the only significant independent predictor of treatment crossover.

Background: At some point, patients with CRS who do not experience adequate symptom control will decide whether to continue with appropriate medical therapies or to elect ESS followed by CMT. An improved understanding of both the prevalence and incidence of escalation of care toward ESS would help patients and otolaryngologists to more efficiently navigate the choices and expectations between treatments.

Study design: Retrospective analysis of a prospective, multi-center cohort of 179 adult patients with CRS enrolled between March 2011 and June 2015.

Setting: Oregon Health and Science University, Portland; Medical University of South Carolina, Charleston; Stanford University, Palo Alto, Calif.; University of Calgary, Alberta, Canada.

Synopsis: A total of 124 study participants elected to remain on CMT during the observational period, while 55 elected ESS within 18 months. Post-treatment follow-up was available for 148 participants. The average CMT cohort follow-up was 15.1 months, compared to 5.5 months for the ESS cohort. Crossover occurred across the entire follow-up period. No significant differences in baseline characteristics between treatment groups were discovered, with the exception of average SNOT-22 sleep dysfunction domain scores, which was also the only cofactor remaining in the final model. ESS patients had greater mean improvements in total endoscopy scores, and greater significant improvement in SNOT-22, rhinologic psychological dysfunction and sleep dysfunction subdomain scores. A low SNOT-22 score (<20) significantly increased in both groups, but was greater in the ESS group. For each single increasing (worsening) point of endoscopy score from baseline, the hazard of treatment crossover increased by ~6%; for every single point increase in baseline SNOT-22 total score, the hazard of crossover increased by ~2%. Limitations included a statistically significant difference between the SNOT-22’s sleep subdomains and the possibility of sources of unmeasured confounding.

Citation: DeConde AS, Mace JC, Ramakrishnan VR, Alt JA, Smith TL. Analysis of factors associated with electing endoscopic sinus surgery. Laryngoscope. 2018;128:304–310.