What Is Considered Adequate Surgery for Chronic Rhinosinusitis with Nasal Polyps?

TRIO Best Practice articles are brief, structured reviews designed to provide the busy clinician with a handy outline and reference for day-to-day clinical decision making. The ENTtoday summaries below include the Background and Best Practice sections of the original article. To view the complete Laryngoscope articles free of charge, visit Laryngoscope.com.

BACKGROUND

Chronic rhinosinusitis (CRS) is among the most prevalent chronic medical conditions globally. A survey of Canadian households reported the prevalence of CRS to be 5%. CRS is a clinical syndrome defined by persistent symptomatic inflammation of the mucosa in the nasal cavities and sinuses. A common subtype of CRS is CRS with nasal polyps (CRSwNP), which is identified through endoscopy or imaging. Cardinal symptoms include congestion, pressure, obstruction, drainage, and smell disorder.

First-line management of CRSwNP is typically medical therapy. Endoscopic sinus surgery (ESS) is the next line of management. ESS creates larger sinus ostia, restores ventilation of the sinuses, and allows for optimal topical medication access. Recently, biologics have been used in cases of failed surgery. This class of medications functions by reducing the Th2 inflammatory response of various interleukins. The introduction of biologics has sparked controversy surrounding the adequacy of sinus surgery, largely stemming from variability in defining both surgical success and optimal extent of surgery before prescribing biologic medication. Biologics are classically reserved for cases of failed sinus surgery but carry significant cost implications as well as a non-benign side effect profile, highlighting the need for a clear understanding of what constitutes a failed versus a successful surgery before prescribing. This definition itself is often predicated on the concept of what is considered adequate surgery for CRSwNP.

BEST PRACTICE

As biologics are increasingly used in CRSwNP treatment, the concept of adequate surgery for CRSwNP has become highly relevant, because surgical success versus failure is vital to guide appropriate use of a high-resource medication. The current literature supports the practice of performing complete ESS, addressing the maxillary, ethmoid, sphenoid, and frontal sinuses when indicated, for successful surgical treatment of CRSwNP. Inadequate surgery can lead to suboptimal outcomes, including persistent symptoms, diminished quality of life, and revision surgery, as well as unnecessary medication prescription that might have been avoided with a more comprehensive surgical procedure. Recent work suggests that although aggressive surgery can significantly reduce the need for oral steroid bursts, biologics may be better suited to addressing olfaction. Appreciating this caveat, comprehensive primary surgical intervention remains key, as management of CRSwNP evolves, to preserving long-term symptom control and reducing the need for revision procedures.