What are the indications for functional endoscopic sinus surgery (FESS), septoplasty, turbinate reduction (turbinectomy) and polypectomy in chronic sinusitis, and what investigations are needed to determine the need for surgery?

Surgical Indications for Chronic Rhinosinusitis

Surgery (FESS, septoplasty, turbinate reduction, polypectomy) should be offered when chronic rhinosinusitis is confirmed by established diagnostic criteria, medical therapy has been attempted, quality of life remains significantly impaired (SNOT-22 ≥20), and CT imaging demonstrates sinus disease (Lund-Mackay score ≥1). 1, 2

Verification of Diagnosis Before Considering Surgery

Before proceeding with any surgical planning, you must verify the diagnosis of chronic rhinosinusitis using established criteria 1, 2:

• Symptoms lasting ≥12 weeks including:
  • Two or more cardinal symptoms: nasal obstruction/congestion, nasal discharge (anterior/posterior), facial pain/pressure, or reduction/loss of smell
  • Plus objective evidence on nasal endoscopy (mucopurulent discharge, edema, polyps) or imaging

Critical pitfall: Do not proceed to surgery without confirming both symptom duration and objective findings. Many patients labeled with "sinusitis" do not meet diagnostic criteria.

Assessment of Surgical Candidacy

The 2025 AAO-HNS guidelines provide a strong recommendation that candidacy must be assessed based on four factors 1, 2:

1. Symptom severity and quality of life impact
2. Disease characteristics (presence of polyps, bony erosion, eosinophilic mucin, fungal disease)
3. Prior medical therapy (but NOT requiring a rigid protocol)
4. Patient understanding of long-term management needs

Medical Therapy Requirements

Important: There is NO mandatory "one-size-fits-all" medical regimen required before surgery 2. The guidelines explicitly reject rigid prerequisites. However, appropriate medical therapy should be attempted:

For CRS with nasal polyps 3:

• Topical intranasal corticosteroids (typically 8 weeks)
• Plus short-course systemic corticosteroids
• Post-treatment SNOT-22 score ≥20 indicates persistent impairment warranting surgery

For CRS without nasal polyps 3:

• Topical intranasal corticosteroids (typically 8 weeks)
• Plus either broad-spectrum/culture-directed antibiotics (approximately 3 weeks) OR prolonged low-dose anti-inflammatory antibiotics
• Post-treatment SNOT-22 score ≥20 indicates persistent impairment warranting surgery

Patients Who Benefit Most from Surgery

Prioritize surgery for these subtypes as they respond poorly to medical therapy alone 2:

• Chronic rhinosinusitis with nasal polyps
• Polyps with bony erosion
• Eosinophilic mucin
• Fungal balls (mycetomas)
• Allergic fungal sinusitis

Required Investigations

Essential Imaging

For any surgical candidate, obtain a fine-cut CT scan of the paranasal sinuses 2. This is a formal recommendation for surgical planning.

Critical caveat: Do NOT plan the extent of surgery based solely on arbitrary CT criteria like minimal mucosal thickening or degree of opacification 2, 3. The CT is for anatomic planning, not for determining which sinuses to operate on based on radiographic appearance alone.

Additional Workup

• Nasal endoscopy: Required for diagnosis and surgical planning
• Quality of life assessment: Use validated instruments (SNOT-22 is most commonly referenced; score ≥20 indicates significant impairment) 3
• Consider allergy testing if allergic triggers suspected
• Rule out underlying conditions: immune deficiency, granulomatosis with polyangiitis, Churg-Strauss syndrome, aspirin-exacerbated respiratory disease 4

Specific Surgical Procedures

FESS (Functional Endoscopic Sinus Surgery)

When polyps, osteitis, bony erosion, or fungal disease are present, perform complete sinus surgery with full exposure of the sinus cavity and removal of diseased tissue—not just balloon dilation or simple ostial opening 2, 5. This is a formal recommendation.

Typical approaches include 6:

• Medial maxillary antrostomy with ethmoidectomy (24-48% of cases)
• Medial maxillary antrostomy with spheno-ethmoidectomy (48% of cases)
• Full house FESS (all sinuses, 27% of cases)

Septoplasty

Perform septoplasty when septal deviation 5:

• Causes nasal obstruction symptoms
• Blocks access for medical therapy (topical steroids, irrigations)
• Obstructs surgical access to sinuses during FESS

Septoplasty is performed in approximately 94% of FESS cases 6, indicating it's nearly routine for adequate surgical access and postoperative care.

Turbinate Reduction (Turbinectomy/Turbinoplasty)

Perform inferior turbinate reduction when 7, 6:

• Turbinate hypertrophy contributes to nasal obstruction
• Access is needed for sinus surgery
• Medical management (topical steroids, antihistamines) has failed

Evidence note: Recent systematic review shows turbinate reduction is safe when combined with FESS but does not consistently improve quality of life outcomes beyond FESS alone 7. Consider it primarily for access and in select patients with documented turbinate hypertrophy contributing to obstruction. Performed in approximately 37% of FESS cases 6.

Polypectomy

Polypectomy is indicated when nasal polyps 4, 8:

• Obstruct airflow causing significant nasal obstruction
• Block access for topical medical therapy
• Are associated with chronic inflammation requiring tissue removal

Polypectomy is required in approximately 62% of FESS cases 6, particularly in CRS with nasal polyps phenotype.

When to Offer Surgery: The Decision Algorithm

Offer surgery when ALL of the following are met 2:

1. Anticipated benefits exceed nonsurgical management alone
2. Clarity exists regarding anticipated outcomes
3. Patient understands expectations for long-term disease management (including potential for recurrence, need for ongoing medical therapy, possible revision surgery)

Counsel patients explicitly that surgery does not "cure" chronic rhinosinusitis—it's part of long-term management 2. Set realistic expectations about:

• Potential for disease recurrence (15-20% revision rates in some populations, higher in cystic fibrosis patients) 9
• Need for continued postoperative medical management
• Postoperative care requirements (debridement, irrigations, topical steroids)

Common Pitfalls to Avoid

1. Operating without confirmed diagnosis: Verify symptom duration ≥12 weeks plus objective findings 1
2. Requiring arbitrary medical therapy duration: No rigid protocol is mandated 2
3. Planning surgery based solely on CT appearance: Use CT for anatomic planning, not to determine which sinuses to operate on based on mucosal thickening alone 2, 3
4. Performing inadequate surgery for polypoid disease: When polyps/osteitis/fungal disease present, complete sinus exposure and diseased tissue removal is required—not just balloon dilation 2, 5
5. Failing to counsel about chronicity: Patients must understand this is long-term management, not a cure 2