What is the treatment algorithm to evaluate a patient for surgical intervention for chronic rhinosinusitis?

From the Guidelines

The treatment algorithm for evaluating a patient for chronic rhinosinusitis surgery begins with confirming the diagnosis through symptoms lasting at least 12 weeks, nasal endoscopy, and CT imaging, and surgery is considered when patients have failed maximal medical therapy for at least 6-12 weeks with persistent symptoms and objective evidence of sinus disease on imaging, as recommended by the most recent guidelines 1. The initial management should focus on medical therapy, including intranasal corticosteroids (such as fluticasone 50mcg 1-2 sprays per nostril daily or mometasone 50mcg 2 sprays daily), saline irrigation (240mL through each nostril twice daily), and a 2-3 week course of antibiotics if purulent discharge is present (amoxicillin-clavulanate 875/125mg twice daily or doxycycline 100mg twice daily) 1. For patients with nasal polyps, consider adding a short course of oral corticosteroids (prednisone 30mg daily for 5-7 days). Before proceeding to surgery, patients should undergo a comprehensive evaluation including:

• Allergy testing
• Immunologic workup if recurrent infections are present
• Assessment for contributing factors like asthma or GERD
• Evaluation of the likely pathologic factors involved in the disease process and the chances of improvement with surgical intervention, as recommended by 1 Functional endoscopic sinus surgery (FESS) is the standard surgical approach, with the extent determined by the disease distribution, as supported by 1. Surgery aims to improve sinus drainage and ventilation by removing diseased tissue and opening natural sinus ostia, which addresses the underlying pathophysiology of impaired mucociliary clearance and chronic inflammation. The decision to proceed with surgery should be based on a thorough evaluation of the patient's condition, including the presence of persistent symptoms, objective evidence of sinus disease on imaging, and failure of maximal medical therapy, as emphasized by the most recent guidelines 1.

From the Research

Treatment Algorithm for Chronic Rhinosinusitis

The treatment algorithm for evaluating a patient for surgical intervention for chronic rhinosinusitis involves several steps:

• Medical treatment is the first line of treatment, which includes antibiotics, decongestants, mucolytics, steroids, and analgesics 2
• If medical treatment fails, surgical treatment may be considered, which can be conservative, functional, or radical 2
• Functional endoscopic sinus surgery (FESS) is currently the "Golden Standard" for surgical treatment of chronic sinusitis, focusing on the middle ostiomeatal complex and the ethmoid cells 2
• The extent of the operation is adapted to each individual case, and precise pre-operative evaluation, good patient preparation, and meticulous surgical technique are crucial to minimize the risk of complications 2

Evaluation and Diagnosis

• Computed tomographic (CT) imaging and rigid endoscopes are used in diagnostic evaluation to identify obstruction of mucociliary drainage in the anterior ethmoid sinus-middle meatus region (ostiomeatal complex) 3
• Nasal endoscopy and CT scanning are used to evaluate chronic sinusitis and identify the cause of symptoms 3
• The Sino-Nasal Outcome Test-20 (SNOT-20) questionnaire and rigid nasal endoscopy scoring system are used to evaluate outcomes and symptom improvement after treatment 4

Surgical Treatment Options

• FESS is a widely accepted treatment modality for chronic rhinosinusitis in adults who have failed maximal medical management 4
• Endoscopic sinus surgery is emerging as the treatment of choice for medically unresponsive chronic sinus disease 3
• Balloon dilation is a newer treatment option that has shown promising results in reducing symptoms and improving quality of life for patients with chronic rhinosinusitis 5
• A prospective, multi-institutional study found that patients who underwent endoscopic sinus surgery (ESS) reported significantly more improvement in quality of life and reduction in symptoms compared to those who continued medical management 6

Patient Selection and Outcomes

• Patients who have failed medical management and have significant symptoms and quality of life impairment may be considered for surgical treatment 6
• Outcomes after surgical treatment are generally good, with significant improvement in symptoms and quality of life reported in several studies 4, 6, 5
• The choice of surgical treatment option depends on individual patient factors, including the extent of disease, symptom severity, and medical history 2, 5