What is the recommended treatment for a 38-year-old female with chronic rhino-sinusitis (CRS) and nasal airway obstruction due to a deviated septum, who has failed medical management and has symptoms of ear pain, nasal obstruction, and post-nasal discharge?

Recommended Treatment for Chronic Rhinosinusitis with Nasal Airway Obstruction

This patient meets criteria for combined endoscopic sinus surgery with septoplasty, and should proceed directly to surgery given the documented failure of maximal medical management and presence of anatomical obstruction that cannot be corrected medically. 1

Rationale for Surgical Intervention

Medical Management Has Been Adequately Attempted

• The patient has completed appropriate medical therapy including saline irrigations, intranasal corticosteroids, oral decongestants, and two courses of antibiotics over the past year, with symptoms persisting beyond 12 consecutive weeks 1
• This satisfies the requirement for documented failure of maximal medical management before proceeding to surgery 2, 3
• The presence of severe anatomical obstruction (large left septal spur with contact point to left lower turbinate) limits the effectiveness of topical medications, making further medical therapy futile 1

Surgical Approach Should Be Comprehensive

The surgeon should perform endoscopic sinus surgery that includes full exposure of the sinus cavity and removal of diseased tissue, combined with septoplasty, rather than balloon dilation alone. 1

Specific Surgical Components Indicated:

• Endoscopic sinus surgery (ESS): The patient has chronic rhinosinusitis lasting >3 years with documented sinus disease on CT involving frontal, ethmoid, and sphenoid sinuses, with bilateral edema on endoscopy 1

• Septoplasty: The deviated left septum with septal spur causing contact with the left lower turbinate creates ostiomeatal complex obstruction, which perpetuates sinus disease and prevents adequate medication delivery 2, 4, 5

• Rhinoplasty component: Medically necessary when performed as an integral part of septoplasty for documented gross nasal obstruction on the same side as the septal deviation 2

• Turbinate reduction: The bilateral turbinate hypertrophy (implied by contact with septal spur) should be addressed concurrently, as compensatory turbinate hypertrophy commonly accompanies septal deviation 2

Why Balloon Dilation Alone Is Insufficient

Balloon dilation should NOT be the primary surgical approach for this patient. 1

• The 2025 AAO-HNS guidelines explicitly state that when sinus disease involves edema, osteitis, or severe obstruction, surgery must include full exposure of the sinus cavity and removal of diseased tissue, not just ostial dilation 1
• The patient has documented mucosal edema bilaterally on endoscopy, which requires tissue removal for adequate treatment 1
• Septal deviation with contact point cannot be corrected by balloon dilation and requires septoplasty 2, 5

Evidence Supporting Combined Approach

Septoplasty Improves CRS Outcomes

• Untreated deviated nasal septum is an independent predictor of higher Lund-Mackay scores and ostiomeatal complex obstruction in patients with recurrent CRS 5
• Septoplasty alone can achieve 93.3% subjective success rates in CRS patients with septal deviation, demonstrating its critical role 6
• Deviated nasal septum is the most common anatomical variation in chronic sinusitis patients (53.7% have multiple anatomical variations) 4

Timing of Surgery Matters

• The 2025 guidelines emphasize avoiding unnecessary delays in care for patients with CRS subtypes that have limited response to medical therapy alone 1
• Delaying surgery in patients with anatomical obstruction leads to ongoing patient discomfort, productivity loss, and disease progression 1
• This patient has already suffered >3 years of symptoms with failed medical management 1

Regarding Eustachian Tube Dilation

The bilateral eustachian tube dilation requires peer review per the insurance determination, which is appropriate given the lack of strong evidence for this procedure. 1

• While the patient has significant ear symptoms (pressure, pain, fullness, muffled hearing) documented on the EDQ-7, eustachian tube dilation is not part of standard CRS surgical management guidelines 1
• The ear symptoms may improve with successful treatment of the underlying CRS and restoration of nasal airway patency 7
• Consider addressing the sinus disease and septal deviation first, then reassessing ear symptoms before proceeding with eustachian tube dilation 7

Critical Pitfalls to Avoid

• Do not require additional medical therapy trials: This patient has already completed appropriate medical management per guidelines (>12 weeks of symptoms, failed intranasal steroids, saline irrigations, and antibiotics) 1, 2

• Do not perform inadequate surgery: Balloon dilation alone will fail because it does not address the mucosal disease, edema, or septal obstruction 1

• Do not delay surgery further: The patient meets criteria for early surgical intervention given the anatomical obstruction that prevents medical therapy from being effective 1

Postoperative Management Expectations

The patient must understand that surgery is not curative and requires ongoing medical management. 1

• Continued use of intranasal corticosteroids and saline irrigations postoperatively 7
• Regular follow-up with nasal endoscopy between 3-12 months after surgery to assess outcomes 1
• Potential need for revision surgery (though less likely with comprehensive initial surgery) 1
• Treatment of any underlying allergic components 7