Indications for Sinus Surgery
Sinus surgery should be offered to adults with chronic rhinosinusitis when anticipated benefits exceed nonsurgical management alone, particularly in patients with nasal polyps, polyps with bony erosion, eosinophilic mucin, or fungal balls, after appropriate medical therapy has been attempted but without requiring a rigid, predefined duration of treatment. 1
Primary Surgical Indications
Disease-Specific Indications (Strongest Evidence)
The most recent 2025 American Academy of Otolaryngology-Head and Neck Surgery guidelines identify specific CRS subtypes that benefit most from surgery and are least likely to benefit from continued medical therapy alone 1:
- Chronic rhinosinusitis with nasal polyps 1
- Polyps with bony erosion 1
- Eosinophilic mucin 1
- Fungal balls 1
Anatomic and Infectious Indications
Surgery is indicated when 1:
- Nasal polyps obstruct sinus drainage and persist despite appropriate medical treatment 1
- Recurrent or persistent infectious sinusitis despite adequate trials of medical management (multiple courses of antibiotics covering anticipated pathogens) 1
- Anatomic defects obstruct the sinus outflow tract, particularly the ostiomeatal complex (and adenoidal tissues in children), contributing to recurrent or chronic infectious sinusitis 1
Emergency/Urgent Indications
Sinusitis with threatened complications requires immediate surgical intervention 1:
Medical Therapy Requirements Before Surgery
Critical Guideline Update (2025)
The surgeon should NOT endorse or require a predefined, one-size-fits-all regimen or duration of medical therapy as a prerequisite to sinus surgery. 1 This represents a significant departure from older approaches and recognizes that rigid adherence to arbitrary treatment timelines can be harmful in select patients with severe disease 2.
Appropriate Medical Therapy Components
While no fixed duration is mandated, appropriate medical therapy should include 3, 2:
Important caveat: The surgeon should NOT prescribe antibacterial therapy to adults with chronic rhinosinusitis if significant or persistent purulent nasal discharge (anterior, posterior, or both) is absent on examination 1.
When to Avoid Delaying Surgery
Identifying patients whose CRS is best treated by proceeding to surgery avoids unnecessary delays in care and disease progression 2. Patients with severe nasal polyposis causing obstruction benefit from expedited surgery to remove sinus drainage obstruction and permit topical medical therapies to be effective 2.
Diagnostic Requirements
Imaging for Surgical Planning
For adults who are candidates for sinus surgery, obtain a CT scan with fine-cut protocol (if not already available) to examine the paranasal sinuses for surgical planning 1.
Critical pitfall to avoid: The surgeon should NOT plan the extent of sinus surgery solely based on arbitrary criteria regarding minimal levels of mucosal thickening, sinus opacification, or outflow obstruction on CT scan 1. The decision must integrate symptoms, disease characteristics, quality of life, and prior therapy 1.
Diagnostic Confirmation
Confirm the diagnosis of chronic rhinosinusitis ensuring established diagnostic criteria (signs and symptoms) from clinical practice guidelines are met 1. CT imaging is the gold standard for diagnostic imaging and can be used for both diagnosis and surgical planning 4.
Pediatric-Specific Considerations
Indications in Children
- Adenoidal tissues obstructing the ostiomeatal complex contributing to recurrent or chronic infectious sinusitis 1
- Acute recurrent or chronic maxillary sinusitis (often combined with bronchial or allergic problems): nasoantral window from the inferior meatus to guarantee adequate drainage 5
- Acute ethmoiditis complications in children: simple displacement of middle turbinate and uncapping of ethmoidal cells assisted by antibiotic and antiphlogistic treatment 5
Special Pediatric Evaluations
Children with chronic sinus disease refractory to medical therapy should be evaluated for GERD and treated before sinus surgery is considered 1. Consider CF evaluation in children with nasal polyps, colonization with Pseudomonas species, or chronic sinusitis at early age 1.
Referral Indications
Refer to a specialist when 1:
- Condition interferes with performance or causes significant loss of school/work on chronic or recurrent basis, or quality of life is significantly affected 1
- Complications of sinusitis present: otitis, asthma, bronchiectasis, nasal polyps, or bronchitis 1
- Condition becomes chronic, persists for several months, or recurs 2-3 times per year despite treatment by primary care physician 1
- Need for biopsy to rule out granulomatous disease, neoplasms, ciliary dyskinesia, or fungal infections 1
- Maxillary antral puncture required 1
Extent of Surgery
When the sinus involves polyps, osteitis, bony erosion, or fungal disease, perform sinus surgery that includes full exposure of the sinus cavity and removal of diseased tissue, NOT just balloon or manual ostial dilation 1, 2. If unable to perform this extent of surgery, refer to a surgeon who can 1.
Preoperative Counseling Requirements
The surgeon should counsel patients before sinus surgery to establish realistic expectations 1:
- Potential for chronicity or relapse 1
- Likelihood of long-term medical management post-operatively, taking into account their CRS subtype 1
- Anticipated postoperative care: pain control, debridement, medical management, activity restrictions, return to work, duration and frequency of follow-up visits, and potential for recurrent disease or revision surgery 1
Postoperative Management
Routinely follow up between 3-12 months after the procedure to assess and document outcomes through history (symptom relief, quality of life, complications, adherence to therapy, need for rescue medications, ongoing care) and nasal endoscopy 1.
Continued medical management post-operatively with intranasal corticosteroids is essential to prevent recurrence 2. Patients should continue twice-daily intranasal corticosteroids indefinitely after surgery 2.
Special Considerations
Associated Conditions to Address
- GERD: In patients with sinusitis refractory to medical therapy, treatment of associated GERD should be considered before surgical intervention 1
- Immunodeficiency: Should be considered in cases of sinusitis resistant to usual medical therapy 1
- Aspirin-exacerbated respiratory disease (AERD): Evaluation should be considered, as patients may benefit from aspirin desensitization post-operatively if present, which can reduce recurrence rates 2
Expected Outcomes
Major complications occur in less than 1% of cases 2. With continued post-operative medical therapy, 60-70% of patients maintain polyp control at 18 months 2. Revision surgery is required in approximately 10% within 3 years 2.