Surgical management of chronic rhinosinusitis and nasal polyposis: A review of the evidence

Department of Otorhinolaryngology-Head and Neck Surgery, Division of Rhinology, University of Pennsylvania, 3400 Spruce Street, 5 Ravdin, Philadelphia, PA, 19104, USA.
Current Allergy and Asthma Reports (Impact Factor: 2.77). 12/2004; 4(6):486-9. DOI: 10.1007/s11882-004-0016-2
Source: PubMed


Functional endoscopic sinus surgery is a common adjunct to medical therapy in the management of chronic rhinosinusitis and nasal polyposis. As with most surgical procedures, there is a paucity of randomized, controlled clinical trials examining the use of functional endoscopic sinus surgery in the management of chronic rhinosinusitis and nasal polyposis. This is primarily a result of the physical and ethical conundrums faced in performing a study that involves comparing a surgical procedure with a placebo. However, there is documentation of the marked impact that chronic rhinosinusitis can have on the overall quality of life and evidence that this improves following combined surgical and medical intervention. There are many case series with large patient populations that have shown significant improvement in short- and long-term patient symptoms following surgery. These outcomes are expected to improve with even greater refinement of technology, experience, and instrumentation, and the quality of future studies may be improved by determining and using objective measures of success and, possibly, by the use of control groups.

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    • "Postoperatively the majority of the patients experience significant reduction of headache, nasal obstruction, post nasal drip and are improved in Quality of Life scores (Damm et al 2002; Chiu et al 2004; Iro et al 2004). In patients with asthma, FESS improves peak expiratory flow and reduces the use of inhaled and systemic glucocorticosteroids (Dhong et al 2001; Palmer et al 2001; Dunlop et al 1999; Goldstein et al 1999; Ikeda et al 1999; Senior et al 1999). "
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    ABSTRACT: Functional endoscopic sinus surgery (FESS) is a recent addition to the treatment armamentarium of sinus disease. Performed through the nasal cavity using endoscopes and inciting no external scars, these advantages have renewed an interest in the surgical intervention of various sinus diseases. With minimal risk and complications associated with FESS, the temptation exists to lower the threshold and expand the indications for sinus surgery. However, regardless of the reduced risk, FESS should be pursued only when the goals are attainable and the limitations of surgery are understood for each specific disease. Chronic rhinosinusitis (CRS), affecting more than 31 million people a year, represents a treatment challenge. The challenge stems from evidence that CRS can result from different etiologies including bacteria, virus, fungi, superantigens, and unfavorable anatomy. With an unclear pathogenesis, success of medical therapy is often limited. Individuals failing medical therapy are candidates for surgical intervention. The controversy, indications, and goals of surgery in CRS are reviewed. Other indications for FESS are less controversial. Nasal polyps, which can interfere with medical therapy and obstruct airflow, often require surgical intervention. In addition, recent data has suggested a link between surgery and a reduction in inflammatory markers. Repair of skull base defects, and resection of benign and limited malignant nasal masses are also indications for FESS. This article reviews the indications of sinus surgery. In addition, it addresses some of the controversies, limitations, and advances in FESS.
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    ABSTRACT: Sinonasal polyps are treated with topical steroids, systemic oral steroids, surgical excision, and intrapolyp steroid injection. Use of steroid injection is not widespread because of reported complications. The objective of this study was to evaluate the complications of intrapolyp steroid injections and compare it to the complications of surgical removal of polyps. All patients seen between 1994 and 2003 with a diagnosis of nasal polyps were reviewed retrospectively. Demographics, complications, follow-up, and comorbidities were collected. Frequency of each treatment modality used and complications of each treatment were compared. Three hundred fifty-eight patients were in the study with a mean follow-up of 30 months. Respiratory comorbidities were asthma alone (35%), aspirin triad (16%), and cystic fibrosis (15%). Other comorbidities were smokers (21%). Treatment modalities were medical treatment alone (14%); medical treatment and steroid injections (19%); medical treatment and surgery (33%); and medical treatment, injections, and surgery (34%). Patients who underwent injection had fewer surgeries (p < 0.001). There was 1 minor complication associated with 1495 injections and 11 major and 16 minor complications associated with the 310 surgeries. The differences in complication rates were statistically significant (p < 0.001). There was no significant difference in demographics, follow-up, or comorbidities between patients who received injections and patients who underwent surgery. Intrapolyp steroid injection is associated with a significantly lower rate of complication than is surgical excision of sinonasal polyps. Steroid injection also may decrease the need for further surgical intervention of polyps.
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