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Annals of
Olology.
Rhinology & Laryngology 12O(3):I62-166.
© 2011 Annals Publishing Company. All rights reserved.
Revision Rates After Endoscopie Sinus Surgery:
A Recurrence Analysis
Daniel Mendelsohn, MSc; Goran Jeremic, MD; Erin D. Wright, MD, MEd, FRCSC;
Brian W. Rotenberg, MD, MPH, FRCSC
Objectives: Chronic rhinosinusitis with nasal polyposis is often refractory to medical and surgical management, espe-
cially in patients with asthma and aspirin intolerance. We used a contemporary database to investigate recurrence and
revision surgery rates following endoscopie sinus surgery.
Methods: We performed a cohort study using a survival analysis technique. Records were reviewed of 549 patients with
nasal polyposis who underwent endoscopie sinus surgery over a 10-year period. The main outcome measure was disease-
free and surgery-free survival following endoscopie sinus surgery, investigated with Kaplan-Meier analyses.
Results: Patients with Samter's triad were significantly more likely to have a recurrence and undergo a second surgery
following recurrence (risk-odds ratio, 2.7; 95% confidence interval, 1.5 to 3.2; p < 0.01) than were patients without asth-
ma or with only asthma from the triad. The presence of initial frontal sinus disease also increased the likelihood of revi-
sion surgery (risk-odds ratio, 1.6; 95% confidence interval, 1.2 to 1.8; p < 0.05).
Conclusions: This is the first study to use survival analysis to document revision surgery rates following endoscopie
sinus surgery. Revision surgery occurs at a high rate, especially in patients with asthma, Samter's triad, or frontal sinus
disease. Patients should routinely be informed during clinical consultations about the likelihood of recurrence. Early in-
tervention for frontal sinus disease may be considered.
Key Words: endoscopie sinus surgery, frontal sinus, nasal polyposis, revision surgery.
INTRODUCTION
Chronic rhinosinusitis (CR) with nasal polyposis
(NP) is a condition that affects up to 5% of the gen-
eral population, causing nasal obstruction, anterior
rhinorrhea, mucopurulent postnasal drip, and anos-
mia.'-^ Several factors are known to be associated
with inflammatory nasal polyps, including asthma
and aspirin intolerance.'-^ The clinical presentation
of asthma, aspirin intolerance, and NP is labeled
Samter's triad."^ Nasal polyposis is present in 7% to
17%
of patients with asthma alone'-^-^ and in 36% to
96%
of patients with the full
triad.-"*
Chronic sinusitis
with NP is commonly managed with local and sys-
temic steroid-based treatments, but a large propor-
tion of patients fail to benefit from a purely medi-
cal approach.^-^ Fndoscopic sinus surgery (FSS) is
often undertaken in this group, and generally has a
very high initial success rate for symptomatic im-
provement in quality of life, as well as for clinical
eradication of polyps.^
Unfortunately, a high rate of recidivism follow-
ing surgery makes the long-term management of
this condition challenging for patients and clini-
cians.^-^
Prior studies have suggested that recur-
rence rates are higher in patients with asthma alone
or with Samter's triad,^"'-^ but precise recurrence
rates in these patients across time remain elusive.
Moreover, a related unclear quantity is the propor-
tion of patients with polyps who undergo revision
surgery; how likely, and how soon, are important
matters to address in counseling patients. At pres-
ent, the literature does not supply the clinician with
long-term data regarding the frequency of revision
surgery and risk factors that might increase the like-
lihood
thereof.
The purpose of this study was there-
fore to use a contemporary database to conduct a
recurrence analysis for polyposis revision surgery
following primary FSS for CR with NP.
MATERIALS AND METHODS
We conducted a review of prospectively gathered
patient data from a preexisting departmental data-
base.
Records were available for review from 2,649
From the Department of Otolaryngology-Head and Neck Surgery. University of Western Ontario, London (Mendelsohn, Jeremic,
Rotenberg), and the Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alberta, Edmonton
(Wright). Canada. This project was funded by the Schulich Research Opportunities Program Grant.
Correspondence: Brian W. Rotenberg, MD, MPH, FRCSC, St Joseph's Health Care, 268 Grosvenor St, London, Ontario, N6A 4V2
Canada.
162
Mendelsohn et al. Revision Rates Afler Endoscopie Sinus Surgery 163
patients who had undergone ESS performed by the
study's senior surgeons (B.W.R., E.D.R.) from Janu-
ary 1999 to January 2009 at St Joseph's Health Care
in London, Ontario. The Research Ethics Board at
the University of Western Ontario approved this
study (UWO Ethics No. 15545E).
Inclusion and Exclusion Criteria. Before we col-
lected data, each record was assessed for complete-
ness and suitability for inclusion. To be included in
the study, each case needed to be consistent with the
American Academy of Otolaryngology-established
definition of CR with NP,'** contain documentation
regarding aspirin sensitivity and the presence or ab-
sence of asthma, and document the absence of extra-
neous systemic factors that could cause polyps (eg,
cystic fibrosis). Each record must have been of
a
pa-
tient who underwent initial complete primary ESS
(polypectomy, maxillary antrostomy, ethmoidecto-
my, sphenoidotomy, or frontal sinusotomy) after
failed medical management (including intranasal
and/or oral corticosteroid therapy and aspirin desen-
sitization therapy in select cases). The senior sur-
geons (B.W.R., E.D.R.) used identical surgical tech-
niques.
Data Collection. Once appropriate records were
identified, they were abstracted for time until clini-
cal recurrence of polyposis, time until revision sur-
gery, and variables that could potentially influence
polyp recurrence or the need for revision surgery:
age,
gender, asthma diagnosis, allergy to aspirin,
specific sinuses involved, and the presence of fungal
mucin during clinical examinations or at the time of
surgery, preoperative and postoperative hyposmia or
anosmia, environmental allergies, smoking history,
and certain co-morbidities (cardiovascular disease,
non-asthma respiratory disease, cancer history, and
diabetes mellitus). Time until clinical recurrence
was defined a priori as the first notation in the record
of diagnosis of recurrent NP following surgery, as
determined through endoscopie examination. Time
until initial revision surgery was defined a priori as
the time between the first and second surgeries.
Statistical Analysis. Differences in gender, sinus
involvement (the total number of sinuses and bilat-
eral or unilateral involvement), presence of mucin,
preoperative and postoperative hyposmia or anosmia
rates,
environmental allergies, and the comorbidi-
ties investigated were compared with the Pearson y}
test. Age, total number of ESS procedures, and du-
ration of follow-up were analyzed by use of analy-
ses of variance with significance values determined
via a Bonferroni correction for a final significance
p value of 0.016. Post hoc Tukey tests were used to
determine significant differences between groups.
PATIENT
Median age (y)
Gender
Male
Female
Mean No. of polypectomies
Sinus involvement
Median No. of sinuses
Unilateral
Bilateral
Mucin
Yes
No
Preoperative anosmia
Yes
No
Postoperative anosmia
Yes
No
Mean duration of follow-up (y)
Smoking (%)
*p<0.05.
DATA
Control
54
29
32
1.19
3
54*
241
25
261
145
54
37*
70*
2.01
41
Asthma
56
83*
104*
1.31
3
18
173
14
173
113
24
59*
49*
2.75
38
Samter
's
Triad
55
191*
101*
1.97*
3
4
59
13*
50*
46
4*
28*
19*
5.16*
35
The time periods between the first surgery and re-
currence and between the first and second surger-
ies were analyzed by the Kaplan-Meier method and
compared with the log-rank test. Cox proportional
hazard models for both disease-free interval and in-
terval to second surgery were constructed with the
following predictor variables: patient group, age,
gender, sinus involvement, presence of fungal mu-
cin, preoperative and postoperative self-reported
anosmia, environmental allergies, smoking history,
and medical comorbidities. Statistical significance
was set at a p level of less than 0.05 for all statisti-
cal tests (except analyses of variance, as mentioned
above),
and all tests were 2-tailed.
RESULTS
Of the 2,649 records, 549 met full inclusion cri-
teria and were abstracted for analysis. This includ-
ed 63 patients with Samter's triad, 191 patients with
asthma but no aspirin sensitivity, and 295 patients
with no asthma or aspirin sensitivity; this last group
was defined as "control" for study purposes. The Ta-
ble depicts demographics, risk factors, and disease
severity information for the study population. Data
regarding other tangential past health characteris-
tics,
such as non-asthma respiratory disease, cardio-
vascular disease, and diabetes, were often subject
to incomplete recording that precluded meaningful
analysis. These data were therefore excluded from
the study. Most of the patients did not have formal
164
¡Mendelsohn
et al. Revision Rates After Endoscopie Sinus Surgery
1.0-
0.8-
0.6-
I 0.4
O
0.2-
0.0-
-o Control group
_- Asthma group
.-•-• Samter's triad group
4 6
Years until polyp recurrence10
0,2-
0,0-
B
2 4 6
Years until revision surgery
Kaplan-Meier curves for A) nasal polyp recurrence and B) revision surgery rates in patients with asthma, patients with
Samter's triad, and controls.
allergy testing performed, and hence, without reli-
able data on the presence of true physiological aller-
gies,
we also excluded these data from the analysis.
Recurrence rates were significantly different be-
tween the groups. The Figure, A, illustrates Kaplan-
Meier disease-free survival analysis for postopera-
tive polyp recurrence, and the Figure, B, illustrates
Kaplan-Meier survival analysis for the time period
between the first and second surgeries. Patients with
Samter's triad were the most likely to have a recur-
rence and did so the soonest (p < 0.001). Patients
with asthma were also more likely to have a recur-
rence and to do so sooner than control patients (p
< 0,001), Patients with Samter's triad also under-
went a second surgery sooner and more often than
did the other groups (p < 0.001), Similarly, patients
with asthma underwent a second surgery sooner and
more often than control patients (p < 0.001). The
overall actuarial polyp-free survival rates at 5 years
were 84%, 55%, and 10%, and the overall actuarial
surgery-free rates at 5 years were 90%, 75%, and
63%
for control patients, patients with asthma, and
patients with Samter's triad, respectively. By the 10-
year follow-up period, these numbers had dropped
to polyp-free survival rates of 78% and 45% for
control patients and patients with asthma, respec-
tively, and surgery-free rates of
83%,
58%,
and
11 %
for control patients, patients with asthma, and pa-
tients with Samter's triad, respectively. Note that
10-year follow-up data for polyp-free survival were
not available for patients with Samter's triad, as ev-
ery such patient followed in our study population
had developed clinical disease recurrence by 3 years
after surgery.
A Cox proportional hazards analysis was con-
ducted to determine which factors were predictive
of either polyp recurrence or surgery recurrence. Of
the possible predictive factors, patient group (con-
trol, asthma only, or Samter's triad) was significant-
ly predictive for both outcomes: polyp recurrence
(risk-odds ratio, 3.7; 95% confidence interval [CI],
2.5 to 5.5; p < 0.01) and surgery recurrence (risk-
odds ratio, 2.7; 95% CI, 1,5 to 3,2; p < 0,01), With
respect to sinus involvement, the presence of frontal
sinus disease before the first surgery predicted polyp
recurrence (risk-odds ratio, 1,4; 95% CI, 1,2 to 1.9;
p < 0.01) and surgery recurrence (risk-odds ratio,
1.6; 95% CI, 1.2 to 1.8; p < 0.05). No other covari-
ate was significantly predictive for either polyp or
surgery recurrence, and all 2-way interactions were
nonsignificant.
DISCUSSION
A number of studies have investigated NP recur-
rence rates after ESS, However, the recurrence rates
reported have varied substantially for several rea-
sons,
including the inherent disease heterogeneity
of CR with NP, inconsistent research methods, non-
differentiation of patient grouping (with and with-
out asthma), variable duration of follow-up, differ-
ent postoperative medical managements, variations
in the surgeries performed, and differing definitions
of recurrence (endoscopie, imaging, symptomatic,
etc).
In addition, the majority of recurrence studies
have expressed relapse rates as a point estimate dur-
ing a mean duration of follow-up; these are not rep-
Mendelsohn et al. Revision Rates Afler Endoseopie Sinus Surgery 165
resentative of recurrence rates across time. Kaplan-
Meier survival analysis enables estimation of instan-
taneous recurrence rates across time, A litetature re-
view shows only 2 prior studies of NP that used this
technique;
1
excluded patients with Samter's triad,*^
and the other did not investigate clinical recurrence,
but rather, the total number of ESS procedures that
patients underwent across time,** Our study is there-
fore novel, in that it is the first study to include suf-
ficient numbers of patients with Samter's triad to
compare recurrence rates across time by use of sur-
vival analysis, and more importantly, is the first to
document rates of revision surgery in all ESS patient
groups over a long-term follow-up period.
We found that polyp recurrence rates at 5 years
were 16%. 45%. and 90% for control patients, pa-
tients with asthma, and patients with Samter's tri-
ad, respectively, and that revision surgery rates at 5
years were 10%,
25%,
and 37% for control patients,
patients with asthma, atid patients with Samter's tri-
ad, respectively; these grew higher at the 10-year
time point. Prior studies have reported recurrence
rates in shorter mean follow-up periods (less than
5 years) of between
21%
and 66% for CR with NP,
but most did not subdivide among patient groupings
or did not comment on revision surgery rates, and all
had shorter follow-up than the current study; hence,
their results are difficult to compare to ^'^^'
Among the prognostic factors investigated, only
asthma, Samter's triad, fungal mucin, and initial
frontal sinus disease increased the rate of revision
surgery. Given that fungal infections have been im-
plicated in the pathogenesis of CR with NP,-^ the in-
creased prevalence of fungal mucin in patients with
Samter's triad may partially explain the increased
recurrence rates in patients with Samter's triad.
With respect to frontal sinus disease, frontal sinus
involvement is believed to reflect a more severe dis-
ease phenotype,-^-^^ although the frontal sinus ap-
pearance on computed tomographic scans appears
to be unrelated to symptom severity.^-^ The finding
that frontal sinus disease presence increased the re-
cutTence risk suggests that frontal sinus involvement
is associated with increased disease severity. Surgi-
cal management of frontal sinus disease is contro-
versial, with some surgeons suggesting avoidance
of frontal sinusotomy at primary surgery, and oth-
ers advocating early intervention.^-^ In this practice,
our general approach was to perform frontal sinus-
otomy in patients with symptoms (ie, headache) or
patients with severe disease identified during clini-
cal examination or by radiography. Given that our
data suggest that frontal sinus disease may predict
both disease and surgery recurrence, further inves-
tigation into this controversy is indicated. The role
of early frontal sinus intervention may need better
definition.
Interestingly, the rates of a second surgery lagged
behind recurrence rates in all patient groups. There
are several explanations for this finding. First, after
recurrence, attempts at conservative management
were often made. In addition, once patients expe-
rienced recurrence, they may have decided to delay
a second surgery or not have one at all, perhaps be-
cause surgery was seen as futile if recurrence was
perceived as inevitable. The time required to sched-
ule a surgery might also explain the lag between re-
currence and a second surgery. It is also possible that
although endoseopie recurrence was recorded, some
patients may have experienced minimal symptoms,
lacking the need for revision operations.
This study has several limitations. Most notably,
data were gathered prospectively for clinical pur-
poses rather than for research, and thus, the infor-
mation used in this study reflected the adequacy of
documentation. The classification of patients by di-
agnosis and operative notes was well documented;
however, the presence of fungal mucin, smoking
history, and comorbid diagnoses may have been un-
detTeported or incompletely reported in sotne cas-
es.
The fact that patients with Samter's triad were
followed up signiflcantly longer than patients with
asthma and control patients introduces the possibil-
ity that the increased revision surgery rates in this
group were in part due to prolonged follow-up.
However, given that increased recurrence rates are
well known in patients with Samter's triad, the lon-
ger follow-up was likely attributable to the refracto-
ry nature of their disease. Our time-point definitions
were based on the best possible data retrieved from
the database, but may not precisely correlate with
clinically significant disease. Last, our analysis of
revision surgery may have been influenced by sev-
eral factors unrelated to tecurrence of NP, including
wait-times for surgery and patients' preferences to
delay surgery for personal reasons.
The results of this study, using contemporary data,
demonstrate that management of CR with NP is cur-
rently inadequate. Although postoperative medical
management with nasal steroids can reduce recur-
rence rates, revision surgery inevitably occurs in a
significant proportion of patients. Although some
studies suggest that postoperative oral corticoster-
oids may delay recurrence, the success rates report-
ed for this method are still low."^ Nasal polyposis is
a recalcitrant condition, especially in patients with
asthma and Samter's triad. Patients should be in-
formed of the significant likelihood of revision sur-
166Mendelsohn et al. Revision Rates After Endoscopie Sinus Surgery
gery. In citing a recurrence risk to a patient, rates
should be stratified according to preoperative co-
morbidities, namely, asthma and Samter's triad.
Patients with these specific disorders in particular
should be aware that ESS might provide only tem-
porary relief of their symptoms.
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