Endoscopic Sinus Surgery for Chronic Rhinosinusitis Has Long-term Benefit on Quality of Life

Endoscopic sinus surgery (ESS) for managing chronic rhinosinusitis is often offered to patients who haven't improved on appropriate medical therapy. Several studies have shown ESS favorably affects the short-term postoperative quality of life (QoL).

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George Scangas, MD, and Ralph Metson, MD, sinus surgeons in the Department of Otolaryngology–Head and Neck Surgery at Mass Eye and Ear, and colleagues have now reported sustained improvement in QoL five years after ESS.

Methods

An ongoing prospective study at Mass Eye and Ear studies clinical outcomes of patients with chronic rhinosinusitis. For this analysis, the researchers enrolled 925 adults who underwent primary or revision ESS by 11 different surgeons between February 2011 and January 2021. 338 of them had at least five years of follow-up.

Patients completed the 22-item Sinonasal Outcome Test (SNOT-22) preoperatively, three months postoperatively, and then yearly starting one year postoperatively.

Change in QoL Over Time

The average SNOT-22 score was:

• Preoperatively—48.5
• 3 months postoperatively—22.2
• 1 year—23.6
• 5 years—25.8

The average score five years postoperatively was significantly better than the preoperative score (P<0.001). This significant improvement was seen at all yearly time points when compared to pre-operative scores.

Influences on Scores

Four factors influenced the SNOT-22 scores that were reported five years after ESS. Patients with greater preoperative disease burden seemed to respond best to surgery:

• Presence of nasal polyps on preoperative endoscopy—6-point better score in patients with polyps than in those without (P=0.002)
• History of environmental allergies—No significant difference between patients with and without allergies, but patients with allergies had an average score of 4.6 points lower than expected after accounting for preoperative score
• Preoperative Lund–Mackay CT score—Each 1-point increase was associated with a 0.68-point decrease in the SNOT-22 score
• History of diabetes—12-point worse score in patients with diabetes than in those without (P=0.011); this finding was unexpected and is thought to be a reflection of increased incidence of postoperative infections in diabetic patients

Minimal Clinically Important Difference

One year after surgery, 77% of patients met the criterion for a minimal clinically important change in SNOT-22 score, an improvement of ≥8.9 points. None of the factors analyzed significantly affected the likelihood of achieving that threshold five years postoperatively.

Revision Surgery

Patients who underwent revision ESS had higher SNOT-22 scores on the three- and four-year surveys. In line with that finding, the average timing of revision surgery was 42 months after enrollment. Interestingly, there was no significant difference in the average SNOT-22 score at five years between those who did and did not undergo revision.

Counseling Patients

When engaging in shared decision-making regarding treatment options for chronic rhinosinusitis, surgeons and patients need to consider that long-term clinical outcomes may be affected positively by the presence of nasal polyps, allergies, or higher preoperative CT score but negatively by comorbid diabetes.

Patients can be advised that rhinosinusitis symptoms can sometimes worsen many years after initial surgical treatment and that ongoing medical treatment is paramount for the control of this chronic disease. For many patients, revision sinus surgery can restore the gains in quality of life that initial surgery provided.

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Learn more about the Department of Otolaryngology–Head and Neck Surgery at Mass Eye and Ear

Refer a patient to Mass Eye and Ear/Mass General Brigham