Medical Therapy vs. Surgery for CRS

How does surgery perform prospectively when compared to medical therapy for chronic rhinosinusitis (CRS)?

Background: Since the introduction of endoscopic diagnosis and surgery for CRS in 1985, very few prospective studies have addressed the question of when patients should be treated with medical therapy alone and when they should have endoscopic sinus surgery (ESS).

Study design: Level 2 prospective multi-institutional study.

Setting: Academic, multi-center study.

Synopsis: A total of 180 patients were included in the study, 55 in the medical treatment arm and 75 in the surgical treatment arm. All patients were measured preoperatively and postoperatively according to two quality of life (QOL) instruments, the Rhinosinusitis Disability Index (RSDI) and the Chronic Sinusitis Survey (CSS). Prior to enrollment, all patients failed three weeks antibiotics and three weeks topical steroids. The patients in the medical treatment group received a second course of medical treatment plus oral steroids.

Patients in the medical management group reported significantly better baseline QOL scores only on one instrument relative to surgery patients (CSS symptom score p = 0.019 and total scores p = 0.010). Surgical patients reported significantly more improvement than medically managed patients (RSDI p = 0.015 and CSS p < 0.001). Surgical patients reported fewer oral antibiotics, oral steroids and missed days of work/school after ESS. When both groups were closely scrutinized after adjustment for enrollment site, age, asthma, previous sinus surgery and baseline QOL, surgical patients had greater odds of improvement on RSDI physical subscales and CSS symptoms subscales, medication use and total scores.

Bottom line: Patients who elected to undergo ESS experienced significantly higher levels of improvement in several outcomes. More severe disease was measured in the preoperative surgical patients, while the medically treated patients reported significantly better QOL for sinus headache, frontal pain and pressure, nasal drainage, congestion and difficulty breathing. It is significant to note that surgical patients did very well in all but two categories compared to the medical therapy group, whose therapy included oral prednisone. This paper stands alone in the American chronic rhinosinusitis literature looking at medical therapy versus ESS. It directly counters a study published in 2004 (Laryngoscope. 114(5):923-930) that showed no difference in QOL and symptoms outcomes between medically and surgically treated patients with chronic sinusitis. This study is important not only to the practitioner, but also to third party payers who are seeking evidence-based information in judging approval for reimbursement.

Citation: Smith TL, Kern RC, Palmer JN, et al. Medical therapy vs. surgery for chronic rhinosinusitis: a prospective multi-institutional study. Int Forum Allergy Rhinol. 2011;1(4):235-241.

—Reviewed by James A. Stankiewicz, MD