LANDMARK: Quality of life measures when looking at medical management versus surgery for chronic rhinosinusitis

Article: Medical therapy vs surgery for chronic rhinosinusitis: a prospective, multi‐institutional study with 1‐year follow‐up

Smith TL, Kern R, Palmer JN, et al. Medical therapy vs surgery for chronic rhinosinusitis: a prospective, multi‐institutional study with 1‐year follow‐up. Int Forum Allergy Rhinol. 2013;3:4–9.

Take Home Points:

  • At 1-year follow‐up, patients electing endoscopic sinus surgery (ESS) experienced significantly higher levels of improvement in Quality of Life (QOL) outcomes compared to patients managed by medication alone.
  • The crossover cohort demonstrated initial stagnation or worsening in QOL on medical therapy followed by significant improvement in QOL after ESS.

The Details:

  • Adults with chronic rhinosinusitis who had previously failed medical management were prospectively enrolled from four tertiary-care hospitals and enrolled in the study and followed-up after 1 year.
  • Failed medical management was defined as a minimum of a course of antibiotics and 3-weeks of topical steroid spray.
  • Patients were divided into three groups: medical management, surgical management, and crossover from medical to surgical management.
  • Study variables included age, gender, race/ethnicity, history of previous sinus surgery, sinonasal polyposis, and septal deviation. Additional study information included a patient history of asthma, aspirin intolerance, allergy, depression, oral steroid dependency, and tobacco use.
  • Primary outcome was QOL determined using the Rhinosinusitis Disability Index (RSDI); which includes physical, functional and emotional subscales; and Chronic Sinusitis Survey (CSS) which includes symptom and medication subscales.
  • 115 patients completed follow-up surveys: 50 medical patients, 17 (34%) of which crossed over after electing for ESS leaving 33 patients on medical management alone, compared with 65 surgical patients.
  • All groups improved.
  • Statistically significant differences between medical and surgical groups were found in RSDI functional subscale, and RSDI total scores, CSS symptom subscale, medication subscale and CSS total scores.
  • After adjustment for enrollment site, age, and previous ESS, patients electing ESS had greater odds of clinically meaningful improvement on the RSDI physical subscale, CSS symptom subscale, and CSS total scores compared to medically treated patients.
  • Limitations include lack of generalizability given tertiary care setting, significant number of patients crossing over, failed medical management definition only including 3 weeks of treatment.

Summary contributed by Andrew Goates, MD