Endoscopic Sinus Surgery for Refractory Chronic Sinusitis

Chronic sinusitis, officially known as chronic rhinosinusitis (CRS), is a common yet under-recognized chronic inflammatory disease of the paranasal sinuses affecting approximately 5% of the Canadian population. Aside from gaining a reputation for its detrimental effects on patient quality-of-life (QoL) and daily productivity, CRS is associated with a lifetime of medical and surgical resource consumption resulting in significant health care expenditure. The estimated direct cost of CRS to the Canadian health care system is $990 million per year, which is comparable to the annual direct costs of asthma. The large economic burden of chronic sinusitis provides a strong incentive to improve both the quality and value of care for this chronic inflammatory disease.

Although the etiology of CRS is considered multi-factorial without one single unifying factor, several studies have investigated the role of a septal deviation as a predisposing factor of CRS. A systematic review and meta-analysis quantified the outcomes and concluded that there was statistical evidence for the association between CRS and septal deviation, especially those with a septal deviation angle > 10-degrees. However, the clinical relevance of septal deviation as an etiologic factor for CRS is still unknown.

Based on several recent evidence-based guidelines, sinonasal 'surgery' can be considered for patients with medically refractory CRS as defined by having persistent symptoms despite a minimum of 3 months with topical sinonasal corticosteroid therapy along with a minimum of a 7-day course of systemic corticosteroid +/- 2-week course of broad-spectrum antibiotic. The important question remains, what is the most appropriate surgical intervention for patients with refractory CRS? Currently there are two surgical options for CRS and both procedures have non-randomized evidence to support their beneficial effects in this patient population: (1) Septoplasty alone (ie. only correcting the deviated septum and not dissecting into the paranasal sinuses), and (2) Endoscopic sinus surgery (ESS) along with a septoplasty (ie. correcting the septal deviation and opening up the paranasal sinuses). With an estimated direct health care cost exceeding $100 million spent on sinonasal surgery in Canada for management of CRS, optimizing the allocation of scarce surgical resources toward interventions with the most proven benefit would result in significant improvements in both the quality and value of care to patients.

In 2005, a prospective non-randomized study compared septoplasty alone to septoplasty plus ESS. They demonstrated that septoplasty alone had a 93% subjective success rate for patients with CRS which was no different than the 88% success rate of ESS plus septoplasty. Although this study has provided some insight into this topic, it was limited by the lack of randomization, lack of stringent inclusion criteria for refractory CRS, and lack of using a validated patient-reported outcome measure. Since 2004, there have been several prospective observational cohort studies evaluating the role of ESS in patients with refractory CRS. Overall the outcomes from these studies suggest that ESS provides improved patient-reported outcomes and objective outcomes. However, despite excellent observational evidence supporting both septoplasty and ESS, there has never been a robust randomized controlled trial (RCT) to prove additional benefit of ESS compared to septoplasty alone for patients with CRS.

In real world practice, ESS is commonly performed in combination with septoplasty despite the lack of a RCT. The lack of level-1 evidence continues to raise questions regarding the true effectiveness and appropriateness of ESS for patients with CRS as opposed to just performing a septoplasty alone. This current gap in the literature provides a strong incentive to evaluate the role of ESS using a RCT design and is the impetus behind this research project.