Analysis of factors associated with electing endoscopic sinus surgery

Abstract

Objective: Medically refractory chronic rhinosinusitis (CRS) can be managed with appropriate continued medical therapy (CMT) or surgery followed by CMT. Patients who initially elect CMT and do not experience adequate symptom resolution may "cross over" to endoscopic sinus surgery (ESS). Our objective was to identify patient covariates associated with this subset of patients who elect this change in treatment modality.

Study design: Retrospective analysis of a prospective, multi-center cohort of adult patients with CRS enrolled between March 2011 and June 2015 in academic, tertiary referral clinics.

Methods: Subjects who initially elected CMT were followed up to 18 months, provided a comprehensive medical history, and completed the 22-item SinoNasal Outcome Test (SNOT-22) at baseline and during 6-month follow-up intervals. Hazard regression modeling was used to identify covariates associated with elective change in treatment modality.

Results: One hundred seventy-nine subjects were followed for an average 15.1 (standard deviation ± 4.6) months. Subjects who elected ESS (55 of 179) had significantly worse average endoscopy scores and reported worse SNOT-22 sleep dysfunction scores at baseline (P ≤ 0.026). For each single increasing (worsening) point of Lund-Kennedy endoscopy score, the hazard ratio (HR) of crossover increased by ∼6%. Similarly, for every point of worsening in baseline SNOT-22 total score, the hazard of treatment crossover increased by ∼2%. After covariate adjustment, only baseline SNOT-22 sleep dysfunction scores were associated with an increased risk of treatment crossover (HR = 1.07; 95% confidence interval: 1.02-1.11; P = 0.003).

Conclusion: Baseline total SNOT-22 and endoscopy scores are associated with treatment crossover, but reported sleep dysfunction is the only significant independent predictor of treatment crossover.

Level of evidence: 2c. Laryngoscope, 128:304-310, 2018.

Trial registration: ClinicalTrials.gov NCT01332136 NCT02720653.

Keywords: Sinusitis; chronic disease; endoscopy; outcome assessment (health care); therapeutics.

Figure 1

Flow diagram for final cohort. ESS, endoscopic sinus surgery.

Figure 2

Kaplan-Meier estimates for treatment modality cross-over from continued medical therapy to endoscopic sinus surgery (ESS) for entire cohort with follow-up (n=149).