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International consensus statement on rhinosinusitis

refractory, untreated, or misdiagnosed CRS. 31 The most common complication of CRS involves orbital infections. In 2 large retrospective reviews of orbital complications, 43% to 58% of cases were associated with CRS, 464,1763 mostly seen in patients with CRSsNP [66% (19/30)] or those who underwent sinus surgery (61% [18/30]). 464 Interestingly, the most severe orbital complications (pre-septal vs post septal) occurred in CRS patients with a history of prior sinus surgery. 464,1763 Mucoceles are relatively rare and grow slowly unless AECRS produces a mucopyocele. They occur most often in the frontoethmoidal region and the symptoms presented in AECRS are those related to an orbital complication of ARS. 31,1764–1769 The most common osseous complication in adults is osteomyelitis of the frontal sinus. It may present as a Pott’s puffy tumor or frontal sinus cutaneous fistula. Eyelid and/or periorbital edema is the most common finding in patients with orbital involvement, and preseptal cellulitis is by far the most prevalent orbital complication in Pott’s puffy tumor. 468 Intracranial complications of AECRS are rare but potentially severe. Bayonne et al. did not find any cases with CRS among 25 patients identified in a retrospec tive study of 13 years. 1770 Goals of Sinus Surgery In recent years, CRS has been increasingly recognized as a diffuse inflammatory disorder with a spectrum of endotypes rather than an obstructive or infectious disease. 61 As a result, treatment regimens have evolved to focus on decreasing mucosal inflammation and not merely improving sinus patency or ventilation. Hence, ESS has become the standard for surgical treatment of CRSsNP and CRSwNP in patients who meet the appropri ate indications. 283 In CRS, the primary surgical aims are: (1) relief of symptoms with improvement in QoL; (2) reduc tion in the amount of mucosal disease as well as enlarge ment of sinus drainage pathways for topical drug deliv ery; (3) avoidance of surgical complications; (4) preven tion of complications related to untreated sinus disease. 1771 While the magnitude of the change in QoL before and after surgery is an important surgical outcome for ESS, 1772 patients are also more likely to undergo ESS if they report more severe symptoms. 1773 Therefore, the decision to rec ommend surgery for CRS should always take into consid eration the severity of associated symptoms. In performing ESS, a stepwise systematic approach should be employed to avoid possible surgical complica XII Surgery for Chronic Rhinosinusitis XII.A General Concepts XII.A.1

tions such as injury to the orbit or skull base. 1774 The goal of opening the natural drainage pathway via the surgi cal removal of diseased mucosa and bony partitions dur ing ESS has been advocated for decades. 1775 By restoring an aerated sinus, previously dysfunctional sinuses may be returned back to a normal state. 1776,1777 Importantly, while enlarging the drainage pathways of the sinuses, attention should be paid to meticulous surgical technique. 1778 A well-performed ESS is not immune to revision; however, there are a number of factors that have been shown to be associated with revision sinus surgery that are poten tially preventable. These factors include the extent of ostial enlargement and sinonasal tissue removal continue to be a matter of significant debate. While some studies have demonstrated a lack of strong evidence for the superi ority of ESS over simple polypectomy, others have sug gested polyp recurrence rates are lower with a more com plete sinus surgery. 1779,1780 In a recent multi-institutional study, a more complete sinus surgery was an indepen dent predictor of greater postoperative improvement in a patient’s SNOT-22 score. 1781 A 2014 Cochrane systematic review 14 concluded that ESS did not appear to be supe rior to medical treatment; however, postoperative medical regimens were not standardized, steroid irrigations were not utilized, and surgeries ranged from simple polypec tomy to full ESS. Therefore, it is difficult to draw conclu sions from this Cochrane review given the heterogeneity of the included studies. Several other studies suggest that the goals of ESS for CRS are broader than simply removing areas of obstruction, 1777,1778,1782 and establishing postoper ative access for topical therapies, which directly deliver medication to the disease site, has increasingly become a goal of surgery. 1089 Unoperated sinuses or those with ostial obstruction cannot be reliably penetrated by nasal irrigation com pared to those in patients who have undergone ESS. 1134 Several cadaveric and computational model studies have also demonstrated that ESS enhances the delivery of topical irrigations to all paranasal sinuses, particularly the frontal and sphenoid sinuses. 1076,1783 Studies comparing the effects of topical therapy with or without ESS have reported greater symptom improvement, decreased polyp recurrence, and decreased polyp size in patients with ESS. 1533,1784 Therefore, the treatment paradigm for CRS has evolved to performing a wide and complete ESS for adequate delivery of topical therapy in patients that meet surgical criteria. 1089,1778,1785,1786 In evaluating CRS patients for ESS, surgeons should carefully consider the potential improvement in QoL and the surgical approach to establishing patent drainage path ways for the delivery of topical medications while safely avoiding complications.