xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.22741 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

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Orlandi et al.

XII.A.2 Surgical Venue: Office vs Operating Room With development of new surgical technologies and heightened awareness toward delivering cost-effective healthcare, office-based sinonasal procedures have become a common part of the rhinology practice. 1787 One example is the rise of balloon catheter dilation (BCD); an analysis of Medicare reimbursements found that in the 6 years after the introduction of CPT codes specific to BCD (in 2011), the frequency of BCD (both in-office and oper ating room) increased from 7496 to 43,936 procedures per year. 1788 Office-based procedures offer several potential patient benefits, including avoidance of general anesthe sia, reduced recovery time, and lower costs compared to procedures in the operating room. 1789 Patient selection is crucial in achieving successful out comes in office-based procedures. Patients with anxiety or difficulty tolerating nasal endoscopy are unlikely to com fortably undergo office-based procedures. 1790 Patients on anticoagulation or antiplatelet therapy may also be poor candidates, as aspirin 325 mg and warfarin have been asso ciated with worse procedural bleeding during BCD. 1791 However, in properly selected patients, office-based pro cedures can be performed safely with relatively few com plications. The largest study to date of 315 patients under going office procedures (166 turbinoplasty, 118 ESS, 35 septoplasty, 34 rhinoplasty, 4 septorhinoplasty) reported a 2.5% complication rate overall (5.9% among ESS), with the most common complications being pain, vasovagal response, and epistaxis. 1792 While office procedures can also be offered to patients whose comorbidities make them poor candidates for general anesthesia, clinicians should be aware that patients may still experience wide, asymp tomatic fluctuations in blood pressure and pulse during office procedures. 1793 For CRSsNP, in-office BCD can be used to dilate the paranasal sinuses. 1794–1802 A randomized multicenter trial demonstrated equivalent improvement in SNOT-20 scores and comparable revision rates at 2 years when comparing in-office BCD to ESS under general anesthesia. 1802 Impor tantly, studies on BCD have been limited to cohorts with milder disease based on radiographic scores. 1803 While tra ditional ESS can be performed in the office under local anesthesia with a low complication rate, 1792 there remains a lack of robust sinonasal outcomes data for these proce dures. For CRSwNP, microdebrider-assisted polypectomy can be utilized in patients with recurrent polyposis after ESS. 1804,1805 Steroid-eluting stent placement in the ethmoid cavity is another effective in-office treatment option for recurrent polyposis after ESS. 1606,1608,1806 In-office primary

ESS and BCD have not been validated in patients with CRSwNP. Adjunctive procedures can also be offered in the office setting to patients undergoing treatment for either CRSsNP and CRSwNP. Office-based image-guided naviga tion is available, offering similar user interfaces to units designed for the operating room. 1807 Inferior turbinoplasty can successfully performed in patients with concomitant nasal obstruction from turbinate hypertrophy, 1808,1809 and cryotherapy can improve rhinorrhea and congestion in selected patients. 1810,1811 When selecting the best setting for sinonasal proce dures, clinicians should consider patient goals, comorbidi ties, and disease severity, as well as provider expertise and equipment availability. While the data suggest that office based sinus procedures can be performed safely, there remain significant gaps in evidence. Robust long-term out comes data is necessary, especially for emerging in-office technologies. Improving the levels of evidence for office based procedures can facilitate matching patients to the best approach based on disease severity or appropriateness criteria. The common goals of both primary and revision ESS for CRS are to relieve subjective symptoms and improve QoL, reduce objective disease burden, and prevent complica tions of untreated disease, all while minimizing surgical risks. 1782 However, these 2 scenarios present distinct chal lenges, and proper patient management requires a thor ough understanding of their respective unique clinical goals to inform the clinician’s decision-making approach. Primary ESS potentially offers the greatest opportu nity for long-term success. 1812,1813 While some studies have demonstrated comparable improvements in both primary and revision ESS groups, 1814 others have shown that out comes are significantly better after primary surgery. 1815,1816 This highlights the potential risk for iatrogenic damage to healthy sinus mucosa, which must be avoided through meticulous mucosal preservation. One study comparing directed ESS to full ESS found similar outcomes on both endoscopy and symptom assessments, supporting a more conservative approach to avoid collateral damage to pre viously uninvolved sinuses while fully dissecting involved sinuses. 1817 However, in cases of more extensive polyposis, more extensive surgery may be required up front. Stud ies that examined CRSwNP patients in both the primary and revision setting found that those who underwent com plete ESS had better sinus-specific outcomes compared XII.A.3 Primary vs Revision Surgery: How Do Decision-Making Approach and Goals Differ?