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XII.B: Indications for Sinus Surgery XII.B.1 Appropriate Medical Management Statements regarding indications for sinus surgery invari ably cite “failure of maximal medical therapy” (MMT) as a requirement before proceeding. Surgery without a prior trial of medical treatment is, and should be, uncom mon. While there is great consistency between guidelines regarding the need for such a trial, there remains signif icantly less consensus on what MMT entails. Additional factors to consider include definitions of failure of MMT, the economics of continued medical therapy, and compar ative clinical outcomes between MMT and surgery. There has been limited additional published evidence on this topic since the ICAR-RS-2016 publication. 1 Thus this ver sion will serve as an update, where appropriate, of the work the previous authors presented. It has now been established that prolonging the time between diagnosis and surgery for CRS may negatively impact outcomes. 95,1917,1918 The term “maximal “ medical therapy has thus fallen out of favor, inasmuch as it implies surgery should be delayed until all available options have been exhausted. Therefore, instead of using the term “max imal medical therapy,” the term “appropriate” medical therapy (AMT) will continue to be used in this updated document. AMT is used in order to suggest striking a bal ance between proceeding to surgery before appropriate nonsurgical options have been tried and delaying too long so that outcomes are negatively impacted. (In referring to past work regarding “maximal” medical therapy in this review, the MMT term will be retained.) XII.B.1.a. What is appropriate medical therapy (AMT)? The development of a sturdy definition of AMT remains elusive, likely due in part to the significant heterogeneity inherent in RS. 278 While there are numerous studies eval uating the efficacy of individual drug classes in the treat ment of CRS, discussed elsewhere in this ICAR-RS-2021 document, there are no clinical trials evaluating the opti mal combination of drugs. There are several guidelines where recommendations are made, and these generally demonstrate consistency with regard to inclusion of INCS and saline irrigation, with more selective use of oral corti costeroids and antibiotics (Table XII-5). 26,526,1919 Asystem atic review from 2015 demonstrated that INCS, oral antibi otics, and oral corticosteroids were used in 91%, 88%, and 62% of all MMT protocols for a mean of 8 weeks, 23 days, and 18 days, respectively. 1920 While incorporating the best available evidence into a recommendation for AMT, including evidence from this

XII.A.6 Sinus Surgery Utilization Trends and Variation Recent studies estimate the utilization of ESS in the United States as between 0.94 1903 to 1.17 1904 cases per 1000 per sons, or about 320,000 cases per year. This is somewhat higher than rates of surgery published in Europe, with around 0.71 cases per 1000 persons. 1905 Evidence suggests that population-adjusted rates of ESS may be decreas ing, with 1 study showing a 24% reduction between 2005 and 2011 in California. 1906 Concurrently, balloon catheter dilation (BCD) has become increasingly adopted by some otolaryngologists as a procedural management option for CRSsNP, 1907–1910 with 1 analysis of a Medicare database demonstrating a 486% increase in utilization from 2011 to 2017. 1788 While 1 hypothesis for the decrease in pop ulation ESS rates may be that balloon catheter dilation (BCD) techniques are supplanting traditional ESS proce dures, it appears that the overall number of ESS procedures over this timeframe has remained relatively stable, 1907,1908 and providers who performed more BCDs did not reduce their volume of other sinus procedures. 1911 Interestingly, when comparing diagnosis codes between ESS and BCD patients, a significantly higher prevalence of headache dis order, facial pain, allergic rhinitis was noted in patients undergoing BCD, 1912 suggesting that balloon sinus dila tion may be used in a different patient population than the traditional ESS cohort. Utilization of balloon sinus dila tion also appears to be significantly associated with finan cial support from industry in 2 studies, 1911,1913 although the authors note evidence for a causative effect is limited. There is substantial geographic variation of ESS utiliza tion, as noted by a recent study by Rudmik et al. that found a 5-fold difference between U.S. regions with the highest rates of ESS utilization compared to those with the lowest, in agreement with prior studies. 1914 A similar finding was noted in a study of state ambulatory surgery databases, which also found variations based on surgeon volume and payer type for CRSwNP patients. 1915 Thisprob lem is not unique to the U.S. healthcare system, as stud ies in Canada 1903 have also found similar regional varia tions. Significant differences in utilization based on ethnic ity and payer are also present, as demonstrated by Woodard et al., who showed the rate of ESS in a Medicaid population was only 0.40 per 1000 persons, substantially lower than the average. 1916 Sex-adjusted rates of ESS for Hispanic and African American patients were also significantly lower than Caucasians in this study across all age groups. The primary drivers of these discrepancies remain an area of active investigation.