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

562

International consensus statement on rhinosinusitis

(12-60 months), and long-term ( > 60 months), using the original criteria as defined by Hopkins et al. Disease specific QoL was measured with the SNOT-22 and the RSDI. The authors found that the length of disease prior to surgical intervention did not predict disease severity or QoL. Further, patients with long-term symptom duration reported the greatest mean postoperative QoL improve ment as measured by the SNOT-22 and RSDI, suggesting that delayed surgical intervention may not reduce QoL improvements following ESS. 1929 Two investigations have evaluated any detrimental effect of surgical wait times In terms of symptomatic benefit from surgery. Newton et al. found no association between wait time for surgery (mean wait time 32 weeks) and outcome from surgery in an observational cohort of 150 patients. 1930 The most recently published study (mean wait time 44 weeks) evaluated the effect of surgical wait times and found that prolonged wait times were associated with detrimental outcomes in terms of the total SNOT-22 score and the rhinological domain. 1931 Although the timing of surgery has not been formally evaluated in a randomized trial, there is a growing body of evidence that suggests that delays in surgical inter vention may be detrimental to QoL improvement and increased risk of asthma. The mechanism for this is not yet clear. Reduction in type 2 inflammation and preven tion of irreversible remodeling of the mucosa by facilitat ing improved access to topical therapies are potentially disease-modifying benefits of surgery. However, obser vation studies are at risk of bias – for example there may be patient behavioral factors, such as compliance with prescribed medications, related to the time that patients seek surgery that influence their post-operative outcomes. Patients included in the observation studies had all received prior medical therapy and therefore it must be highlighted that there is no evidence to suggest that patients should be offered surgery prior to a trial of appro priate medical therapy. All groups studied in relation to timing of surgery still derived symptomatic improvement therefore surgery can be considered regardless of symptom duration as data sug gest that it is never “too late.”

Harm: Risk of encouraging unnecessary or early ESS prior to undergoing appropriate medical man agement. Cost: Provided indications for surgery are unchanged, there should be no increase in costs. Benefits-Harm Assessment: Provided indications for surgery are unchanged, this recommendation will not increase rates of surgery and therefore increased risk of harm is avoided while having the potential to optimize benefit. Value Judgments: The context in which the stud ies were initiated was to consider the impact of delayed surgery, and not encourage early interven tion, or a change in threshold for surgery. Policy Level: Recommendation, though weak based on strength of evidence. Intervention: As part of a shared decision-making process with a patient, it is reasonable to avoid prolonged delays in offering surgery if appropri ate medical therapy has failed to achieve adequate symptom control. At a health system level, patient pathways should be optimized to avoid unneces sary delays in surgery. XII.B.3 Patient Selection and Achieving a Minimally Clinically Important Difference in Sinus Surgery ESS for CRS with and without NP has been validated in its efficacy and safety. 1932,1933 Surgical success is often mea sured by improvement in patient reported outcome mea sures (PROMs), and in particular, CRS-specific QoL met rics. The minimal clinically important difference (MCID) estimates the smallest clinically detectable change of a PROM and therefore is a meaningful endpoint when defin ing a change threshold for surgical success. 1934 In post surgical CRS patients the MCID has been defined as 8.9 points on the SNOT-22 using both anchor-based meth ods that compare change scores to external metrics and distribution-based methods that utilize the statistical prop erties of a PROM. 71,1935 Prior studies showed that 70% to 80% of CRS patients achieve an MCID post-ESS. 1816,1936,1937 A variety of base line conditions have been explored as potential risk factors for failure to reach an MCID with variable conclusions. The presence of asthma and decreased productivity improve the likelihood of obtaining at least 1 MCID of improvement, 1352,1938,1939 whereas the effects of nasal polyposis, prior sinus surgery, and age

Timing of Sinus Surgery Aggregate Grade of Evidence: C (6 level 4 studies; Table XII-10). Benefit: Potential to optimize QoL outcomes of ESS for patients with CRS, though the evidence is indirect and conflicting.