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Orlandi et al.

TABLE XII-10 Evidence for timing of sinus surgery Study Year LOE Study Design

Study Groups Early < 1 year Mid 1-5 years Late > 5 years

Clinical Endpoint Absolute improvement on SNOT-22, RSDI

Conclusions

Alt 1929

Greater symptom

2019

4

Prospective

improvement in late group.

observational cohort study

n-78

Yip 1931

2019

4

Prospective

Single cohort of

Postoperative

Prolonged wait-time for ESS negatively correlated with outcome. Wait > 41 weeks associated with clinically significant reduction in symptomatic benefit. Time spent on waiting list did not adversely impact on symptomatic improvement. Yearly incidence of new onset asthma reduced in all groups after surgery from 4.5% to 0.4%. Rates of asthma at time of surgery were 9.4%, 12.8%, 18.2%, and 22.4% in each group. Greatest % improvement in early group. Time to surgery significant predictor or outcome in regression. Patients in early cohort had significantly fewer doctor contacts and prescription usage after surgery than the late cohort.

observational cohort study

patients on wait list for surgery, mean wait time 44 weeks

improvement on SNOT-22

N = 104

Newton 1930

Multivariate regression of improvement on SNOT-22 Incidence of new onset asthma at time of surgery and postoperatively

Single cohort of

2017

4

Prospective

patients on wait list for surgery, mean wait time 32 weeks

observational cohort study

N = 150

Benninger 97

2016

4

Electronic health records analysis

Patients without

asthma at time of CRS diagnosis.

Grouped by time between CRS diagnosis and surgery.

Hopkins 95

% improvement in

Early surgery < 1 year from diagnosis

2015

4

Prospective

SNOT-22 score from baseline multivariate regression

observational cohort study

Mid 1-5 years Late > 5 years

N = 1493

Hopkins 1917

2015

4

Electronic health records analysis

Early surgery < 1 year Late surgery > 5 years

Post-operative healthcare

utilization – doctor visits and drug prescriptions

are controversial. 1352,1816,1934,1938-1943 Consistently, though, higher baseline SNOT-22 scores have been shown to be predictors of achieving an MCID. Subjects with baseline SNOT-22 > 30 points have a > 70% chance of achieving an MCID post-operatively. 1934,1940,1944,1945 Conversely, CRS patients with SNOT-22 < 20 have a low probability of reach ing an MCID due to presumed floor effects. 3,12,18 This find ing has prompted the suggestion of a minimal criteria for offering ESS which include a SNOT-22 ≥ 20 post-medical therapy with topical intranasal steroids and either sys temic steroids for CRS with NP or systemic antibiotics for CRS without NP as well as CT Lund-Mackay score ≥ 1. 283 Following these guidelines appear to result in high post operative clinically significant improvement in both CRS subsets. 1946 Despite these recommendations, it is recognized that surgical decision-making remains nuanced, with up to

32% of surgical patients deviating from these criteria. 1947 Patient perceived importance of an individual SNOT-22 domain and achievement of domain-specific MCIDs may impact surgical decision-making. 5 Thus, patients report high levels of satisfaction even without achieving an over all SNOT-22 MCID if their most severe symptoms are addressed. 1948 ESS results in greater improvement of facial pressure, nasal obstruction, and discharge compared to medical treatment. 1949 Those with sleep dysfunction tend to favor surgery, but may ultimately experience lower lev els of improvement despite achieving an MCID. 1176,1950 Further research may help us guide appropriate surgical candidacy for CRS, and careful consideration is warranted for patients with low SNOT-22, but a tailored shared deci sion making process between surgeon and patient remains the guiding principle.