Further Results from the Chronic Rhinosinusitis Epidemiology Study

Further Results from the Chronic Rhinosinusitis Epidemiology Study

We reported initial findings from the chronic rhinosinusitis epidemiology study (CRES), led by Carl Philpott, in an earlier newsletter. More results have recently been published and will be of interest to many members since chronic rhinosinusitis (CRS) is one of the main causes of anosmia.The study started in East Anglia in 2007 and was rolled out across numerous sites in England, Scotland and Wales in 2012. This part of the study looks at 1249 participants:651 having CRS with polyps, 553 CRS without polyps and45 allergic fungal rhinosinusitis (AFRS) covering England, Scotland and Wales. They were recruited in ENT clinics following referral by their GPs for their CRS, and the recently published paper looks at the rates of previous nasal surgery among the three subgroups of CRS patients. For those patients reporting previous surgery, their current referral for CRS treatment implies that the surgery had been ineffective in providing lasting relief. The paper also looks at the possible reasons for this.

The results showed:

-from the total of 1249 CRS participants, 556 (45%) had previously undergone some form of sinonasal surgery including 325 (26%) who had received at least one nasal polypectomy and 169 (14%) who had undergone at least one instance of endoscopic sinus surgery (ESS)

-of those with CRS with polyps or AFRS,396 (57%) reported previous sinonasal surgery of which 99 (14%) reported having undergone ESS and 315 (45%) nasal polypectomy

-Of those with CRS without polyps, only 160 (29%) patients reported sinonasal surgery in whom 70 (13%) specifically reported ESS

-157 of 315 patients with CRS who reported having undergone a nasal polypectomy previously (50%) had received more than one operation with a mean number of 3.3 polypectomies and a range of 2–30 polypectomies each

-21 of 160 patients with CRS without polyps (13%) reported repeated previous sinonasal surgery

-among those reporting previous surgery the average duration from first surgery to inclusion in the study was 15.5 years (range 0–74 years) giving a clear indication of the chronicity of the disease

-the time since the most recent surgical intervention to completion of questionnaire ranged from 0 to 70 years with a mean of 10 years for all CRS but notably a mean of 3.68 years in patients with AFRS

-asthma and aspirin-exacerbated respiratory disease (AERD) were significantly more likely to be present in patients who had had multiple surgeries (60% asthma, 35% AERD) than those who had not (43% and 11%)

These results clearly show the burden of CRS on both the patients and the NHS. The rate of previous surgery for those with CRS with nasal polyps is almost twice that of those without nasal polyps and there is a growing acceptance that patients with and without polyps have distinct underlying differences. The role of surgery in patients with CRS with polyps is likely to be no more than achieving temporary access for direct medication( e.g. steroid spray), and it may not change the underlying disease. The need for recurrent surgery is therefore not unexpected. In contrast, for CRS without polyps, sinus surgery should permanently remove the obstruction which may be predisposing the sinuses to infection and is unlikely to need repeating.

The authors suggest that a crucial factor in the success or failure of surgical intervention will be patient compliance with ongoing postoperative medical management. Anecdotal evidence from the qualitative arm of the study suggests that compliance with topical treatments (e.g. sprays) is a problem and that patient education at the outset of treatment is crucial, with a need for regular reinforcement.

The authors conclude that it is essential that carefully designed clinical trials are undertaken to assess the effectiveness of surgery in treating the different types of CRS. Fifth Sense continues to support the efforts to obtain funding for research in this area.