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Endoscopic sinus surgery compared to continued medical therapy for patients with refractory chronic rhinosinusitis.

ABSTRACT: The decision to continue medical therapy or recommend endoscopic sinus surgery (ESS) can be challenging in patients with refractory chronic rhinosinusitis (CRS). The objective of this study was to evaluate continued medical therapy vs ESS for patients with refractory CRS who have severe reductions in baseline disease-specific quality of life (QoL).This was a prospective longitudinal crossover study between August 2011 and June 2013. All patients were >18 years old, diagnosed with CRS based on guideline recommendations, failed initial medical therapy and elected ESS. While waiting for ESS, all patients received continued medical therapy. The preoperative waiting period outcomes (continued medical therapy) were compared to the postoperative outcomes. The primary outcome was change in disease-specific QoL (22-item Sinonasal Outcome Test [SNOT-22]). Secondary outcomes were change in endoscopic grading (Lund-Kennedy score), medication consumption, and work days missed in the preceding 90 days.Thirty-one patients were enrolled. Mean baseline SNOT-22 score was 57.6. After a mean of 7.1 months of continued medical therapy, there was a worsening in SNOT-22 score (57.6 to 66.1; p = 0.006). After ESS, with a mean postoperative follow-up of 14.6 months, there was a significant improvement in SNOT-22 score (66.1 to 16.0; p < 0.001). There was also a significant improvement in endoscopic grading (p < 0.001) coupled with a reduction in both work days lost (p < 0.001) and medication consumption (p < 0.01).Results from the study suggest that ESS is a more effective intervention compared to continued medical therapy for patients with refractory CRS who have severe reductions in their baseline disease-specific QoL.

SUBMITTER: Smith KA

PROVIDER: S-EPMC4182136 | biostudies-literature | 2014 Oct

REPOSITORIES: biostudies-literature

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Endoscopic sinus surgery compared to continued medical therapy for patients with refractory chronic rhinosinusitis.

Smith Kristine A KA Smith Timothy L TL Mace Jess C JC Rudmik Luke L

International forum of allergy & rhinology 20140911 10

<h4>Background</h4>The decision to continue medical therapy or recommend endoscopic sinus surgery (ESS) can be challenging in patients with refractory chronic rhinosinusitis (CRS). The objective of this study was to evaluate continued medical therapy vs ESS for patients with refractory CRS who have severe reductions in baseline disease-specific quality of life (QoL).<h4>Methods</h4>This was a prospective longitudinal crossover study between August 2011 and June 2013. All patients were >18 years ...[more]

PMID: 25213088

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Project description:Patient-reported measures are designed to detect a true change in outcome, but they are also subject to change from biases inherent to self-reporting: changing internal standards, changing priorities, and changing interpretations of a given instrument. These biases are collectively known as "response shifts" and can obscure true change after medical interventions.To determine the presence of response shifts in patients with chronic rhinosinusitis (CRS) after endoscopic sinus surgery.Multisite, prospective, observational cohort study conducted at academic tertiary care centers between February 2011 and May 2013. Study participants comprised a population-based sample of 514 adults (age ?18 years) with CRS, who elected surgical intervention for continuing medically refractory symptoms.Endoscopic sinus surgery.Preoperative and postoperative data from the 22-item Sinonasal Outcome Test (SNOT-22) survey instrument was characterized using exploratory factor analysis. Subsequent longitudinal structural equation models were estimated to test structure, potential response shifts, and true change in the SNOT-22 scores.A total of 339 participants (66.0%) provided survey evaluations at baseline and 6-month follow-up. Factor analysis of the SNOT-22 revealed 5 correlated, yet distinguishable, underlying factors. Endoscopic sinus surgery had a differential impact across these factors, with the largest effect size in rhinologic symptoms (mean [SD] SNOT-22 scores before and after surgery, 13.18 [5.11] and 7.37 [5.48], respectively; d?=?-1.13 [P?<?.001]) and extranasal rhinologic symptoms (8.31 [3.46] and 4.83 [3.68], respectively; d?=?-1.00 [P?<?.05]) (d is an effect size measure defined as the difference in means divided by the presurgery SD). Endoscopic sinus surgery had a smaller, yet significant, effect size on the remaining 3 factors: ear/facial symptoms (7.32 [4.6]) and 3.90 [4.07], respectively; d?=?-0.74 [P?<?.001]), psychological dysfunction (11.90 [7.21] and 6.50 [6.69], respectively; d?=?-0.75 [P?<?.05]), and sleep dysfunction (10.12 [5.59] and 5.88 [5.37], respectively; d?=?-0.76 [P?<?.001]). Participants were found to undergo recalibration, reprioritization, and reconceptualization of symptoms after intervention; however, the magnitude of these response shifts was small and not clinically significant.The SNOT-22 measures 5 distinct factors, not a single construct. Reporting of individual subscale scores may improve sensitivity of this instrument in future studies. Participants undergoing endoscopic sinus surgery experience only clinically insignificant response shifts, validating assessment of change through use of presurgery and postsurgery SNOT-22 responses.clinicaltrials.gov Identifier: NCT01332136.

Project description:BackgroundPsychological dysfunction is highly prevalent among patients with chronic rhinosinusitis (CRS). Previous study has identified various measures of anxiety and depression as predictors of quality-of-life outcomes following endoscopic sinus surgery (ESS). Psychological dysfunction scores, as measured by the 22-item Sino-Nasal Outcome Test (SNOT-22), have been found to influence treatment decision making in CRS. This study aims to further elucidate improvement in discrete psychological symptoms following ESS for CRS.MethodsAdult patients with medically recalcitrant CRS electing to undergo ESS were prospectively enrolled into a multi-institutional, observational cohort. Psychological-related symptom severity and postoperative outcomes were assessed using psychological domain items of the SNOT-22, including subgroup analysis of patients with and without comorbid depression.ResultsA total of 374 participants met inclusion criteria and were followed postoperatively for a mean ± standard deviation (SD) of 14.6 ± 5.0 months. Total mean psychological domain scores improved from 15.9 ± 8.2 to 8.5 ± 8.4 (p < 0.001). Significant relative mean improvements were reported in "waking up tired" (23%; p < 0.001), "fatigue" (25%; p < 0.001), "reduced productivity" (28%; p < 0.001), "reduced concentration" (27%; p < 0.001), " frustrated/restless/irritable" (27%; p < 0.001), "sad" (15%; p < 0.001), and "embarrassed" (8%; p < 0.001) scores. A total of 64% to 66% of participants reported improvement in "reduced productivity," "waking up tired," "fatigue," and "frustrated/restless/irritable," compared to 46% and 38% reporting improvement in "sad" and "embarrassed," respectively.ConclusionPatients with CRS report significant improvement in common mental health-related symptoms following ESS. Despite these improvements, some degree of persistent postoperative psychological dysfunction was reported. Further study is necessary to determine which factors are associated with persistent psychological dysfunction after ESS in order to optimize treatment outcomes.

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Endoscopic sinus surgery compared to continued medical therapy for patients with refractory chronic rhinosinusitis.

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Endoscopic sinus surgery compared to continued medical therapy for patients with refractory chronic rhinosinusitis.

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