Primary Endoscopic Sinus Surgery
Primary ESS is indicated for severe unilateral or bilateral CRSwNP
symptoms that persist or recur despite treatment with nasal rinsing,
intranasal corticosteroids (INCS) and usually one or more courses of SCS
within the preceding two years (1, 19). Hence, the role of primary ESS
managing CRSwNP is critical in cases where first-line medical therapy
proves to be insufficient. Despite previous treatments, patients may
report significant nasal obstruction as a consequence of large nasal
polyps and nasal secretions filling the nasal cavities.
The primary goals of ESS in CRSwNP are to remove the diseased mucosa
including nasal polyps, facilitate the delivery of intra-nasal
corticosteroids to the sinuses, in turn reducing the inflammatory burden
of the disease and improving the outcomes of post-EES medical treatment,
with the expected outcome of improvement of overall sinonasal symptoms.
overall. ESS results in limited operative morbidity, rapid recovery
(within weeks in most patients) and improved patient outcomes (20).
While both the expected outcome and the recurrence rates of ESS vary
depending on factors such as the elapsed time since surgery, the extent
of the procedure, the presence of comorbidities, and the exposure to
environmental/occupational irritants most patients do well after ESS
(21-23). Furthermore, ESS has shown effectiveness in reducing both upper
and lower airway inflammation (24-27). Although evidence is limited, the
expert panel advises against performing a polypectomy
without a complete ESS, although consensus is lacking about the extent
of ESS and whether it should be related to the radiological extent of
the disease or the endotype of CRSwNP.
Some patients might, however, fear general anaesthesia and/or ESS and
think surgery is only a temporary solution (28). In addition, whilst in
the short-term significant improvements are observed both in upper and
lower airway symptoms, regular saline rinsing and INCS use is needed to
ensure good results both in the mid-term (one to five years
post-surgery) and long-term (more than five years post-surgery) (25, 29,
30). ESS might also be contra-indicated in patients with
medical/surgical contra-indications for anaesthesia and surgery, such as
in patients with severe uncontrolled asthma. Physicians should also keep
in mind that there can be considerable indirect cost related to ESS due
to sick leave after the procedure (31).