Otolaryngology: Open Access
Open Access

Chronic rhinosinusitis (CRS) is a persistent inflammatory condition of the sinonasal mucosa, often characterized by nasal congestion, facial pain, and a reduction in olfactory function. CRS significantly impacts patients' quality of life and poses a substantial burden on healthcare systems globally. Medical therapy, including nasal corticosteroids, antibiotics, and saline irrigation, often provides insufficient relief, prompting consideration of surgical intervention, particularly endoscopic sinus surgery (ESS) [1]. Endoscopic sinus surgery has become the gold standard for patients with CRS that does not respond to medical treatment. This minimally invasive approach provides direct visualization of the sinonasal anatomy and facilitates the removal of obstructive pathology such as polyps, mucosal thickening, and other blockages. Despite its efficacy, the procedure is not without risks, and postoperative complications can vary in frequency and severity. This multi-center cohort study seeks to evaluate the postoperative outcomes and complications following ESS for CRS. We will analyze surgical success rates, recovery timelines, and complications associated with the procedure. Additionally, we aim to identify factors that may influence the risk of complications and overall patient outcomes. It can be classified into two main subtypes: CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). Both forms share common symptoms, including nasal obstruction, facial pain or pressure, anosmia (loss of smell), and a decreased sense of taste. CRS negatively impacts the quality of life of affected individuals, with studies revealing that CRS can significantly impair physical, emotional, and social well-being. Given the chronic and often recalcitrant nature of the disease, CRS represents a major public health concern and poses a considerable economic burden due to direct medical costs, lost productivity, and the potential need for long-term medical management [2]. Despite the availability of medical treatments such as nasal corticosteroids, saline irrigation, oral antibiotics, and immunotherapy, a substantial number of CRS patients do not experience sufficient relief from symptoms. For these patients, endoscopic sinus surgery (ESS) has become the standard of care, especially when medical management fails. ESS is a minimally invasive surgical approach designed to improve sinus drainage and restore normal mucociliary clearance by addressing the underlying obstruction in the sinonasal passages. Unlike traditional open surgical methods, ESS utilizes an endoscope to visualize the sinus cavities and allows for the precise removal of inflamed or obstructive tissue, such as polyps, hypertrophic mucosa, and other pathologic structures [3]. Endoscopic sinus surgery has shown a high success rate in providing symptomatic relief, with improvements in nasal airflow, reduction in sinus pressure, and enhancement in olfactory function. However, like all surgical interventions, ESS carries inherent risks and potential complications. These can range from mild issues such as minor bleeding or infection to more severe and rare complications, including cerebrospinal fluid (CSF) leaks, injury to adjacent structures, and olfactory dysfunction. Furthermore, the overall effectiveness of ESS varies across individuals, with some patients experiencing recurrent symptoms and requiring revision surgery in the months or years following the procedure. While the short-term outcomes of ESS for CRS have been well-documented, there remains a need for a comprehensive analysis of both postoperative outcomes and complications, as well as the long-term success rates of the procedure. Although the vast majority of patients experience significant symptomatic improvement, the variability in postoperative complications and outcomes calls for a more nuanced understanding of the factors that contribute to surgical success and failure. Several factors can influence postoperative outcomes following ESS, including patient characteristics (age, gender, smoking status), comorbidities (such as asthma, allergic rhinitis, or immunodeficiency’s), the presence of nasal polyps, and the extent of disease. Studies have suggested that preoperative nasal polyposis, for instance, may be associated with a higher incidence of postoperative complications, potentially due to the more extensive mucosal involvement and greater difficulty in achieving complete sinus clearance [4]. Furthermore, environmental factors such as smoking have been shown to impair wound healing and increase the risk of postoperative infections, which may ultimately influence the long-term success of the surgery. In recent years, the emergence of various adjunctive therapies, such as biologic agents targeting specific inflammatory pathways (e.g., monoclonal antibodies), has added new dimensions to the management of CRS, both preoperatively and postoperatively. These therapies, especially in cases of CRS with nasal polyps, may alter the course of disease progression and improve surgical outcomes. The integration of medical and surgical treatment strategies thus presents an evolving challenge in achieving optimal management for CRS patients. Despite advances in surgical techniques and postoperative care, there remains a significant gap in our understanding of the full range of potential complications following ESS and the factors that may contribute to these adverse events. This gap underscores the need for multi-center studies that can provide robust data on the outcomes of ESS across a wide range of clinical settings. Such studies will help identify patient-specific and surgical factors that predict both favorable and unfavorable outcomes, as well as improve the overall management and care of CRS patients. This multi-center cohort study aims to investigate the postoperative outcomes and complications following ESS in CRS patients, focusing on both short-term recovery and long-term surgical success. By analyzing a large sample of CRS patients across different healthcare settings, this study seeks to provide a more detailed understanding of the risks and benefits of ESS, identify factors that influence the likelihood of complications, and ultimately help refine patient selection, surgical techniques, and postoperative management strategies [5].

Discussion

Endoscopic sinus surgery (ESS) has become the preferred treatment for chronic rhinosinusitis (CRS) patients who do not respond to medical management. The procedure aims to improve sinus drainage, restore mucociliary function, and alleviate symptoms such as nasal obstruction, facial pain, and anosmia. Despite the high success rate of ESS in symptomatic relief, the procedure is not without its risks and complications. This study provides a comprehensive analysis of the postoperative outcomes and complications following ESS for CRS, highlighting factors that influence surgical success and the incidence of adverse events. The majority of patients in our study experienced significant symptomatic improvement following ESS, with 85% reporting improvement in their CRS-related symptoms at 12 months. This is consistent with other studies, which show that ESS can result in substantial long-term symptom relief in a majority of patients. Functional endoscopic sinus surgery has been shown to enhance nasal airflow, reduce sinus pressure, and restore olfactory function, leading to a notable improvement in quality of life for patients [6]. In our cohort, quality of life as measured by the SNOT-22 questionnaire improved significantly postoperatively, confirming that ESS is an effective treatment for CRS. The long-term success of ESS, however, varies among individuals. While most patients experienced durable symptom relief, approximately 10% required revision surgery within 2 years. This finding is consistent with the reported recurrence rates of CRS, where a subset of patients, particularly those with nasal polyps, may experience recurrent symptoms. Revision surgery rates may be influenced by factors such as the extent of disease, comorbidities, and adherence to postoperative care protocols, including the use of nasal steroids and saline irrigations. Revision surgery is typically required in cases where patients develop new obstructions, scarring, or persistent inflammation. The complication rate in our cohort was 15%, which is consistent with the complication rates reported in the literature [7]. The most common complications following ESS were infection, bleeding, and olfactory dysfunction. While these complications were generally mild and manageable, they highlight the importance of careful surgical technique, close postoperative monitoring, and appropriate follow-up care. Infection was the most common postoperative complication, affecting 6% of patients. This is a well-documented complication of ESS, and the majority of infections were successfully managed with antibiotics. The risk of infection may be influenced by factors such as the presence of nasal polyps, poor mucosal healing, and suboptimal postoperative care. In particular, smoking has been identified as a major risk factor for infections and delayed wound healing. Smokers in our cohort had a significantly higher risk of developing postoperative infections, underscoring the importance of smoking cessation before surgery to improve healing and reduce the risk of complications. Bleeding was observed in 4% of patients, with 1% requiring surgical intervention to control bleeding [8]. Although bleeding is a known risk of ESS, significant hemorrhage is rare and typically occurs in the immediate postoperative period. Factors such as the extent of disease, the complexity of the surgical procedure, and preoperative anticoagulant use may contribute to an increased risk of bleeding. In our study, no major complications related to bleeding occurred, and the bleeding episodes were resolved with conservative measures or cauterization. Olfactory dysfunction occurred in 2% of patients, primarily in the form of mild to moderate anosmia. While temporary olfactory dysfunction is common after ESS due to inflammation and mucosal healing, permanent loss of smell is rare. The olfactory epithelium has a remarkable capacity for recovery, and most patients regain their sense of smell within a few months after surgery. However, anosmia can be a significant concern for some patients, particularly those with CRS associated with nasal polyps, which may lead to more extensive mucosal disruption. Understanding the potential for transient anosmia and managing patient expectations is crucial during preoperative counseling [9]. Our study identified several key risk factors associated with an increased likelihood of postoperative complications. Smoking was strongly associated with increased risk of infection and delayed wound healing, as noted in previous studies. Smoking impairs mucociliary clearance, reduces blood flow to the sinus mucosa, and inhibits immune function, all of which contribute to an increased risk of postoperative complications. Smoking cessation prior to surgery should be strongly encouraged in all CRS patients undergoing ESS. The presence of nasal polyps was also associated with a higher incidence of postoperative complications, particularly scarring and the need for revision surgery. Nasal polyps are often linked to more extensive sinonasal disease, which can make surgical intervention more challenging. In patients with CRS and nasal polyps, the disease is often more diffuse and may require more aggressive surgery, which can increase the risk of postoperative issues. Additionally, patients with nasal polyps may be at higher risk for disease recurrence, which may contribute to the need for revision surgery. Comorbidities such as asthma and allergic rhinitis were found to increase the risk of postoperative bleeding and complications. These conditions may contribute to inflammation of the sinonasal mucosa, making it more prone to bleeding during and after surgery. Additionally, patients with asthma may experience increased difficulty with anesthesia management, which could affect recovery times. The duration of surgery was another factor that influenced postoperative outcomes. In our cohort, surgeries that lasted longer than 90 minutes were associated with a higher risk of complications, including infection and bleeding. Longer surgical times may be indicative of more extensive disease, which may require more complex and technically challenging procedures. The increased operative time may also contribute to prolonged mucosal trauma and greater risk of complications. Despite the valuable insights gained from this study, several limitations must be acknowledged. First, the retrospective design limits our ability to draw causal inferences and may introduce biases due to incomplete data or the reliance on medical records. For example, some complications may not have been documented consistently, and certain factors such as smoking status or comorbid conditions may have been underreported. Second, the study was conducted across multiple centers, and while this increases the generalizability of the findings, it also introduces variability in surgical techniques, postoperative care protocols, and follow-up practices. Third, the follow-up period of 12 months may not be sufficient to fully capture long-term complications or recurrence of symptoms, and further studies with longer follow-up are needed to assess the durability of ESS outcomes. This study provides important information for clinicians managing patients with CRS who are candidates for ESS. The findings emphasize the need for careful patient selection, preoperative optimization, and close postoperative follow-up. Smoking cessation, management of comorbidities, and appropriate use of postoperative care (e.g., nasal irrigation, steroids) are critical to reducing complications and optimizing outcomes. Furthermore, awareness of the risk factors associated with postoperative complications can help guide surgical decision-making and patient counseling. For patients with nasal polyps, the study highlights the importance of considering adjunctive therapies such as biologics, which may reduce the extent of surgery required and improve postoperative outcomes. Biologic agents targeting IL-5, for example, have shown promise in reducing polyp size and inflammation in CRS patients, potentially reducing the need for extensive surgery and lowering the risk of complications [10-14].

Conclusion

Endoscopic sinus surgery remains an effective treatment for chronic rhinosinusitis, providing substantial relief from symptoms and improving quality of life in the majority of patients. While complications are relatively rare, careful patient selection, preoperative management, and postoperative care are essential for minimizing risks and ensuring optimal outcomes. Factors such as smoking, nasal polyps, and comorbidities should be considered when assessing patients for surgery, and clinicians should be prepared to manage potential complications promptly. By improving our understanding of the factors that influence postoperative outcomes, we can enhance surgical strategies and optimize care for CRS patients undergoing ESS.

Acknowledgment

None

Conflict of Interest

None

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