Hope for Patients Suffering with Chronic Rhinosinusitis
For patients with chronic rhinosinusitis (CRS), every day can mean dealing with headaches, pain, facial pressure, and severe nasal congestion. In my practice, I treat patients who have struggled for years with nasal and sinus problems, and I see how this suffering impacts them physically, functionally and emotionally. But the reality for these patients is that there are ways to find relief.
A lot of patients come in after being treated for years with various medications, including broad-spectrum antibiotics, nasal saline, nasal steroid sprays, and oral steroids – first-line treatments that have simply not done the job. And, many have never been referred to an ear, nose and throat (ENT) specialist before, potentially because either the primary care provider (PCP) or the patient are hesitant to consider surgery as an option.
There are a number of reasons why PCPs should start to refer these patients to ENT specialists – even if going under the knife is a concern. With recent advances in treatment, ENTs are able to provide relief to CRS patients with minimally-invasive, office-based procedures, including balloon sinus dilation. These procedures are performed without the time, risk and expense of surgery, and they have shown greater improvements in quality of life. When patients are treated promptly, they have better results over those who have continued on medical management. It is also in the best interest of CRS patients to be evaluated for balloon sinus dilation sooner rather than later.
Better Outcomes from Alternatives to Medical Management
One of the most common medical conditions in the United States, CRS affects approximately 31 million people each year.[i], Like many medical conditions, sinus problems can often be successfully eliminated with conventional medical management, such as broad spectrum antibiotics for at least 14 days, oral steroids, intranasal corticosteroids, antihistamines, decongestants, and saline irrigation. And if all that works – great! We’ve done our job, and have a happy, healthy patient.
However, at least 20 percent of patients do not respond adequately to such treatment.[ii] [iii] For patients who fail to respond, and have symptoms that persist for 12 weeks or more, we need to start thinking about procedural intervention options. A minimally-invasive, office-based approach can be an effective alternative to continued medical management, as well as surgical interventions (such as functional endoscopic sinus surgery) done under general anesthesia in the operating room.
In-Office, Minimally Invasive Procedures
Today, ENTs are able to use the same technology that revolutionized the field of cardiology several decades ago. Flexible, wire-based intravascular balloon catheters are now being used in rhinology. Over-the-wire balloon catheters have been modified specifically for use in the nose to reach and dilate paranasal sinus openings.
For appropriate patients, balloon sinus dilation can be performed safely, efficiently, and at lower cost in the office. In this setting, local anesthesia is used, which allows for general anesthesia to be avoided altogether. The procedure takes about 30 minutes to complete, and patients recover in only one to two days. Additionally, these procedures may help patients concerned about surgery in the OR due to time, cost, or other confounding medical conditions or risks.
Patients treated with balloon sinus dilation often do better than those treated with continued medical management. The American Journal of Rhinology & Allergy published a study that evaluated clinical outcomes of balloon sinus dilation versus continued medical management and found that CRS patients who opted for surgery showed significantly greater improvements in quality of life and less nasal steroid use compared to those who elected for continued medical management.[iv]
I’ve seen this in my own practice. Ellen, for example, suffered from chronic sinusitis with acute episodes for decades. Her symptoms included sinus congestion which left her unable to breathe through her nose, bad breath, pain, and foul drainage. She had been treated with antibiotics, nasal sprays and traditional surgical interventions. Nothing helped. After being treated with balloon sinus dilation, she was finally able to find relief. Ellen said that she hasn’t felt as good in years and recommends the procedure over other treatments.
Early Referral Key to Improving Patient Outcomes
When we see a patient with symptoms of CRS, we often start with medication, as most patients respond positively. However, when a patient has failed a few rounds of antibiotics, it makes good sense to promptly refer the patient to an ENT who can perform a diagnostic nasal endoscopy – looking for pus, polyps, or growths – to determine if imaging is necessary.
There are a variety of factors that come into play when determining when and if a procedural intervention is needed, such as intra-nasal anatomy, patient preference, and tolerability of an awake nasal procedure. The critical factor, however, is ensuring these patients are evaluated by an ENT specialist to discuss treatment options.
That said, the sooner a patient is referred, the better the outcome. Recent studies have shown that surgical intervention has a higher likelihood of success when surgery is performed within 12 months of diagnosis. Delaying surgical intervention may reduce both the extent and symptomatic benefit from surgery and significantly reduce the percentage of CRS patients who experience sustained clinical improvement.[v] Clinical outcomes beyond five years are superior in those patients, compared to those that delay. Patients that delay also have been shown to have higher healthcare utilization, including a greater number of prescriptions and an increased number of office visits. [vi]
Understanding the Best Path Forward for Treatment
In conclusion, when evaluating a patient with CRS symptoms, there are a few important points to keep in mind, based on advances in treatment and recent studies:
- Procedural intervention is preferable to ongoing medical management, once medical management has failed.
- Procedural intervention is more feasible, technically easier, less expensive, and better if performed early rather than later.
- A significant proportion of nasal and sinus procedures may be performed safely and efficiently in a familiar office setting, without the time, expense, or recovery time of a surgical intervention in the OR.
Continuing patients on medical management and not referring appropriate patients to a trained ENT surgeon can have significant negative implications for patients, leading to worsened outcomes and a greater need for healthcare utilization down the line. Pursuing other options can help our patients greatly improve their quality of life.
Daniel Charous, MD is a Board-certified Ear, Nose and Throat (ENT)-Head and Neck Surgeon in Goodyear, Arizona. He serves as chairman of the department of ENT at Integrated Medical Services (IMS), practicing all aspects of general ear, nose and throat with a particular focus on the management of chronic sinusitis, chronic nasal and sinus issues, allergic rhinitis, snoring, and sleep solutions.
Dr. Charous is affiliated with multiple hospitals, including Phoenix Children’s Hospital and St. Joseph’s Hospital and Medical Center. He received his medical degree from NYU School of Medicine and has been in practice more than 10 years. In addition, he is the President-Elect of the Arizona Society of Otolaryngology-Head & Neck Surgery and serves as a consultant for Acclarent, Inc.
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[i] Benninger M. Adult chronic rhinosinusitis: Definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg. 2003; 129S: S1-S32.
[ii] Hessler J, Piccirillo J, et al. Clinical outcomes of chronic rhinosinusitis in response to medical therapy: Results of a prospective study. Am J Rhinol. 2007; 21(1):10-18.
[iii] Lal D, Scianna J, et al. Efficacy of targeted medical therapy in chronic rhinosinusitis, and predictors of failure. Am J Rhinol Allergy. 2009; 23: 396-400.
[iv] Payne SC, Stolovitzky P, Mehendale N, et al. Medical therapy versus sinus surgery by using balloon sinus dilation technology: A prospective multicenter study. Am J Rhinol Allergy. 2016; 30(4): 279-286.
[vi] Benninger M, Sindwani R, Holy CE, Hopkins C. Early versus Delayed Endoscopic Sinus Surgery in Patients with Chronic Rhinosinusitis: Impact on Health Care Utilization. Otolaryngol Head Neck Surg. 2015; 152(3): 546-552.