Photo Credit: Yacobchuk

 A small but significant portion of patients with chronic rhinosinusitis with nasal polyps require revisional endoscopic sinus surgery to control the disease.

A small but significant portion of patients with chronic rhinosinusitis with nasal polyps (CRSwNP) require multiple endoscopic sinus surgeries to control the disease, and frequent use of antibiotics and oral steroids is common in this subset of patients, according to findings published in Clinical and Translational Allergy.

“Whilst most patients benefit from surgical treatment and achieve disease control, some patients experience recurrent polyps leading to repeated procedures,” Sanna Toppila-Salmi, MD, and colleagues wrote.

An Unmet Need in Nasal Polyps

However, data on the factors that predict revisional endoscopic sinus surgery [ESS] are sparse, they continued, and previous studies have shown varying rates of revision ESS in patients with CRSwNP. One study published in the Journal of Personalized Medicine noted that about 11% of patients undergoing ESS required more surgeries within 3 years, whereas 19% required additional surgeries at 5 years. Furthermore, the authors of that paper noted that revision surgery can impact quality of life and come with surgical complications.

To address this knowledge gap, Dr. Toppila-Salmi and colleagues conducted a nationwide population-based study to assess predictors of revision ESS and the timing of revision surgery utilizing real-world data.

The analysis included 3,506 Finnish patients with recorded diagnoses of CRSwNP and surgical procedural codes indicating they had ESS. Patients underwent surgery from January 1, 2012, to December 31, 2018, and follow-up continued for at least one year, through December 31, 2019. The researchers used logistic regression analyses to calculate adjusted ORs for the likelihood of patients needing revision surgery at 1 and 3 years after their first, or index, surgery.

Prevalence of ESS & Associated Factors

Median follow-up was 4.3 years (IQR: 2.70-5.96). Most patients (79.7%; N=2,794) had only one surgery.

Overall, 15.9% of patients (N=559) had at least one revision surgery during the study period, the researchers reported, and some (4.4%, N=153) had two or more surgeries. These patients had a median of 425 days between their index and revision surgeries (interquartile range [IQR]: 213–898).

Asthma at baseline was significantly associated with multiple surgeries, according to Dr. Toppila-Salmi and colleagues (OR=1.58, 95% CI: 1.17-2.12), as was antibiotic use (OR = 1.61, 95% CI: 1.27-2.04).

Patients who received extensive surgery initially were significantly more likely to need revision ESS within 3 years compared with those who had limited surgery (OR=14.13, 95% CI: 3.41-95.64). Furthermore, Dr. Toppila-Salmi and colleagues added, patients who needed revision surgeries commonly used oral corticosteroids and had higher cumulative doses of steroids compared with those who did not undergo revision (63%, n=97, median daily dose, 3.29 mg, IQR: 1.64–3.70, vs 49%, n=1,361 and 1.64 mg, IQR: 1.64–3.29, P< 0.001).

Achieving Disease Control in Nasal Polyps

Dr. Toppila-Salmia and colleagues noted that the incidence rate of revision surgeries they calculated, 15.9%, was like other studies, which have estimated rates of 9% to 25%. A 2019 meta-analysis found an incidence rate of 16.2%.

Furthermore, the link between asthma and revision surgeries was similar to that of earlier research: 21% of patients undergoing revision in the Finnish study had asthma at baseline, close to the 22.6% noted in a meta-analysis.

“This nationwide study demonstrates that a small proportion of [patients with CRSwNP] require multiple ESS revision surgeries to manage their disease,” Dr. Toppila-Salmi and colleagues wrote. “This highlights the need for effective therapies, such as biologics, to achieve disease control and reduce the oral corticosteroid and antibiotic burden in these patients.”