When should revision FESS leave you reaching for the script pad?
Reviewed by Suki Ahluwalia

This very interesting work from the professorial team in London seeks to define a group of patients with CRSwNP who may benefit from early biological treatment since they are at risk of failure of surgical and conventional medical management. Approximately one in six patients may require repeat FESS surgery within five years of their index procedure and, therefore, treatment failure could be considered as a common occurrence. Type 2 inflammation in these patients could be controlled using monoclonal antibody treatments aimed at blocking interleukin action, or other targets, such as dupilumab (anti IL 4/13) and omalizumab (anti IgE), which have both been shown to cause significant reduction in polyp size and nasal congestion. Due to the high cost and need for longer-term treatment protocols, biologicals are not for everybody and many patients are well managed with conventional medical or surgical treatment, which is usually much more cost effective. Data from the National Audit of Surgery for CRSwNP was used, where baseline clinical data has been prospectively collected for 3128 patients. Of these, 2039 had an index procedure performed and 980 completed a five-year follow-up. Of the 980, half had undergone a previous procedure before their index procedure. The five-year revision rate was 15%; it was higher in the group who had had previous surgery. Of the five-year respondents, 102 (10%) had undergone a further additional FESS procedure within this five-year study, therefore three in total. All patients who underwent a second procedure within 10 years were significantly at risk of requiring a third procedure, compared to those presenting for a revision procedure after 10 years. If a patient required a second procedure within three years of the first, they were significantly at risk of needing another operation within a short timeframe. Patients who underwent more extensive sinus surgery earlier tended to do better, requiring fewer revision procedures, since the cavity is well ventilated and allows for better drug delivery in the postoperative period. Therefore, patients presenting with a significant symptomatic recurrence within three years of surgery would seem to be ideal candidates for an alternative strategy, such as biologicals. In line with EPOS guidance, the study advises to consider biologicals in patients who have ‘failed’ primary surgery, as this already identifies them at higher risk of requiring intervention, and for whom costs of care will be higher. Furthermore, a significant symptomatic recurrence within three years of sinus surgery for CRSwNP could be used to help identify those at highest risk of requiring multiple further surgical procedures and, therefore, in whom biologicals will be more cost-effective. Patients with non-steroidal exacerbated sinus disease are least likely to benefit from current standard of care and often require repeated surgery and, therefore, may be considered to be good candidates in whom to target biologicals early.

Does time from previous surgery predict subsequent treatment failure in Chronic Rhinosinusitis with Nasal Polyps?
Hopkins C, Lund V.
RHINOLOGY
2021;59(3):277-83.