Is sinus surgery indicated for recurrent acute rhinosinusitis?

BACKGROUND Recurrent acute rhinosinusitis is clinically defined as having around four or more episodes per year of active sinus infection with asymptomatic periods in the interim. Clinical practice guidelines recommend a primary evaluation for an acute bacterial infection including a nasal endoscopy. To meet the criteria for acute rhinosinusitis, there must be presence of purulent nasal discharge or nasal obstruction and congestion. Initial treatment should include a preliminary period of several days of supportive care to confirm that the inflammation is not the result of a viral etiology, which would resolve without requiring antibiotics. If these symptoms are still present after this withhold period, suggested medical management includes a course of amoxicillin or Augmentin as well as a topical nasal steroid spray or an oral steroid. If medical management fails or infections recur, then a computed tomography (CT) scan of the sinuses and possible allergy testing are recommended. Despite the detail with which medical treatment of recurrent acute rhinosinusitis is described, the point at which surgery is indicated as an alternative to continual treatment with antibiotics and nasal or oral steroids is not well defined. Patients with recurrent acute rhinosinusitis reported the impact of disease on quality of life and productivity levels similar to those with chronic rhinosinusitis for whom surgery is indicated and well studied as an efficacious treatment. This dearth of literature regarding recurrent acute rhinosinusitis and its treatment makes it difficult to pinpoint the medical and economic threshold at which surgical intervention is indicated. LITERATURE REVIEW Due to the intermittent nature of recurrent acute rhinosinusitis, it may be difficult to define the threshold at which patients are good candidates for surgical intervention. Current research and clinical practice seem to indicate several areas of evaluation for physicians to consider, including failure of medical management and physical indicators as seen on exam and sinus imaging. In a study comparing endoscopic sinus surgery outcomes for patients with recurrent acute rhinosinusitis and chronic rhinosinusitis, Bhattacharyya recommended endoscopic sinus surgery for those patients whose symptoms failed to improve after utilizing nasal steroid spray and, when indicated, antihistamines or decongestants as well. In addition, he required an office visit including a nasal endoscopy and a CT of the sinuses while in a noninfected state. As recurrent acute rhinosinusitis is typified by asymptomatic periods between infections, CT and endoscopy findings may be relatively limited. As a result, Bhattacharyya recommends performing a nasal endoscopy during an episode of acute infection before proceeding with surgery in cases where the diagnosis of recurrent acute rhinosinusitis is not certain. In a recent study, Costa et al. compared outcome measures for recurrent acute rhinosinusitis patients who opted to undergo endoscopic sinus surgery versus those who continued with medical management. This study required diagnostic criteria including four or more episodes a year lasting no longer than 4 weeks each and, additionally, the presence of anatomic variants on exam or CT. Either the presence of mucosal thickening in at least one sinus or the presence of edema or purulence on endoscopy were necessary for definition as recurrent acute rhinosinusitis for the study. This study also compared CT scans of patients with recurrent acute rhinosinusitis with scans from patients without a history of sinus disease and found that those with recurrent acute rhinosinusitis had CT scans showing a significantly higher prevalence of conchae bullosa, accessory ostia, and infraorbital ethmoid cells. Although a patient may meet the clinical requirements for sinus surgery, deciding whether to proceed with surgery is largely dependent on patient motivation and lifestyle. In addition to the risk–benefit analysis of surgery, the patient should evaluate continuing From the Department of Otolaryngology–Head and Neck Surgery, New York-Presbyterian/Weill Cornell Medical College, New York, New York, U.S.A.