Guidance from the American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) Foundation emphasizes evidence-based, individualized counseling to support shared decision-making (SDM) regarding sinus surgery for chronic rhinosinusitis (CRS). The guideline highlights that CRS management should not rely on rigid treatment pathways. Instead, decisions about surgery should consider symptoms, disease characteristics, quality of life, prior treatment response, and patient goals.
This emphasis creates many opportunities for shared decision-making (SDM). While not every recommendation in the guideline requires a discussion, several key decisions do.
For clinicians caring for adults with CRS, three of the most important SDM conversations include:
- Deciding which medical therapy to initiate
- Deciding whether to proceed with endoscopic sinus surgery (ESS) if medical therapy fails
- Determining the surgical plan after ESS is chosen
The discussion below focuses on these three points.
1. Deciding Which Medical Therapy To Initiate
One of the most notable recommendations in the guideline is that surgeons should not require a predefined, "one-size-fits-all" medical regimen before considering surgery. Instead, treatment decisions should be individualized.
This recommendation highlights a SDM opportunity because multiple therapies may be appropriate for CRS. The therapies, considerations, and examples outlined below can help facilitate discussions about treatment preferences, expected benefits, and potential burdens.
Comparing Common CRS Treatment Options
| Therapy | Cost | Access | Availability | Ease of Use | Adherence | Side Effects | Follow-Up Required | Possible Benefits |
|---|---|---|---|---|---|---|---|---|
| Saline Nasal Irrigation | $ | OTC | Widely available in pharmacies and retail stores | Moderate | Daily use can be inconvenient for some patients | Minimal; occasional irritation | Minimal | Improves mucus clearance, congestion, and symptom control |
| Intranasal Corticosteroids, including Xhance | $-$$$ | Depending on product OTC or Rx (More easily covered by insurance) | Widely to generally available | Easy to Moderate | Requires proper technique and ongoing use | Nasal irritation, dryness, epistaxis | Minimal to moderate | Reduces inflammation and improves symptoms |
| Oral Corticosteroids | $ | Rx (More easily covered by insurance) | Widely available | Easy | If short course, generally acceptable adherence | Mood changes, insomnia, elevated blood glucose, weight gain, systemic adverse effects | May require monitoring, especially in patients with comorbidities | Often provides rapid short-term symptom improvement |
| Antihistamines | $-$$ | OTC or Rx (More easily covered by insurance.) | Widely available | Easy | Generally acceptable adherence | Drowsiness, dry mouth, dizziness, headache | Minimal | More beneficial when allergic rhinitis contributes to symptoms |
| Biologics | $$$ | Rx (Harder to get covered by insurance.) | More limited availabiity than others | Moderate | Injection schedule and long-term treatment commitment required | Varies by agent; injection-site reactions most common | Regular specialist follow-up | Can reduce polyp burden and symptoms in appropriate patients |
2. Deciding Whether To Proceed With Endoscopic Sinus Surgery (ESS) If Medical Therapy Fails
Perhaps the most significant SDM opportunity in CRS management is deciding whether to proceed with ESS.
The guideline recommends identifying patients who are most likely to benefit from surgery and offering ESS when the anticipated benefits outweigh those of continued medical management, expected outcomes are well understood, and patients recognize the need for ongoing disease management.
Comparing Continued Medical Therapy and ESS
| Consideration | Continued Medical Therapy | ESS |
|---|---|---|
| Upfront cost | Generally lower | Higher procedural cost |
| Symptom improvement | Variable | Often substantial in appropriately selected patients |
| Need for future therapy | Common | Common |
| Procedural risks | N/A | Surgical and anesthetic risks |
| Recovery time | N/A | Requires recovery period |
Setting Expectations
A particularly important recommendation in the guideline is counseling patients regarding realistic expectations before surgery.
Key discussion points include:
- CRS is a chronic disease
- Disease recurrence or relapse may occur
- Long-term medical management is often necessary even after surgery
For many patients, ESS can be best understood as a disease management strategy instead of a cure.
Which Patients May Be Likelier to Benefit from Surgery?
Some patients are less likely to benefit from continued medical therapy alone, including those with:
- Nasal polyps
- Bony erosion
- Eosinophilic mucin
- Fungal balls
In addition, surgery may be more strongly considered when CRS significantly affects:
- Sleep
- Work/school productivity
- Daily functioning
- Overall quality of life
3. Determining The Surgical Plan After ESS Is Chosen
While the surgeon ultimately recommends a procedure based on imaging findings, anatomy, disease severity, and prior treatment history, several aspects of surgical planning may still benefit from patient involvement.
Potential discussion topics include:
- The extent of surgery (e.g., more targeted versus more comprehensive sinus procedures)
- Whether concurrent procedures, such as septoplasty, should be performed
- The use of steroid-eluting implants or other adjunctive technologies
- Expected recovery time and postoperative care requirements
- Potential costs and insurance coverage considerations
Overall, the guideline emphasizes that decisions regarding sinus surgery for chronic rhinosinusitis should be individualized and grounded in SDM. SDM should incorporate diagnostic certainty, symptom burden, disease subtype, treatment preferences, quality-of-life, expectations for surgery, and the need for long-term disease management.
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