Adherence to Postop Treatment May Indicate Early Recurrence of CRSwNP

In the setting of chronic rhinosinusitis with nasal polyps (CRSwNP), a dual-pronged approach that encompasses regular follow-up exams and administration of topical steroids is recommended for patients who have undergone functional endoscopic sinus surgery (ESS).

Findings were published in American Journal of Otolaryngology–Head and Neck Medicine and Surgery from the investigation that analyzed outcomes among 60 patients receiving care at the Division of Otorhinolaryngology, Department of Surgical Sciences, University of Turin, Italy.

“There is no clear consensus among surgeons on the frequency and timing of clinical examinations following surgery,” the study investigators wrote. “These examinations also patients the opportunity to discuss symptoms and their impact on quality of life. We analyzed patients’ symptoms according to the presence of relapsing polyps.”

For this analysis, a minimum mark of presence at 75% of the patient’s appointments for administration of nasal steroids was considered adherent. Clinical data were collected on age, sex, smoking status, comorbidities, number/times of recurrence, treatment for recurrence, and nasal symptoms. Follow-up exams took place biannually in the first year after surgery and yearly thereafter, and nasal steroid treatment comprised 50 mcg/d of mometasome furoate nasal spray for at least 2 months, once or twice a year.

The overall adherence rate was 25% (n = 15) among the study population, whose mean age was 57.03 (range, 23-74) years and of whom 56.7% had eosinophil inflammation/relapse at histologic exam after a mean (SD) follow-up of 9.88 (5.06) years.

Most cases of relapse were seen in the ostio-meatal complex only (79.45%), followed by 6 cases in the ostio-meatal complex and spheno-ethmoidal recess. Just 1 case of recurrence was seen in the spheno-ethmoidal recess only. Of the total 91 disease recurrences—with the mean annual total per patient of 0.14—54.9% were treated with oral or intramuscular systemic steroids and 45.1% with revision ESS; the mean time from first surgery to first recurrence was 78.43 (54.49) months. The most common recurrent nasal polyp grade was grade 1, which occurred in 12 patients.

Forty-seven patients (78.3%) underwent daily nasal washings with isotonic saline solution. Most participants were male patients (68.3%) and never-smokers (48.3%), and their most common comorbidity was allergy (48.3%).

At their last follow-up exam, most patients (51.7%) complained about hyposmia, which is a decreased sense of smell. However, the investigators found no significant differences between patients who did or did not have recurrence (P > .05), even with their data trending to “higher nasal obstruction in relapsed patients.” Nor were correlations found between any of the clinical items evaluated and disease recurrence (P > .05).

Overall, regular fiber optic evaluation and prompt recurrence treatment led to a rate of relapse at the final follow-up exam that was almost 5 times lower compared with patients who were not as adherent: 7.7% vs 38.2% (P < .001). Adequate adherence also led to grade > 2 polyps in 15.4% of the patients who met the 75% mark compared with 42.9% who were not adherent (P = .022).

The study investigators note that long-term postop care in patients with CRSwNP includes nasal washings and topical corticosteroids, and that to reduce recurrence risk, clinicians should encourage the use of intranasal steroids after surgery. They attribute the low adherence rate seen in their investigation “to insufficient information given to the patients by the surgeons and mostly to the fear of steroids’ potential side effects.”

This finding, in particular, “highlights the importance of regular follow-up examinations in order to identify recurrences in an early stage. Thus, patients could be unaware of the relapse or underestimate their symptoms,” they concluded.

Strength in their findings can be attributed to the long follow-up and that they evaluated the importance of regular follow-up exams, which they say are especially important in the aftermath of biologic agents being introduced into clinical practice.

Reference

Riva G, Pizzo C, Carraro M, Moresco M, Pecorari G. The importance of follow-up examinations in chronic rhinosinusitis with nasal polyposis. Am J Otolaryngol. 2023;44(1):103672. doi:10.1016/j.amjoto.2022.103672