title: Medical therapy vs surgery for chronic rhinosinusitis: a prospective, multi-institutional study.
abstract: BACKGROUND
  Evidence evaluating the comparative effectiveness of various treatments for chronic rhinosinusitis (CRS) is insufficient. This study evaluates outcomes in patients who failed initial medical management and elect a subsequent treatment option, either continued medical management or endoscopic sinus surgery (ESS) coupled with continued medical management.
  
  
  METHODS
  Adult subjects were prospectively enrolled into a nonrandomized, multi-institutional cohort. Baseline characteristics and objective clinical findings were collected. Primary outcome measures included 2 disease-specific quality-of-life (QOL) instruments: the Rhinosinusitis Disability Index (RSDI) and Chronic Sinusitis Survey (CSS). Bivariate and multivariate analyses compared QOL improvement by treatment type, as well as differences in antibiotic and oral steroid utilization and work/school productivity.
  
  
  RESULTS
  Subjects (n = 180) were enrolled between March 2009 and April 2010. Patients electing medical management (n = 55) reported significantly better baseline QOL on 1 instrument relative to surgery patients (CSS symptom [p = 0.019] and total scores [p = 0.010]). Surgical patients (n = 75) reported significantly more improvement than medically managed patients (RSDI, p = 0.015; CSS, p < 0.001). Surgical patients reported significantly fewer oral antibiotics (p = 0.002), oral steroids (p = 0.042), and missed days of work/school (p < 0.001) following ESS. After adjustment, more frequent improvement was found within the surgical cohort as measured by the RSDI physical (78.7% vs 56.4%; odds ratio [OR], 3.36; 95% confidence interval [CI], 1.15-9.87; p = 0.027), CSS symptom (80.6% vs 57.4%; OR, 2.65; 95% CI, 1.06-6.66; p = 0.038), medication (49.3% vs 29.6%; OR, 2.33; 95% CI, 0.96-5.64; p = 0.060), and total scores (76.4% vs 53.7%; OR, 2.20; 95% CI, 0.86-5.59; p = 0.099).
  
  
  CONCLUSIONS
  Patients electing ESS experienced significantly higher levels of improvement in several outcomes. Further investigation with a larger cohort is warranted as treatment selection bias may confound the magnitude of improvement experienced with each treatment.
authors.affiliation: Division of Rhinology and Sinus Surgery, Oregon Sinus Center, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR, USA. smithtim@ohsu.edu
authors.forename: Timothy L
authors.initials: TL
authors.lastname: Smith
authors.forename: Robert C
authors.initials: RC
authors.lastname: Kern
authors.forename: James N
authors.initials: JN
authors.lastname: Palmer
authors.forename: Rodney J
authors.initials: RJ
authors.lastname: Schlosser
authors.forename: Rakesh K
authors.initials: RK
authors.lastname: Chandra
authors.forename: Alexander G
authors.initials: AG
authors.lastname: Chiu
authors.forename: David
authors.initials: D
authors.lastname: Conley
authors.forename: Jess C
authors.initials: JC
authors.lastname: Mace
authors.forename: Rongwei F
authors.initials: RF
authors.lastname: Fu
authors.forename: James A
authors.initials: JA
authors.lastname: Stankiewicz
mesh_terms: D000041:Absenteeism; D000284:Administration, Oral; D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002908:Chronic Disease; D003131:Combined Modality Therapy; D017558:Elective Surgical Procedures; D004724:Endoscopy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011788:Quality of Life; D012220:Rhinitis / Q000188:drug therapy* / Q000601:surgery*; D012852:Sinusitis / Q000188:drug therapy* / Q000601:surgery*; D013256:Steroids / Q000008:administration & dosage; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D013256:Steroids