Comparisons with Other Studies
Current literature regarding the benefit of endoscopic sinus surgery in
the CF population is conflicting. A few studies suggest that sinus
surgery and management of CRS can lead to improved pulmonary and
clinical outcomes in the CF population, while many others have not shown
much benefit. Shatz [16] examined a cohort of 15 pediatric patients
with CF and found improvements in pulmonary function test results, fewer
courses of IV antibiotics, and a significant decrease in number of
hospital admissions (all p < 0.006) after sinus surgery. This
cohort of patients underwent aggressive combined surgery (open and
endoscopic) and had previously undergone least 3-revision surgeries.
Liang et al [17] performed a systematic review of surgical
management of chronic rhinosinusitis in cystic fibrosis encompassing the
last 25 years with 24 articles meeting their inclusion criteria. The
outcomes examined included sinonasal symptoms, endoscopic findings,
pulmonary function testing, recurrence or revision surgery,
hospitalization, need for antibiotic therapy, radiographic findings, and
pulmonary exacerbations. Most studies in their review found improvement
in symptom measures and endoscopic findings with no improvement in lower
airway function after surgical therapy. The postoperative measures of
the other outcomes were inconclusive or inconsistent.
In a systematic review examining the role of endoscopic sinus surgery on
pulmonary function in patients with cystic fibrosis, nineteen studies
involving 586 patients were analyzed [18]. The authors found
consistent evidence of improved sinonasal symptoms. Overall, pulmonary
function tests were not improved by ESS in six cohort trials, with one
small study finding significant improvement. No significant difference
in FEV1 scores was confirmed by meta-analysis and no consistent
improvement in pulmonary function testing. Conflicting results with
regards to endoscopy scores, days spent in hospital, and courses of
intravenous antibiotics was identified.
Henriquez et al [19] examined the effect of endoscopic sinus surgery
on lung function, IV antibiotic use, and hospitalization in 15 adults
with CF. 12 month pre-operative and 12 month post-operative forced vital
capacity (FVC) and FEV1, IV antibiotic courses, total number of days IV
use, number of inpatient hospital days (IHD) were assessed. They found a
significant reduction in the number of IHDs in the postoperative period
(36.7 days vs 59.1,p=0.03) without evidence of improved lung function or
the need for IV antibiotics. Similarly, in a study examining the effect
of endoscopic sinus surgery on the pulmonary status of adults with
cystic fibrosis [20], 12 month pre and post-operative FEV1, days
hospitalized, and days of IV antibiotics was assessed in 32 patients.
The authors found that endoscopic sinus surgery did not reduce days
hospitalized or days on IV for a respiratory exacerbation in the pre- vs
postoperative period and concluded that there was no effect of FESS on
progression of lung disease in patients with CF.
A recent study by Alanin et al [21] examined chronic Gram-negative
lung infection 3 years post-endoscopic sinus surgery in 106 patients
with cystic fibrosis including pediatric and lung transplant patients.
Similar to our findings, the authors found that lung function declined
in the 3-year post-operative period. Although the number of
gram-negative bacteria non-colonized and intermittently colonized
patients significantly increased over the study period (16/106 patients
pre-operatively (15%) vs 35/106 patients (33%) post-operatively and 61
(58%) to 34 (32%) respectively) after three years, the number of
chronically infected patients increased from 29 (27%) to 37 (35%).
They also found that SNOT-22 scores improved while the global quality of
life scores decreased.
More recently, Khalfoun et al [22] performed a retrospective chart
review of 181 patients who underwent FESS from January 2009 to July
2014. Lung function data, including the forced expiratory volume in one
second (FEV1), forced vital capacity (FVC), and FEV1/FVC, were retrieved
within 1 year before and after surgery. They found that for the entire
cohort, lung function did not change related to FESS. Among patients
with FEV1 <80%, FEV1 declined presurgery by 3.5% per year
(95% CI, -6.1% to -0.8%; P = .010), which halted after surgery with
these patients, then showing no subsequent change in FEV1 (95% CI,
0.9%-3.7%; P = .240). No benefit was identified for patients with FEV1
>80%. They concluded that their findings suggest FESS may
benefit pulmonary outcomes.