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.