ABSTRACT
Objective
This study evaluates if undergoing bariatric surgery for patients with obesity results in a decreased incidence of chronic rhinosinusitis (CRS) and fewer functional endoscopic sinus surgeries (FESS).
Methods
A retrospective cohort analysis was conducted using the US Collaborative Network on the TriNetX Analytics Platform. Adult patients with obesity (most recent value of BMI ≥ 30 kg/m2) were included and separated into two cohorts: one that underwent bariatric surgery (n = 53,454) and another that did not (n = 17,006,670). Patients in the two cohorts were matched by age, gender, race, tobacco use, and asthma and allergic rhinitis comorbidities. Outcomes analyzed included the incidence of CRS and FESS, identified by ICD‐10 and CPT codes, respectively, within 2, 5, and 10 years. Patients with outcomes prior to the follow‐up window were excluded.
Results
Two years after surgery, patients with obesity who underwent bariatric surgery had a decreased risk of developing CRS, with a relative risk (RR) of 0.79 (95% CI: 0.70–0.88). The risk remained lower at 5‐ and 10‐year post‐surgery, with a RR of 0.79 (95% CI: 0.73–0.86) and 0.73 (CI: 0.68–0.79), respectively. For patients with obesity and CRS, undergoing bariatric surgery resulted in fewer FESS at 2, 5, and 10 years after surgery, with a RR of 0.52 (95% CI: 0.35–0.79), 0.56 (95% CI: 0.42–0.76), and 0.50 (95% CI: 0.38–0.67), respectively.
Conclusion
In patients with obesity, bariatric surgery is associated with a decreased incidence of CRS and fewer FESS. Further studies are needed to confirm results and consider other comorbidities and medical interventions.
Level of Evidence
3
Keywords: bariatric surgery, chronic rhinosinusitis, obesity
Obesity is associated with an increased risk of chronic rhinosinusitis (CRS) and increased recurrence of CRS after functional endoscopic sinus surgery (FESS). This study found that in patients with obesity, undergoing bariatric surgery decreases the risk of new‐encounter diagnoses of CRS and results in fewer FESS.
1. Introduction
Chronic rhinosinusitis (CRS) affects over 10% of adults in the United States, with an overall (direct and indirect costs) annual economic burden of $22 billion USD [1, 2]. Numerous risk factors, from genetics and comorbid medical conditions to environmental factors, have been associated with CRS [3]. Among the various comorbidities, CRS has been found to be highly associated with patients with asthma and allergic rhinitis [4, 5, 6]. These comorbidities are also thought to affect the treatment response for CRS. For example, asthma is associated with increased severity of CRS symptoms and results in a more comprehensive treatment approach being needed for symptom management [7]. The relationship between CRS and asthma is hypothesized to stem from their shared inflammatory pathways, with both conditions characterized by a type 2, eosinophilic inflammation [4].
As an airway inflammatory condition, asthma is also linked to obesity, with the prevalence rate of asthma being higher in patients with obesity compared to lean or overweight individuals [8]. Numerous studies have shown that bariatric surgery, which achieves a loss of 50%–70% of excess weight, can also improve airway hyperresponsiveness, reduce asthma medication use, and decrease asthma exacerbations requiring hospital management [9, 10, 11]. Like asthma, CRS is also associated with obesity, with numerous studies demonstrating increased risk for developing CRS in patients with obesity [12, 13, 14]. With over 40% of the US population being affected by obesity, the correlation between obesity and CRS suggests the need for exploring treatment options in obesity that may reduce the risk and symptom burden of CRS [15].
Given the overlap between CRS and asthma alongside the impact of weight loss through bariatric surgery on asthma outcomes, our study aims to look at the effects of bariatric surgery on CRS incidence and treatment response with functional endoscopic sinus surgery (FESS). To our knowledge, no study has specifically assessed the effects of bariatric surgery on obesity‐related CRS. In this study, we utilize a large, population‐based analytics platform to conduct a retrospective cohort analysis on patients with obesity, comparing the risk of a new‐encounter diagnosis of unspecified CRS between patients with and without a history of bariatric surgery. Additionally, to measure the effects of bariatric surgery on the management of patients with obesity and CRS, we performed a secondary analysis to compare the risk of requiring FESS in patients with and without a history of bariatric surgery. Finally, as GLP‐1 receptor agonists (GLP‐1RAs) have been shown to reduce the risk of respiratory diseases in patients with obesity [16], we conducted sub‐analyses that looked at the risk of developing CRS and needing FESS after excluding all patients with a GLP‐1RA prescription.
2. Materials and Methods
This retrospective cohort study was conducted using the US Collaborative Network within the TriNetX Analytics Platform. This network consists of deidentified electronic health record (EHR) data for over 120 million patients in 69 health care organizations (HCOs). No ethics approval was needed for this study as the use of the TriNetX platform has been approved by the Cleveland Clinic IRB as exempt human subject research.
In this retrospective cohort analysis, two separate analyses were conducted. For each analysis, the cohorts were matched by age, gender, race, tobacco use, and asthma and allergic rhinitis diagnoses. Both analyses began with a cohort of adult patients (≥ 18 years of age) with obesity. In this study, obesity was defined using the LOINC code of 39156‐5, with a most recent value of BMI ≥ 30 kg/m2. The BMI classification was based on the definition for obesity by the Centers for Disease Control and Prevention BMI classifications.
2.1. Primary Analysis
For the first analysis, the patients were divided into two cohorts: the first with no history of bariatric surgery and the second with a positive history of bariatric surgery. A bariatric surgery event was identified by the CPT code for bariatric surgery procedures: CPT 1007385. The primary outcome for this analysis was the new incidence of CRS at 2‐, 5‐, and 10‐year follow‐up. Chronic rhinosinusitis was defined by an ICD‐10 code of J32. A sub‐analysis was conducted within the primary analysis that followed the same methodology but excluded patients with a GLP‐1RA prescription, as identified by an ATC code of A10BJ.
2.2. Secondary Analysis
The second analysis looked at adult patients with diagnoses of both obesity and CRS. The cohort was then separated into the following groups: the first with no history of bariatric surgery and the second with a positive history of bariatric surgery. For this analysis, the primary outcome was the new incidence of FESS at 2‐, 5‐, and 10‐year follow‐up. FESS included procedures that were identified by the following CPT codes: 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, and 31288. Following the secondary analysis, a sub‐analysis following the same methodology was conducted to evaluate results after excluding patients with a GLP‐1RA prescription.
2.3. Statistical Analysis
The statistics for this study were performed with the analytics tool that is built‐in within the TriNetX platform. 1:1 propensity matching was completed within the platform between surgical and non‐surgical cohorts using logistic regression. Given the large sample size of the study population, the analytics platform only permitted 1:1 propensity matching for 6 variables. The matched tolerance level was 0.01 with a standardized mean difference (SMH) of less than or equal to 0.1 between covariates. Patients with a prior diagnosis or history of the procedure included in the primary outcome were excluded. Risk and relative risk with a 95% confidence interval were calculated to compare results.
3. Results
As shown in Figure 1, the study population of this retrospective cohort analysis included 17,006,670 patients with a BMI ≥ 30 kg/m2 and 845,973 patients with obesity and an ICD‐10 diagnosis of unspecified CRS. Of those patients with obesity, 53,454 had a history of bariatric surgery. Similarly, 5346 patients from those with obesity and CRS had a history of bariatric surgery. For our sub‐analyses, after excluding patients with a GLP‐1RA, there were 16,332,388 patients with obesity and 733,745 patients with obesity and CRS. Of those with obesity, 41,030 had a history of bariatric surgery, while 3276 patients with obesity and CRS had a history of bariatric surgery.
FIGURE 1.
Study population enrolled from the US Collaborative TriNetX platform for the evaluation of the impact of bariatric surgery on the incidence of CRS and FESS. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
The impact of bariatric surgery on the risk of new‐onset CRS in patients with obesity can be seen in Table 1. The patients in each cohort were matched for age at index, gender, race, tobacco use, and asthma and allergic rhinitis diagnoses. At 2, 5, and 10 years after bariatric surgery or an obesity diagnosis, patients with a history of bariatric surgery consistently demonstrated a lower risk of new‐onset CRS diagnosis, with a relative risk of 0.79 (95% CI: 0.70–0.88), 0.79 (95% CI: 0.73–0.86), and 0.73 (0.68–0.79), respectively. After excluding patients with a GLP‐1RA prescription, the results remained similar. As shown in Table 2, patients with a history of bariatric surgery had a relative risk of 0.67 (95% CI: 0.59–0.77), 0.78 (95% CI: 0.69–0.88), and 0.79 (95% CI: 0.72–0.86), at 2, 5, and 10 years after surgery. When looking at the effects of bariatric surgery on the number of FESS needed for the management of CRS in patients with obesity, a similar correlation was seen. As depicted in Table 3, patients with a history of bariatric surgery were observed to have a lower risk of requiring FESS at 2, 5, and 10 years follow‐up, with a relative risk of 0.52 (95% CI: 0.35–0.79), 0.56 (95% CI: 0.42–0.76), and 0.50 (95% CI: 0.38–0.67), respectively. As seen in Table 4, an analogous trend in results was seen after excluding patients with a GLP‐1RA prescription, as patients with a history of bariatric surgery had a relative risk of 0.63 (95% CI: 0.43–0.93), 0.41 (95% CI: 0.27–0.61), and 0.47 (95% CI: 0.33–0.67) at 2, 5, and 10 years after surgery.
TABLE 1.
Comparing risk of new‐onset CRS in obesity between patients with and without a history of bariatric surgery.
| Follow‐up | Matched parameter | Patient groups | Patients in cohort | Patients with outcome | Risk | Relative risk | 95% CI |
|---|---|---|---|---|---|---|---|
| 2 years | Before matching | Obesity | 14,813,808 | 175,132 | 1.18% | Reference | |
| Obesity + bariatric surgery | 39,280 | 536 | 1.37% | 1.15 | 1.06–1.26 | ||
| After matching | Obesity | 37,827 | 669 | 1.77% | Reference | ||
| Obesity + bariatric surgery | 36,639 | 509 | 1.39% | 0.79 | 0.70–0.88 | ||
| 5 years | Before matching | Obesity | 15,670,863 | 315,876 | 2.02% | Reference | |
| Obesity + bariatric surgery | 42,675 | 1038 | 2.43% | 1.21 | 1.14–1.28 | ||
| After matching | Obesity | 43,953 | 1354 | 3.08% | Reference | ||
| Obesity + bariatric surgery | 42,675 | 1038 | 2.43% | 0.79 | 0.73–0.86 | ||
| 10 years | Before matching | Obesity | 15,670,863 | 409,687 | 2.61% | Reference | |
| Obesity + bariatric surgery | 42,675 | 1269 | 2.97% | 1.14 | 1.08–1.20 | ||
| After matching | Obesity | 43,953 | 1782 | 4.05% | Reference | ||
| Obesity + bariatric surgery | 42,675 | 1269 | 2.97% | 0.73 | 0.68–0.79 | ||
TABLE 2.
Comparing the risk of new‐onset CRS in obesity between patients with and without a history of bariatric surgery after excluding all patients prescribed a GLP‐1RA.
| Follow‐up | Matched parameter | Patient groups | Patients in cohort | Patients with outcome | Risk | Relative risk | 95% CI |
|---|---|---|---|---|---|---|---|
| 2 years | Before matching | Obesity | 12,469,810 | 139,379 | 1.12% | Reference | |
| Obesity + bariatric surgery | 28,617 | 325 | 1.14% | 1.02 | 0.91–1.13 | ||
| After matching | Obesity | 30,487 | 517 | 1.70% | Reference | ||
| Obesity + bariatric surgery | 29,883 | 342 | 1.14% | 0.67 | 0.59–0.77 | ||
| 5 years | Before matching | Obesity | 11,392,230 | 206,774 | 1.82% | Reference | |
| Obesity + bariatric surgery | 25,310 | 508 | 2.00% | 1.11 | 1.01–1.20 | ||
| After matching | Obesity | 24,512 | 637 | 2.60% | Reference | ||
| Obesity + bariatric surgery | 24,057 | 488 | 2.03% | 0.78 | 0.69–0.88 | ||
| 10 years | Before matching | Obesity | 12,117,163 | 280,185 | 2.31% | Reference | |
| Obesity + bariatric surgery | 28,282 | 740 | 2.62% | 1.13 | 1.05–1.22 | ||
| After matching | Obesity | 30,366 | 1008 | 3.32% | Reference | ||
| Obesity + bariatric surgery | 29,784 | 778 | 2.61% | 0.79 | 0.72–0.86 | ||
TABLE 3.
Comparing the risk of FESS between patients with obesity and CRS with or without a history of bariatric surgery.
| Follow‐up | Matched parameter | Patient groups | Patients in cohort | Patients with outcome | Risk | Relative risk | 95% CI |
|---|---|---|---|---|---|---|---|
| 2 years | Before matching | Obesity + CRS | 653,646 | 13,759 | 2.11% | Reference | |
| Obesity + CRS + bariatric surgery | 4050 | 35 | 0.86% | 0.41 | 0.30–0.57 | ||
| After matching | Obesity + CRS | 3701 | 66 | 1.78% | Reference | ||
| Obesity + CRS + bariatric surgery | 3646 | 34 | 0.93% | 0.52 | 0.35–0.79 | ||
| 5 years | Before matching | Obesity + CRS | 664,943 | 18,175 | 2.73% | Reference | |
| Obesity + CRS + bariatric surgery | 3908 | 61 | 1.56% | 0.57 | 0.45–0.73 | ||
| After matching | Obesity + CRS | 4589 | 115 | 2.51% | Reference | ||
| Obesity + CRS + bariatric surgery | 4535 | 64 | 1.41% | 0.56 | 0.42–0.76 | ||
| 10 years | Before matching | Obesity + CRS | 668,083 | 19,498 | 2.92% | Reference | |
| Obesity + CRS + bariatric surgery | 4144 | 64 | 1.54% | 0.53 | 0.41–0.68 | ||
| After matching | Obesity + CRS | 4618 | 139 | 3.01% | Reference | ||
| Obesity + CRS + bariatric surgery | 4546 | 69 | 1.52% | 0.50 | 0.38–0.67 | ||
TABLE 4.
Comparing the risk of FESS between patients with obesity and CRS with or without a history of bariatric surgery after excluding all patients prescribed a GLP‐1RA.
| Follow‐up | Matched parameter | Patient groups | Patients in cohort | Patients with outcome | Risk | Relative risk | 95% CI |
|---|---|---|---|---|---|---|---|
| 2 years | Before matching | Obesity + CRS | 541,842 | 13,823 | 2.55% | Reference | |
| Obesity + CRS + bariatric surgery | 2321 | 33 | 1.42% | 0.56 | 0.40–0.78 | ||
| After matching | Obesity + CRS | 2911 | 66 | 2.27% | Reference | ||
| Obesity + CRS + bariatric surgery | 2876 | 41 | 1.43% | 0.63 | 0.43–0.93 | ||
| 5 years | Before matching | Obesity + CRS | 592,895 | 19,543 | 3.30% | Reference | |
| Obesity + CRS + bariatric surgery | 2768 | 45 | 1.63% | 0.49 | 0.37–0.66 | ||
| After matching | Obesity + CRS | 2229 | 79 | 3.54% | Reference | ||
| Obesity + CRS + bariatric surgery | 2209 | 32 | 1.45% | 0.41 | 0.27–0.61 | ||
| 10 years | Before matching | Obesity + CRS | 536,222 | 17,572 | 3.28% | Reference | |
| Obesity + CRS + bariatric surgery | 2473 | 34 | 1.38% | 0.42 | 0.30–0.59 | ||
| After matching | Obesity + CRS | 3019 | 92 | 3.05% | Reference | ||
| Obesity + CRS + bariatric surgery | 2996 | 43 | 1.44% | 0.47 | 0.33–0.67 | ||
4. Discussion
To our knowledge, this is the first study to assess the impact of bariatric surgery on CRS incidence and management in patients with obesity. In our study, the risk of a new encounter diagnosis of unspecified CRS was decreased in patients with obesity who underwent bariatric surgery compared to their non‐surgical counterparts.
In our study population, approximately 1.2% of patients with obesity had a new onset diagnosis of CRS within 2 years, with this number increasing to 2.6% within 10 years. The 1.2% is comparable to the findings in a study by Hoying et al., which reported a 1.02% risk of new‐onset unspecified CRS in patients with obesity during a 2‐year follow‐up [13].
While most literature has focused on the impacts of bariatric surgery on common obesity comorbidities like diabetes, hypertension, and hypercholesterolemia [17, 18], additional studies have also identified airway inflammatory conditions like asthma as a potential comorbidity affected by weight loss in patients with obesity [19, 20, 21]. The chronic inflammation alongside increased leptin and decreased adiponectin levels seen in obesity are implicated in the increased susceptibility to asthma seen in these patients [22]. Given that bariatric surgery can reverse the adipokine imbalance and decrease leptin and IL‐6 levels, researchers have studied the effects of bariatric surgery in the obese asthma population [23, 24, 25, 26]. The results have shown that in patients with obesity and asthma, bariatric surgery can reduce anti‐asthmatic drug dosing and improve asthma control and quality of life [27].
Given the overlap in the type of inflammation and epithelium between CRS and asthma, this study built on the current knowledge to evaluate the effects of bariatric surgery on CRS. The three time points that were analyzed were chosen based on longitudinal data regarding the effects of bariatric surgery on weight loss. Studies looking at various bariatric surgeries have shown that optimal clinical response weight loss is seen in 47%–80% of patients within 1–2 years after bariatric surgery [28]. Approximately 30%–60% of patients maintain this weight loss at 5‐ and 10‐year post‐surgery, depending on the bariatric procedure [28, 29]. In our study, the risk of CRS remained equally lower at 2, 5, and 10 years after bariatric surgery, suggesting that the protective effects of bariatric surgery for CRS risk may be similarly sustained over the course of 10 years. These results parallel the findings seen with asthma control and bariatric surgery. Maniscalco et al. reported an overall improvement in asthma control in the surgical group 5 years after laparoscopic adjustable gastric banding surgery [30]. In a longitudinal study by Witte et al., while patients undergoing bariatric surgery did experience significant weight regain at 8 years follow‐up compared to 12 months follow‐up, asthma control and small airway function scores remained clinically stable, indicating a sustained benefit of bariatric surgery on obesity‐related asthma control [31]. Our study adds to the existing literature regarding bariatric surgery and asthma by looking at a closely related inflammatory condition, CRS, and showing that even after controlling for asthma, bariatric surgery remains associated with a decreased risk of CRS.
As some patients with obesity may already have CRS prior to bariatric surgery, we conducted a secondary analysis to evaluate the effects of bariatric surgery on CRS management. FESS is one of the more rewarding yet costly and burdensome management procedures for patients with CRS [32]. As such, we primarily evaluated the effects of bariatric surgery on the management of CRS based on the number of FESS undergone by patients after CRS diagnosis. Our results showed that in patients with obesity and CRS, undergoing bariatric surgery can significantly decrease the number of FESS needed for the management of CRS. Prior literature has established that an elevated BMI can increase the recurrence of CRS after FESS [33]. Additionally, comorbid obesity in patients with CRS has been correlated with reduced relative mean percentage improvement on the Rhinosinusitis Disability Index scoring and SNOT‐22 scoring compared to normal weight participants after endoscopic sinus surgery, suggesting that the effects of surgery on CRS treatment differ by comorbid obesity status [34].
Prior literature has shown that alongside bariatric surgery, GLP‐1RAs can also reduce the risk of asthma exacerbations in patients with obesity [35]. Given the overlapping inflammatory profiles of asthma and CRS, it is possible that the use of a GLP‐1RA may be contributing to the decreased CRS risk seen in our study. In our study population, we found that 4% of patients with obesity were prescribed a GLP‐1RA while 23% of patients with obesity and bariatric surgery were prescribed a GLP‐1RA. To remove the confounding effect of the GLP‐1RAs, we conducted a sub‐analysis that excluded patients with a GLP‐1RA prescription. After excluding patients with a GLP‐1RA prescription, our results remained the same, showing that bariatric surgery is associated with a decreased risk of CRS and fewer FESS. Further studies are needed to compare bariatric surgery and GLP‐1RA use for their relative risk reduction of CRS and FESS in patients with obesity.
This database study shows initial findings that bariatric surgery may provide an added benefit in patients with obesity, reducing the incidence of both new‐onset CRS and the number of FESS needed in the management of CRS. Future prospective studies are needed to correlate whether the observed changes in CRS and FESS risk are directly attributable to changes in BMI. Moreover, given the substantial overlap in the inflammatory cytokine profile between obesity and CRS [36, 37, 38, 39], further investigation into changes in the CRS inflammatory landscape following bariatric surgery is needed to identify specific mechanisms of disease progression.
This study does have limitations. Given that the analysis relies on data recorded in the EHR, there is a possibility of reporting and measurement bias. The ICD‐10 and CPT codes used for measuring outcomes of CRS and sinus surgeries, respectively, mean these diagnoses and procedures could not be confirmed with traditional CRS criteria or operative notes. Additionally, the LOINC codes in the TriNetX database do not allow for the monitoring of BMI changes over time, and as such, it is not possible to assess whether changes in CRS risk over time are directly correlated with changes in BMI. Similarly, this study does not allow for changes in BMI to be correlated with severity of CRS and FESS rates. Finally, given that the database study limits the number of covariates that can be matched for, there is a limitation regarding the investigation of additional confounding factors.
5. Conclusion
This study suggests that bariatric surgery in patients with obesity may reduce their risk of developing CRS. Simultaneously, for patients with CRS and obesity, bariatric surgery may have benefits extending beyond weight loss, specifically decreasing the number of sinus surgeries needed for management of CRS. Given the increasing prevalence of obesity in the United States alongside the positive association between obesity and CRS, identifying strategies to prevent and manage the progression of CRS in patients with obesity is crucial to improving overall quality of life and reducing health costs. Future prospective studies should explore this relationship to characterize the mechanistic link and understand if the timing of bariatric surgery influences the development and management of obesity‐associated CRS.
Conflicts of Interest
The authors declare no conflicts of interest.
Thatte S. and Chaaban M. R., “Bariatric Surgery Lowers Incidence of Chronic Rhinosinusitis and Functional Endoscopic Sinus Surgery,” The Laryngoscope 135, no. 10 (2025): 3542–3549, 10.1002/lary.32265.
Funding: The authors received no specific funding for this work.
Triological Society 2025 Combined Sections Meeting, Orlando, Florida, U.S.A. January 23‐25, 2025.
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