Abstract
Background:
Chronic rhinosinusitis with asthma (CRS-A) has a significant impact on patient morbidity and quality of life. Nevertheless, little is known about the natural history of endoscopic sinus surgery (ESS) in this cohort. The objective of this study was to evaluate revision rates of ESS in CRS-A and identify risk factors associated with increased likelihood for revision surgery compared to those with CRS without asthma (CRS-alone).
Methods:
The Utah Population Database was queried for patients age > 18 with CRS who underwent at least one ESS between 1996 and 2018. Demographic information and history of ESS were collected and compared between CRS-A and CRS-alone using chi-square tests for categorical variables and t-tests for continuous variables. Risk factors for revision surgery were analyzed using Cox proportional hazard models.
Results:
A total of 33,090 patients (7693 CRS-A and 25,397 CRS-alone) were included in the final analysis. Mean follow up was 9.8 years in CRS-A and 9.1 years in CRS-alone (p<0.001). The revision rate among patients with CRS-A (21.5%) was twice that of CRS-alone (10.8%) (p<0.001). Among patients with CRS, a history of allergy (p<0.001), asthma (p<0.001), and nasal polyposis (p<0.001) was independently associated with increased risk of revision ESS. Patients with CRS-A and nasal polyposis were 6 times more likely to require revision surgery than those with CRS-alone (p<0.010).
Conclusion:
The rate of revision ESS in CRS-A was twice that of CRS-alone; patients with CRS-A and nasal polyposis were 6 times more likely to require revision than those with CRS-alone.
Keywords: chronic rhinosinusitis, asthma, endoscopic sinus surgery, revision surgery, nasal polyposis
Introduction
Asthma affects over 26 million Americans,1 with 22–45% of these patients concurrently suffering from chronic rhinosinusitis (CRS).2 The overall prevalence of both diseases is continuing to rise, with asthma affecting 7.7% of the US population3 and CRS affecting up to 12% of the population.4 There is evidence to suggest significant overlap between these two diseases, both in pathophysiology and management.5 Asthma with comorbid CRS (CRS-A) can be particularly challenging to manage, with patients demonstrating poorer outcomes, increased exacerbations, and greater healthcare costs than those with asthma alone.5 Similarly, the sinonasal disease in patients with CRS-A is often challenging to treat and recalcitrant to medical therapy, resulting in patients electing endoscopic sinus surgery (ESS).6,7
Regardless, the relationship between the upper and lower airway has not been well studied in the literature. Here, we seek to bring attention to this new area of study by highlighting the role of ESS (and revision ESS) in managing patients with CRS-A, including both those with and without nasal polyposis. The latter observation is important as it emphasizes the shortcomings of the prior literature, which has been limited to investigating the classic association of nasal polyposis with asthma only (CRSwNP-A), ignoring the subset of patients with CRS without nasal polyposis and asthma (CRSsNP-A).8,9
Prior investigations have identified asthma as a risk factor for revision surgery, but there remains a lack of exploration examining patients with CRS-A as a unique cohort and phenotype.10,11 Having a better understanding of revision rates among patients who suffer from both asthma and CRS may improve the management and care of these patients, as well as aid with patient counseling. The objectives of this study were to define characteristics of ESS in CRS-A both with and without nasal polyposis, including long-term revision rates and mean duration between revision surgeries, and identify patient factors that increase the risk of revision surgery. Variations between revision rates in CRS-alone versus CRS-A, as well as differences based on polyp status, were also examined.
Methods
Utah Population Database (UPDB)
The UPDB is a unique research resource that contains 42 million records spanning several decades, representing 11 million individuals, and including genealogy records and Utah birth and death certificates. Moreover, beginning in 1996, records of hospitalizations, ambulatory surgeries, and emergency department visits, with links to clinical records of the statewide University of Utah Healthcare system, are available for review.12 It is the only database of its kind in the United States, and one of only a few in the world. This population-based cohort study was approved by the institutional review board (IRB) of the University of Utah and by the Utah Resource for Genetic and Epidemiologic Research, which oversees use of the UPDB resource. An IRB waiver of consent and authorization were obtained to conduct this study. We utilized UPDB data resources for this study similar to our previous research as described.12–14 The breadth and longevity of the database provides a unique opportunity to assess the longitudinal natural history of patients who undergo ESS.12
Study Population
The UPDB was queried for patients age 18 and older diagnosed with CRS between 1996 and 2018.13 Patients were included in the study if they satisfied both of the following criteria (Figure 1):
Figure 1:
Flow chart depicting exclusion criteria. CRS = chronic rhinosinusitis.
CPT (Current Procedural Terminology) endoscopy code 31231 AND at least one or more ICD-9/10 diagnosis codes for: chronic rhinosinusitis without nasal polyposis (CRSsNP): ICD-9 473.0–473.9; ICD-10 J32.0-J32.9 or chronic rhinosinusitis with nasal polyposis (CRSwNP): ICD-9 471.x; ICD-10 J33.0-J33.
CPT sinus surgery code: 30115, 30110, 31233, 31237, 31254, 31255, 31256, 31267, 31276, 31287, 31288, 31253, 31257, 31259
Patients with asthma were defined as anyone who were diagnosed with ICD-9 493.x or ICD-10 J45.x. Patients with CRS without asthma were included as a comparison group. Revision rates and risk factors were compared between CRSwNP and CRSsNP phenotypes. Patients were excluded if they had any history or diagnosis of asthma exacerbated respiratory disease (AERD, i.e. aspirin allergy) (ICD-9 V14.6, ICD-10 Z88.6), cystic fibrosis (ICD-9 277.x, ICD-10 E84.x), malignant sinonasal neoplasms (ICD-9 160.0–160.9, ICD-10 C30.0), inverted papilloma (ICD-9 212.0, ICD-10 D14.0), and a history of head or facial trauma (ICD-9 801.0–804.9; ICD-10 S01-S09). Additionally, patients were excluded if there was no documentation of patient gender or if the date of last follow up in the UPDB preceded the date of first surgery. This excluded patient records with potential documentation errors and ensured adequate follow-up.
The overall revision rate for this cohort was defined as patients who had an initial episode of sinus surgery (defined by any combination of CPT codes 31288, 31267, 31233, 31254, 31255, 31256, 31276, and 31287), followed by an additional episode of sinus surgery on a later date. Subsequent distinct episodes of these codes were counted as 3rd or 4th revisions, etc., based on the number of previous surgeries.
Demographics
The following demographic information was collected for each patient: age, gender, race/ethnicity, and history of allergies, nasal polyposis, and tobacco use.
Statistical Analysis
Demographic characteristics and ESS history of patients with CRS-A was compared to those of patients with CRS-alone using t-tests for continuous variables and chi-squared tests for categorical variables. Cox proportional hazard models were used to estimate the effect of gender, age at diagnosis procedure, race/ethnicity, history of tobacco use, history of allergy, and nasal polyposis on risk of revision surgeries separately for patients with CRS-A and CRS-alone. Statistical analysis was performed using R software version 3.4.2.
Study Outcomes
The primary outcome of this study was the long-term revision rate for ESS in patients with CRS-A. Additional outcomes include the average number of sinus surgeries, the duration of time between surgeries, and characteristics that increase risk for revision surgery in CRS-A.
Results
Demographics
A total of 33,090 patients (7693 CRS-A and 25,397 CRS without asthma (CRS-alone) were included in the final analysis. Mean duration of follow up was 9.8 years in the CRS-A group and 9.1 years in the CRS-alone cohort. A significantly larger proportion of the CRS-A cohort was female (60.5%) compared to the CRS-alone cohort (48%) (p<0.001). Similarly, a larger proportion of the asthma cohort demonstrated a concomitant diagnosis of allergies (12.3%) and tobacco use (23.5%) compared to the non-asthma cohort (5.8% and 18.7%, respectively) (p<0.001) (Table I). Patients with CRS-A were more likely to be of Hispanic/Latino descent compared to CRS-alone (p<0.001) (Table I).
Table I:
Baseline demographic data. All patients with chronic rhinosinusitis (CRS) (N = 33,090)
| CRS-A (N = 7693) | CRS-alone (N = 26583) | p-values | |
|---|---|---|---|
| Age at 1st surgery | <0.001 | ||
| - Mean (SD) | 45.6 ± 15.4 | 43.5 ± 15.3 | |
| - Range | 18.0 – 91.9 | 18.0 – 95.8 | |
| Age at last follow up* | 55.7 ± 16.2 | 52.7 ± 15.8 | <0.001 |
| Follow up time from 1st procedure | 9.8 ± 5.3 | 9.1 ± 5.3 | <0.001 |
| Gender | <0.001 | ||
| - Female | 4656 (60.5%) | 12183 (48.0%) | |
| - Male | 3037 (39.5%) | 13214 (52.0%) | |
| Ethnicity | <0.001 | ||
| - Non Hispanic/Latino | 6244 (81.2%) | 19950 (78.6%) | |
| - Hispanic/Latino | 625 (8.1%) | 1795 (7.1%) | |
| - Not available | 824 (10.7%) | 3652 (14.4%) | |
| Allergy | <0.001 | ||
| - No | 6746 (87.7%) | 23931 (94.2%) | |
| - Yes | 947 (12.3%) | 1466 (5.8%) | |
| Tobacco Use | <0.001 | ||
| - No | 5886 (76.5%) | 20652 (81.4%) | |
| - Yes | 1807 (23.5%) | 4745 (18.7%) | |
| Nasal polyposis | < 0.001 | ||
| -No | 2690 (35.0%) | 11020 (43.5%) | |
| -Yes | 5003 (65.0%) | 14377 (56.5%) |
Individuals were only followed until 2017.
Note: Demographic characteristics of chronic rhinosinusitis (CRS) with (CRS-A) and without (CRS-alone) asthma were compared using t-tests for continuous variables and chi-square tests for categorical variables.
Revision ESS Percentage
The rate of revision ESS was twice as high (21.5%) among patients with CRS-A compared to patients with CRS-alone (10.8%) (p<0.001) (Table IIa). The revision rate was the greatest among the CRSwNP-A cohort (28.8%) compared to patients with CRSwNP-alone (15.2%) (Table IIb) (p<0.001), and also greater in patients with CRSsNP-A (7.9%) compared to those with CRSsNP-alone (5.0%) (Table IIc) (p<0.001). A similar observation was seen across subsequent revision surgeries as well (p<0.001) (Table IIa–c).
Table II:
Percentage of patients who underwent multiple endoscopic sinus surgeries over the study duration 1996–2017. CRS-A = chronic rhinosinusitis with asthma; CRS-alone = chronic rhinosinusitis without asthma; CRSwNP-A = chronic rhinosinusitis with nasal polyposis and asthma; CRSwNP-alone = chronic rhinosinusitis with nasal polyposis but without asthma; CRSsNP-A = chronic rhinosinusitis without nasal polyposis but with asthma; CRSsNP-alone = chronic rhinosinusitis without nasal polyposis and without asthma
| a) All patients with chronic rhinosinusitis (CRS) | |||
| Number of revision surgeries | CRS-A (N = 7693) | CRS-alone (N = 25397) | p-values |
| Any revision surgery | 1652 (21.5%) | 2746 (10.8%) | <0.001 |
| Number of revision surgeries | <0.001 | ||
| - 0 revision | 6041 (78.5%) | 22651 (89.2%) | |
| - 1 revision | 1159 (15.1%) | 2260 (8.9%) | |
| - 2 revisions | 307 (4.0%) | 363 (1.4%) | |
| - 3–5 revisions | 173 (2.2%) | 117 (0.5%) | |
| - 6+ revisions | 13 (0.2%) | * | |
| b) Patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) | |||
| Number of revision surgeries | CRSwNP-A (N = 5003) | CRSwNP-alone (N = 14377) | p-values |
| Any revision surgery | 1440 (28.8%) | 2191 (15.2%) | <0.001 |
| Number of revision surgeries | <0.001 | ||
| - 0 revision | 3563 (71.2%) | 12186 (84.8%) | |
| - 1 revision | 968 (19.3%) | 1766 (12.3%) | |
| - 2 revisions | 289 (5.8%) | 309 (2.1%) | |
| - 3–5 revisions | 170 (3.4%) | 110 (0.8%) | |
| - 6+ revisions | 13 (0.3%) | * | |
| c) Patients with chronic rhinosinusitis without nasal polyposis patients | |||
| Number of revision surgeries | CRSsNP-A (N = 2690) | CRSsNP-alone (N = 11020) | p-values |
| Any revision surgery | 212 (7.9%) | 555 (5.0%) | <0.001 |
| Number of revision surgeries | <0.001 | ||
| - 0 revision | 2478 (92.1%) | 10465 (95%) | |
| - 1 revision | 191 (7.1%) | 494 (4.5%) | |
| - 2 revisions | 18 (0.7%) | 54 (0.5%) | |
| - 3–5 revisions | * | * | |
| - 6+ revisions | 0 (0.0%) | 0 (0.0%) | |
Cell size between 1 and 10 are suppressed
Risk factors associated with need for revision ESS after 1st surgery
Utilizing Cox proportional hazard models, the following variables were independently associated with significantly decreased likelihood to undergo revision ESS after the first surgery in the CRS-A cohort (Table IIIa): older age at initial surgery (OR 0.87, CI 0.83–0.92), history of tobacco use (OR 0.85, CI 0.76–0.95), and Hispanic ethnicity (OR 0.81, CI 0.67–0.98). A history of allergies (OR 1.34, CI 1.17–1.54) and nasal polyposis (OR 4.14, CI 3.58–4.78) was associated with an increased likelihood of revision ESS in this cohort. Among all patients with CRS, a patient with CRS-A was 1.46 times more likely to undergo a revision operation after initial surgery compared to CRS-alone (Table IV). The risk of revision ESS after initial surgery in the presence of both asthma and nasal polyposis was 6.05, meaning that a patient with CRSwNP-A was almost 6 times more likely to have a revision operation after initial surgery compared to a patient with CRS but without asthma or nasal polyposis (p<0.010) (Table IV).
Table III:
Risk of revision after initial surgery using Cox proportional hazard models broken down by asthma status. Time was measured in years. Individuals were first followed from initial CRS surgery during 1996–2017 and right-censored at the time of death or last date residing in Utah or 12/31/2017 or date of 1st revision surgery, whichever occurred first. CRS-A = chronic rhinosinusitis with asthma; CRS-alone = chronic rhinosinusitis without asthma; CRSwNP-A = chronic rhinosinusitis with nasal polyposis and asthma; CRSwNP-alone = chronic rhinosinusitis with nasal polyposis but without asthma; CRSsNP-A = chronic rhinosinusitis without nasal polyposis but with asthma; CRSsNP-alone = chronic rhinosinusitis without nasal polyposis and without asthma
| a) All patients with chronic rhinosinusitis (CRS) | ||||
| CRS-A (N = 7693) |
CRS-alone (N = 25397) |
|||
| OR (95% CI) | p-value | OR (95% CI) | p-value | |
| Sex (Male vs Female) | 0.92 (0.83–1.02) | 0.101 | 0.78 (0.73–0.84) | <0.001 |
| Age at initial surgery | 0.87 (0.83–0.92) | <0.001 | 0.94 (0.91–0.98) | 0.010 |
| White (No vs Yes) | 1.01 (0.80–1.29) | 0.920 | 0.89 (0.74–1.07) | 0.190 |
| Hispanic (Yes vs No) | 0.81 (0.67–0.98) | 0.030 | 0.95 (0.82–1.09) | 0.440 |
| Tobacco Use (Yes vs No) | 0.85 (0.76–0.96) | 0.010 | 1.09 (1.00–1.20) | 0.060 |
| Allergy (Yes vs No) | 1.34 (1.17–1.54) | <0.001 | 1.68 (1.47–1.91) | <0.001 |
| Nasal Polyp (Yes vs No) | 4.14 (3.58–4.78) | <0.001 | 3.22 (2.94–3.54) | <0.001 |
| b) Patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) | ||||
| CRSwNP-A (N = 5003) |
CRSwNP-alone (N = 14377) |
|||
| OR (95% CI) | p-value | OR (95% CI) | p-value | |
| Gender (Male vs Female) | 0.94 (0.85–1.05) | 0.260 | 0.77 (0.71–0.84) | <0.001 |
| Age at initial surgery | 0.86 (0.82–0.91) | <0.001 | 0.91 (0.87–0.95) | <0.001 |
| White (No vs Yes) | 1.04 (0.81–1.34) | 0.770 | 0.89 (0.73–1.10) | 0.284 |
| Hispanic (Yes vs No) | 0.90 (0.74–1.09) | 0. 280 | 0.93 (0.79–1.10) | 0.396 |
| Tobacco Use (Yes vs No) | 0.84 (0.74–0.96) | 0.010 | 1.07 (0.96–1.19) | 0.200 |
| Allergy (Yes vs No) | 1.30 (1.13–1.51) | <0.001 | 1.61 (1.39–1.86) | <0.001 |
| c) Patients with chronic rhinosinusitis without nasal polyposis patients | ||||
| CRSsNP-A (N = 2690) |
CRSsNP-alone (N = 11020) |
|||
| OR (95% CI) | p-value | OR (95% CI) | p-value | |
| Gender (Male vs Female) | 0.79 (0.58–1.06) | 0.110 | 0.83 (0.70–0.98) | 0.030 |
| Age at initial surgery | 0.94 (0.82–1.08) | 0.380 | 1.08 (0.99–1.18) | 0.09 |
| White (No vs Yes) | 0.85 (0.42–1.73) | 0.650 | 0.87 (0.56–1.35) | 0.520 |
| Hispanic (Yes vs No) | 0.31 (0.14–0.69) | 0.004 | 0.89 (0.63–1.26) | 0.500 |
| Tobacco Use (Yes vs No) | 0.93 (0.67–1.29) | 0.670 | 1.19 (0.97–1.46) | 0.10 |
| Allergy (Yes vs No) | 1.64 (1.14–2.35) | 0.010 | 1.98 (1.50–2.61) | <0.001 |
Table IV:
Risk of revision after initial surgery using Cox proportional hazard models among all patients with CRS. Time was measured in years. Individuals were first followed from initial CRS surgery during 1996–2017 and right-censored at the time of death or last date residing in Utah or 12/31/2017 or date of 1st revision surgery, whichever occurred first.
| Coefficient estimates | OR (95% CI) | p-value | |
|---|---|---|---|
| Sex (Male vs Female) | −0.19 | 0.83 (0.78–0.88) | <0.001 |
| Age at initial surgery | −0.08 | 0.92 (0.89–0.95) | <0.001 |
| White (No vs Yes) | −0.07 | 0.94 (0.81–1.08) | 0.380 |
| White (Unknown vs Yes) | −0.13 | 0.88 (0.78–0.99) | 0.030 |
| Hispanic (Yes vs No) | −0.01 | 0.99 (0.92–1.07) | 0.850 |
| Hispanic (Unknown vs No) | −0.21 | 0.81 (0.74–0.90) | <0.001 |
| Tobacco Use (Yes vs No) | −0.01 | 0.99 (0.92–1.06) | 0.730 |
| Allergy (Yes vs No) | 0.41 | 1.50 (1.37–1.65) | <0.001 |
| Nasal Polyp | 1.17 | 3.23 (2.94–3.54) | <0.001 |
| Asthma (Yes vs No) | 0.38 | 1.46 (1.25–1.72) | <0.001 |
| Asthma * Nasal Polyps† | 0.25 | <0.010 |
Of note, the interaction between asthma and nasal polyposis is significant (p<0.01). The risk of revision after initial surgery for CRSwNP-A is exponential (1.17+0.38+0.25) = 6.05, which means that a CRSwNP-A is almost 6 times more likely to have a revision after initial surgery compared to a CRSsNP-alone.
When broken down by phenotype, Hispanic ethnicity was no longer noted to be associated with a decreased likelihood for revision ESS in patients with CRSwNP-A (Table IIIb). In patients with CRSsNP-A, neither age at initial surgery nor a history of tobacco use was significantly predictive of revision ESS (Table IIIc).
Risk factors associated with need for revision ESS after 2nd surgery
The risk of a 2nd revision surgery in the presence of both asthma and nasal polyposis was 3.49. Among patients with CRS-A, older age at initial surgery (OR 0.85, CI 0.77–0.93) was associated with a decreased likelihood for a 2nd revision ESS. Older age at initial surgery was also associated with a decreased risk for a 2nd revision ESS in both CRSwNP-A and CRSsNP-A.
Characteristics of Revision ESS
The mean duration of time between initial ESS and revision ESS was slightly shorter in CRS-alone (4.23 years) compared to the CRS-A (4.42 years) (p<0.001) (Figure 2). Although not detailed here, the most common sinus operated on, and the most common sinus requiring revision surgery in both the CRS-A and CRS-alone cohorts was the anterior and posterior ethmoid (i.e. total ethmoidectomy), similar to the data published by our group in the past.13
Figure 2a:
Histogram plot of distribution of duration between 1st and 2nd surgeries (years) overlaid with density plot and mean line (blue) among patients with CRS-A only who have undergone a 2nd surgery.
Discussion
Limited data suggest that ESS may improve asthma symptoms and exacerbations, as well as asthma- and sinonasal-specific healthcare related quality of life (HRQOL) among patients with CRS-A.15–19 There is also evidence that ESS may impact pulmonary function among patients with CRS-A.17,19 To the best of our knowledge, no investigations have evaluated revision surgery rates in patients with CRSsNP-A. Here, we demonstrate an overall long-term revision ESS rate of 21.5% among a large cohort of adult patients with CRS-A. This revision rate was significantly greater than that seen among patients with CRS-alone (10.8%). Interestingly, patients with CRS-A 1.46 times more likely to have a revision operation after initial surgery compared to CRS-alone (p<0.001). The revision rate was noted to be highest among the CRSwNP-A cohort (28.8%) compared to the CRSsNP-A cohort (7.9%). Moreover, a patient with CRSwNP-A was shown to be 6 times more likely to have a revision after initial surgery compared to a patient with CRS without asthma or nasal polyposis (p<0.010).
A recent subgroup analysis of 576 patients reported a revision rate of 22.6% in patients with asthma and CRSwNP only over a mean follow-up of 7.5 years.8 A separate investigation noted a 5-year revision rate of 45% after ESS among 26 patients with asthma; this investigation also focused on CRSwNP only.9 Neither of these investigations examined patients with CRSsNP or contrasted the asthma cohort to controls without asthma. Thus, unlike our investigation, these studies were unable to comment on risk factors associated with revision surgery in an asthma cohort both with and without nasal polyposis; they were also unable to evaluate the impact of polyp status on revision rates. Interestingly, Loftus et al examined the role of temporal variation on revision rates, noting that papers published prior to 2008 had a revision rate of 22.7 %, while those published after 2008 documented a revision rate of 16.6% (p<0.0001).8 The authors chose 2008 as the cut-off for this was the year that topical nasal steroid irrigations were introduced as an adjunct medical therapy. We acknowledge that over time revision rates are confounded by changes and advances in both medical and surgical treatments and were not controlled for in the present investigation. Finally, Smith et al. recently examined ESS revision rates in 59 patients over 10 years of follow up, demonstrating an overall revision rate of 17%.20 The majority of patients who needed revision in this cohort had CRSwNP (8/10). Although the authors noted that patients undergoing revision surgery were more likely to develop new onset asthma, they did not examine revision rates in patients with comorbid asthma.
The diagnosis of allergic fungal sinusitis, a history of asthma, and a history of prior polypectomy have previously been associated with revision ESS in CRSwNP-alone in a meta-analysis performed by Loftus et al.8 Smith et al., reported that female gender, age at first procedure, as well as a personal history of asthma, allergy, nasal polyposis, and family history of CRS were all significantly associated with likelihood to undergo revision surgery in all patients with CRS.13 Stein et al confirmed increased risk of revision surgery in the presence of nasal polyposis and female gender, but also demonstrated that Hispanic ethnicity was associated with a decreased likelihood for revision surgery.10 Other investigations have also implicated severity of nasal polyposis as predictive of need for revision ESS.21,22
In the present study, we demonstrated that among patients with CRS-A, only a history of allergies and nasal polyposis was independently associated with increased likelihood for revision surgery. Similar to Stein et al, we demonstrated that Hispanic ethnicity was associated with a decreased risk for revision surgery.10 It has been postulated that this difference based on ethnicity may be due to decreased access to care among Hispanics, and/or decreased prevalence of CRS compared to Caucasians.10,23 Providers should consider the contrast between CRS-A and CRS-alone when counseling patients about the potential need for revision ESS – unlike the non-asthmatic cohort, revision rates among those with CRS-A do not appear to be influenced by gender, a novel observation that was noted in prior data outlining risk factors for revision surgery in all patients with CRS.13 However, the presence of concomitant allergies and nasal polyposis does increase the risk for revision surgery in this cohort. Unlike the differences in aforementioned risk, the mean number of revision surgeries and the time to first revision surgery did not significantly differ between patients with CRS-A versus those with CRS-alone.
There are several limitations to this study that should be taken into consideration. First, the UPDB was developed in 1996 and thus patients who had ESS prior to this were not included; this may underestimate revision rates.13 Second, the present study is dependent on ICD coding and thus at risk of inaccuracy.13 Nevertheless, the cohort analyzed in the present investigation has previously been validated in regards to their CRS diagnosis through chart review with a high sensitivity and specificity.13,14 Finally, in this Utah population-based study, the findings including severity/type of sinonasal disease, population diversity, complexity of comorbidities, and decision to proceed with surgical intervention may not be generalizable to other populations. Despite these limitations, the large sample size, appropriate exclusion of AERD due to known increased risk of revision ESS,24 prolonged follow-up time, and broad range of variables analyzed support the novel findings described in this study.
Conclusion
The rate of revision ESS among patients with CRS-A was twice that of patients with CRS-alone (p<0.001), but the average time between the first and second surgery was approximately 4 years in both cohorts. Revision surgery in CRS-A was driven mostly – but not entirely – by polyp status, with CRSwNP-A demonstrating a revision rate that was almost 6 times greater than that among patients without nasal polyposis and asthma. These findings may help inform both patients and clinicians as they consider surgical therapy for patients with asthma and comorbid CRS.
Figure 2b:
Histogram plot of distribution of duration between 1st and 2nd surgeries (years) overlaid with density plot and mean line (blue) among patients with CRS without asthma who have undergone a 2nd surgery.
Acknowledgments
We thank the Pedigree and Population Resource of Huntsman Cancer Institute, University of Utah (funded in part by the Huntsman Cancer Foundation) for its role in the ongoing collection, maintenance and support of the Utah Population Database (UPDB). We also acknowledge partial support for the UPDB through grant P30 CA2014 from the National Cancer Institute, University of Utah and from the University of Utah’s program in Personalized Health. We thank the University of Utah Center for Clinical and Translational Science (funded by NIH Clinical and Translational Science Awards) and University of Utah Information Technology Services and Biomedical Informatics Core for establishing the Master Subject Index between the UPDB and the University of Utah Health Sciences Center. This research was supported by the NCRR grant, “Sharing Statewide Health Data for Genetic Research” (R01 RR021746, G. Mineau, PI) with additional support from the Utah State Department of Health and the University of Utah.
Footnotes
Potential Conflict(s) of Interest:
Amarbir S. Gill: None
Kristine A. Smith: None
Huong Meeks: None
Gretchen Oakley: None
Karen Curtin: None
Laurie LeClair, MD: None
Heather Howe, MD: None
Richard R. Orlandi: None
Jeremiah A. Alt: Consultant for OptiNose, Medtronic, AstraZeneca and GlycoMira Therapeutics
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