Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And today, our discussion focuses on Clinical Practice Guideline: Surgical Management of Chronic Rhinosinusitis. Joining me is Dr. Bruce Tan. He's an Irene and Walter Wayne Templin Professor of Oral Pathology and an Associate Professor of Otolaryngology Head and Neck Surgery and Medicine in Allergy and Immunology at Northwestern Medicine.

Dr. Tan, thank you so much for joining us today. I'd like you to start by telling us how treatment for chronic rhinosinusitis has evolved over the past few years. Give us a little background on the standard treatments that you've used. And do the treatments generally include a combination of therapies that target symptoms, medication, surgical? Speak just a little bit about the evolution. What's happened?

Bruce K. Tan, MD: Sure. Thank you very much for having me, Melanie. Management of chronic rhinosinusitis certainly has undergone quite a bit of change in the last 15 years. When I started, I would say a lot of the medical management was very focused on use of antibiotics, which was based on an understanding of chronic sinusitis, mostly as an extension of an infectious disease.

But as the evolution and understanding of the disease has progressed, we increasingly understand it as a chronic inflammatory disease much akin to many other inflammatory diseases that exist in other parts of the body, such as skin or lungs. And so, that one-size-fits-all approach to treating all sinusitis as an infectious disease has sort of evolved and changed.

But interestingly, in this chronic inflammatory disease, there is a role for sinus surgery, which has demonstrated to improve quality of life, improve symptoms and some work from our lab that has even shown that it can modify the nature of inflammation in this chronic inflammatory disease. And so, as you mentioned, it is a uniquely multi-modality form of treatment, involving medication, surgery.

I neglected to mention, another big thing that has changed as we increasingly understand it is in chronic inflammatory disease, there are now biologic therapies that are available for some subtypes of chronic sinusitis that FDA approved, and trying to figure out where in the sequence of management they play roles is something that is an ongoing discussion. So, as you alluded to, there has certainly been a big expansion in modalities of treatment and changes in the philosophy of treatment over the last 15 years.

Melanie Cole, MS: Thank you, Dr. Tan, for that overview. So then, can you summarize the key recommendation of the clinical practice guideline for surgical management that you were just touching on?

Bruce K. Tan, MD: Yeah. So, the guidelines are prioritized on the basis of sort of strength of the recommendation of the guideline development group. And the key recommendations were that prior to performing sinus surgery, a surgeon should really verify that the patient really does have chronic sinusitis, using both patient-reported symptoms, but also clinical signs of disease, which include identification of subtypes that include things like nasal polyps or whether they don't have nasal polyps. We should also look at whether or not a patient would benefit from surgery based on whether or not they have actual disease and whether they have the appropriate symptoms that can be improved following surgical treatment.

Other guidelines involve sort of moving away from requiring antibiotic therapy be prescribed for chronic sinusitis with that understanding that not all chronic sinusitis is a persistent infection. After verifying that the patient does have the typical signs and symptoms associated with chronic sinusitis, we recommended that not all patients need to undergo an extended course of antibiotic therapy anymore, because we increasingly recognize that there are forms of chronic sinusitis that primarily comprise of inflammation and less so infection.

Other guidelines were to use the information gained as part of the confirmation that the patient has chronic sinusitis to look for certain subtypes that may more rapidly benefit or maybe have a bigger effect from surgery, which includes forms of chronic sinusitis that have nasal polyps, forms of chronic sinusitis that are demonstrating erosion of the bone around the sinus cavities, certain forms of fungal sinusitis that also may more greatly benefit from surgery should be identified; that surgeons should discuss with patients realistic expectations that some forms of chronic sinusitis may have increased rates of relapse after surgery, and counsel patients that treatment for the sinus condition may involve both surgical management and ongoing medical management that may extend long beyond surgery itself; that CT scans be performed for patients going into sinus surgery, which helps surgeons be able to examine the extent of disease and the extent of surgery that should be planned for; and that there should be no arbitrary cutoffs stating a certain amount of mucosal change has to be present in every sinus that is operated on, because this sometimes inhibits what is appropriate for a patient; that surgeons should educate patients about anticipated post-surgical recovery that patients should be counseled on potential for need for ongoing medical management after surgery, and also discussions about how long patients can expect to be unable to work, unable, or have activity restrictions after surgery. If patients have relatively extensive disease or forms of sinusitis that require very complete surgery, such as patients with nasal polyps with forms of fungal sinusitis, that sinus surgery be performed in a manner that allows full exposure of the sinus cavity and removal of inflamed tissue and not limited forms of sinus surgery, such as balloon sinuplasty, in those specific instances.

Then, finally, post-surgical intermediate to long-term surveillance should be performed for patients after surgery, definitely beyond three months after surgery to ensure that patients are getting good resolution of their sinus problems following surgery. And those post-surgical visits would guide further followup care.

Melanie Cole, MS: Dr. Tan, as you tell us how you envision that ideal balance between surgical intervention and that ongoing medical management, speak about the multidisciplinary collaboration that helped shaped these recommendations. The Otolaryngology team is focused on providing that approach to treat patients, but even a collaboration with the Division of Allergy, or any other providers that you would like to mention that you feel are part of the ongoing care for these patients?

Bruce K. Tan, MD: Sure. Because this was a surgical guideline, I would say a lot of this guideline was focused on otolaryngologists. Even within Otolaryngology, however, there are subspecialties such as rhinologists, who primarily do nasal and sinus surgery. But I would say this guideline was focused more on the otolaryngologists, not necessarily one that just subspecialize in sinus disease.

But I think things that are relevant to the non-otolaryngologists, certainly that emphasis earlier on in the guideline, which was to really confirm that patients truly do have chronic sinusitis. As someone who practices in the area, what you realize is there are a lot of patients who have symptoms of chronic sinusitis, but not necessarily have the diagnosis because of lack of changes in the CT scan or changes in the nose that are necessary to diagnose the condition. So, I think that part of the guidelines try to establish some testing that should be performed on patients who start the medical management of chronic sinusitis and tries to establish certain criteria that should be confirmed prior to telling a patient that they have this diagnosis.

And as far as other stakeholders, I think we had patient representatives on the guideline development group. And they were very helpful in shaping the discussion so that it was not exclusively just meant for physicians. We wanted it to be understandable and the value of the guidelines to be understandable to the patients as well. And so, that was also an important contribution to this guideline.

Melanie Cole, MS: What an exciting time in your field, Dr. Tan. And so, I'd like you to speak to providers about what you see on the horizon for research, future advances in the field of Otolaryngology, and as specifically as it relates to chronic rhinosinusitis. What do you see happening? What would you like to see happening and as a result of these guidelines?

Bruce K. Tan, MD: Yeah. So, I think the changes that are coming are primarily that, as mentioned, there's a lot of modalities of care. There are increasing medications that are approved for management of this condition. However, chronic sinusitis is, at the end of the day, a clinical syndrome that has a relatively heterogeneous cause. So, there are different subtypes of chronic sinusitis, that different aspects of inflammation, infection play roles in.

And so, the biggest unknown is really who is going to benefit best from which therapies, and how do we best identify these subgroups for the specific therapy that would benefit them the most. I guess that falls under a general theme of precision medicine, which I think something that is changing across the entire medical field, that tries to understand both the biological and pathobiological mechanisms that drive disease and tries to understand, who has certain mechanisms of disease at play and therefore may benefit most from specific forms of therapy.

Melanie Cole, MS: Thank you so much, Dr. Tan, for joining us today and giving us a really great update on the surgical management of chronic rhinosinusitis. Thank you again. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/ent to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole.