Description of the condition
The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS 2020) defines chronic rhinosinusitis (CRS) as a clinical syndrome caused by enduring inflammation of the mucosa of the nose and paranasal sinuses, with at least two symptoms, of which one needs to be either nasal blockage/obstruction/congestion or nasal discharge ± facial pain/pressure ± reduction or loss of smell for ≥12 weeks.1-3
This condition affects 5 to 28% of the population and dramatically impacts patients’ socioeconomic conditions and quality of life. CRS is responsible for greater costs in health care than in diseases such as peptic ulcers, asthma, and hay fever. Moreover, it leads to absenteeism and reduces productivity increasing indirect costs since affects working-age people.2-7 A health state utility study found that patients with CRS had worse utility values than those with chronic obstructive pulmonary disease, coronary artery disease, chronic heart failure, and Parkinson’s disease.8
The etiology of CRS is associated with bacterial superantigens, epithelial cell defects, biofilm formation, T helper 1 and 2 inflammation responses, and tissue remodeling.9-12 CRS is classified into CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP).10,11
Endoscopic sinus surgery (ESS) began in the late ‘80s and the early ‘90s and was responsible for significant advances in the managing of CRS.12 The reduction of type 2 inflammation and minimizing irreversible remodeling of the mucosa by facilitating improved access to topical therapies are potential disease-modifying benefits of surgery.2
Nonetheless, ESS can be the cause of significant iatrogenic damage due to the anatomical proximity of the paranasal sinus to critical structures such as the skull base, orbit, internal carotid artery, and optic nerve.13 Patients submitted to more than one surgical procedure are at increased risk of injuries because of the removal of anatomical landmarks.14-16 The complication rate of ESS is approximately 0.5%, with 0.11% for intracranial complications and 0.04% for orbital complications, which can be considered low risk.17,18 However, in the event of injury these can result in high morbidity.17,19