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