The Journal of Laryngology and Otology · 4 authors, 2 centres
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This retrospective study of 221 chronic rhinosinusitis with nasal polyps patients found that 24.3% required medical polypectomy or revision surgery over a mean follow-up of 5.3 years. Key predictors for recurrence included age <55 years, prior sinus surgery, peripheral blood eosinophil count ≥300 cells/μl, Lund-Mackay score >17, and aspirin-exacerbated respiratory disease. These factors can help clinicians identify high-risk patients for closer monitoring and earlier intervention.
**Background:** Chronic rhinosinusitis with nasal polyps (CRSwNP) is a common inflammatory condition affecting 2-4% of the population. Despite functional endoscopic sinus surgery (FESS), many patients experience recurrence requiring oral corticosteroids (medical polypectomy) or revision surgery. Identifying predictive factors for recurrence could improve patient counseling and follow-up. This study aimed to identify phenotypic associations with the need for medical polypectomy or revision surgery after FESS.
**Methods:** A retrospective review was conducted of 221 patients who underwent bilateral FESS for severe CRSwNP between January 2015 and December 2018 at Ninewells Hospital, Dundee, Scotland. Patients were identified from electronic operating theatre records. Exclusion criteria included regular systemic corticosteroids, immunosuppressive drugs, monoclonal antibodies, and aspirin desensitization therapy. Patients were categorized into three phenotypes: CRSwNP only, CRSwNP plus asthma, and CRSwNP plus aspirin-exacerbated respiratory disease (AERD). Data collected included demographics, clinical history, peripheral blood eosinophil counts, total and specific IgE, nasal polyp scores (modified Lildholdt grading, 0-8), Lund-Mackay CT scores (0-24), and history of previous FESS. Medical polypectomy was defined as a minimum 5-day course of at least 20 mg daily oral prednisolone for CRSwNP (not for asthma). Revision surgery was defined as revision FESS or simple endoscopic polypectomy. Combined polypectomy was defined as either medical polypectomy or revision surgery. Follow-up was until December 31, 2021 (mean 5.3 years, range 3.1-7.0). Statistical analysis used logistic regression with odds ratios adjusted for age and gender.
**Key Results:** Follow-up data were available for 210 patients. Overall, 44 (21.6%) underwent medical polypectomy, 19 (9%) underwent revision surgery, and 51 (24.3%) underwent combined polypectomy. Mean patient age was 52.9 years (SD 13.8), and 74% were male. Mean peripheral blood eosinophil count was 380 cells/μl (95% CI 348-412). Mean Lund-Mackay score was 13.3 (95% CI 12.6-14.1). Significant predictors for medical polypectomy included: age <55 years (28.7% vs 13.5%, p=0.01), peripheral blood eosinophil count ≥300 cells/μl (28.7% vs 11.5%, p=0.011), Lund-Mackay score >17 (adjusted OR 1.58, p<0.05), and AERD (p<0.001). For revision surgery, significant predictors were: age <55 years (15% vs 2.1%, p=0.001), Lund-Mackay score >17 (adjusted OR 1.89, p<0.01), and AERD (37.5% vs 4.9% for CRSwNP only, p<0.001). Peripheral blood eosinophil count ≥300 cells/μl was not significantly associated with revision surgery alone (p=0.261) but was for combined polypectomy (31.4% vs 13.1%, p=0.009). History of previous FESS was also a significant predictor for all outcomes. No significant associations were found for total IgE or specific IgE with any outcome.
**Clinical Implications:** This study identifies several easily obtainable clinical and laboratory factors that predict recurrence of nasal polyps requiring medical or surgical intervention after FESS. Younger patients (<55 years), those with elevated peripheral blood eosinophils (≥300 cells/μl), high Lund-Mackay scores (>17), prior FESS, and especially those with AERD are at significantly increased risk. These findings can help clinicians stratify patients for closer follow-up and earlier consideration of adjunctive therapies, including biologics such as dupilumab. The study highlights the importance of distinguishing AERD from asthma alone, as AERD carries a much higher risk of revision surgery (37.5% vs 6% for asthma alone). Limitations include the retrospective design, missing data for some laboratory tests, and potential under-ascertainment of medical polypectomies prescribed in primary care. Nonetheless, the results provide practical guidance for postoperative management of CRSwNP patients.