The National Comparative Audit of Surgery for Nasal Polyposis and Chronic Rhinosinusitis

Background

Chronic sinusitis is a common chronic disorder affecting 15% of the population. Nasal polyps are estimated to affect 2%, and often coexists with sinusitis. Both conditions reduce quality of life in affected patients, and can cause unpleasant symptoms such as nasal obstruction, facial pain, nasal discharge and loss of smell and taste. When medical treatment fails, or in cases of severe obstruction, surgery becomes the treatment of choice. There are currently many different operations suitable for the treatment of sinonasal disease, and it remains unclear if some achieve better long-term results than others. The National Sinonasal Audit was set up in collaboration with the Clinical Effectiveness Unit at the Royal College of Surgeons and ENT UK. The main aim of the project was to compare surgical outcomes among all units and consultants carrying out sinonasal surgery. We also hoped to answer questions regarding the effectiveness of different procedures, and to identify patient factors associated with poor surgical outcome.

Methods

All trusts undertaking sinonasal surgery in England and Wales were asked to participate. Unfortunately, only 57% of Trust Chief Executives agreed to participate in the study, the remainder refusing for financial reasons. There was high level of participation by both ENT consultants and patients undergoing sinonasal surgery. In total data has been collected on 3128 patients undergoing sinonasal surgery during a six-month period in 2000. Surgeons completed a questionnaire at the time of operation. Patients have so far completed questionnaires before their operation, at 3 months and 12 months after surgery. They are currently being asked to complete a 3-year follow-up questionnaire. The main outcome that has been studied is the symptom status of each patient. We have used a validated questionnaire, the Sinonasal Outcome Test (SNOT22), which creates a score out of 110 points reflecting the severity of symptoms.

Results

There is a significant reduction in patients' symptoms following sinonasal surgery, but a slight deterioration from 3 to 12 months. The majority of patients are satisfied with the results of surgery (Figure 1). Many patients report minor problems with bleeding after surgery, but most return to normal daily activities with 2 - 3 weeks, and the rates of major complications are very low (0.26%, with no long term problems). However, within a year of operation 8.6% of patients are awaiting or have already undergone further surgery for their sinonasal disease.

We have shown that there are no trusts or surgeons, for whom we have sufficient data from the study, producing outlying results for which there are clinical concerns. Each surgeon and participating trust has been fed back his or her individualised results.

We have also found that patients with nasal polyps, and patients having surgery for the first time, derive greater symptom reduction following surgery than other patients, but that patients with polyps or asthma are more likely to require further surgery. There does not appear to be any significant difference in the different operations available in terms of symptom reduction at 1 year. However, we will study this again using the 3-year results, particularly looking at revision rates. We have found that the best predictor of outcome in terms of symptom status at 1 year is the pre-operative symptom score.

The audit raises concerns over patient selection for surgery as over 100 patients underwent sinonasal surgery in the absence of significant symptoms.

How this audit may improve patient care

• We have found no individual trust or surgeon to be achieving outcomes which raise clinical concerns
• We now know that patient symptoms are the best predictor of outcome
• We can better advise patients of surgical outcome and complication rates

Future of the sinonasal audit

The collection of 3-year follow-up questionnaires will be completed in March 2004, and analysis of results will occur soon after. This will help us to better understand which types of sinonasal operations are associated with the best outcome in terms of symptomatic improvement and the need for further surgery.

We are hoping to confirm the usefulness of the SNOT22 questionnaire, with the aim that it will become used in all departments to assess the severity of symptoms and improvement after treatment. This will facilitate future comparison of results.

Miss Claire Hopkins,
ENT Specialist Registrar & Research Fellow, Clinical Effectiveness Unit, Royal College of Surgeons

Further information

Further information on this study may be requested from:

Dr John Browne or Miss Claire Hopkins,
Clinical Effectiveness Unit, Royal College of Surgeons, 35 – 43 Lincoln’s Inn Fields, London.

A copy of the report on The National Comparative Audit of Surgery for Nasal Polyposis and Chronic Rhinosinusitis may be purchased from the Clinical Effectiveness Unit for a fee of £10.00. It should be noted that it is not possible to identify the outcome of individual surgeons or trusts in this report.

Figure 1. Mean SNOT 22 score preoperatively, and at 3 and 12 months post sinonasal surgery (higher scores reflect greater severity of symptoms)