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CRSwNP) Discussion Many interviewed participants reported significant levels of distress before ESS. Amongst our participants, the decision to undergo ESS was motivated by the desire to improve symptoms and QoL, which is consistent with findings from Soler et al. [20]. Indeed, in a group of 242 patients among which 180 patients elected to have ESS rather than medical management, there was no difference in demographic characteristics, social support, personality types or physician-patient relationship between groups. The only difference between the surgery group and the medical management group was a greater negative impact on disease-specific QoL in the ESS group as assessed by SNOT-22 score (a validated measure of CRS symptoms and health-related QoL) [21]. In light of this data, it is not surprising that our group of post-ESS participants reported a significant preoperative impact of CRS on their daily life. Symptoms reported in our population pre-operatively were similar to those reported in the literature. Mattos et al. found that preoperatively, symptoms most often reported by CRS patients were nasal obstruction, smell/taste, discharge and sleep symptoms [22]. One notable difference in our study is that we questioned participants a posteriori rather than a priori. Despite this variation, our overall impression was similar: these symptoms seem to be the ones which lead patients to seek ESS, especially in the CRSwNP group. Some patients described symptoms they believed were associated with CRS, but which are not usually considered a part of the disease spectrum. In these instances, they may describe unrealistic goals. For example, pruritus may be due to an atopic predisposition, which is associated with CRS; that said, one does not necessarily expect this patient to resolve with the control of CRS. It is imperative that patients learn through counselling which symptoms are amenable to improvement and which are not. If patients undergo ESS with the goal of improving a symptom unrelated symptoms to CRS, disappointment is inevitable. Even rhinologic symptoms associated with CRS do not always respond to ESS. It is unclear which symptoms are most improved by ESS, but certain clinical presentations (symptom clusters) may predict overall SNOT-22 score improvements [23]. Patient-reported outcome measures (PROMs), such as the SNOT-22, are validated clinical tools that produce a numerical score which can be interpreted as an improvement or a deterioration in disease state. One of the most interesting findings of this study is the heterogeneity of patient definitions of operative success. Patient satisfaction seems to depend greatly on the extent to which expectations and goals are met, rather than the actual process or quality of outcome. We believe that patient satisfaction remains an overly simplistic measure of success after ESS, even in the busy clinical setting. Some participants in our study reported that they would be content with any noticeable improvement, while others were expecting a complete and indefinite resolution of their symptoms. Interestingly, patients had a tendency to have the highest expectations before their first surgery. First-time ESS patients with excessively high expectations should be proactively counselled preoperatively, in the hopes of avoiding or mitigating post-operative disappointment. Conversely, patients with recurrent disease did not expect to be cured with a subsequent ESS and were more realistic regarding long-term outcomes. Counselling in these patients should focus on the increased risks of operative complications in revision ESS [24].The great disparity between patients’ objectives, expectations and definitions of success emphasizes the importance of a thorough presurgical counselling and a strong physician-patient partnership. Last year, the Quality Improvement Committee of the American Rhinologic Society published a framework termed the CRS Appropriate Presurgical Algorithm (CAPA), which relies on 4 main quality metrics [25]. One of those is the occurrence of “a patient-centered discussion regarding treatment options for refractory CRS while focusing on risks and benefits, the need for long-term medical compliance and understanding of patient preferences and expectations”. Vennik et al. have recently published their extensive work on both patient and physicians’ (Otolaryngologists and primary care physicians) experiences and views on current management of CRS in the UK [26, 27]. Previously, Erskine et al. had also explored CRS patients’ experiences in both primary and secondary care, again in the UK [28]. A thorough understanding of the patient experience is essential to optimal care, especially in chronic illnesses such as CRS. This qualitative approach to the topic of ESS permitted
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