Embedded Files
an in-depth exploration of certain theme. This permitted us to collect rich and granular information directly from primary stakeholders. Clinicians strive to offer the best surgical treatments, and to follow evidence-based recommendations. That said, emphasis must also be placed on tailoring the right treatment to the right patient. As we have shown, patients’ goals and expectations may vary widely. Physicians should play a role in assessing – and modulating if necessary – expectations because unrealistic goals are often synonymous with postoperative disappointment. Moreover, open and frank discussion should be geared to the severity of patients’ disease and previous experience with ESS. Preoperative counselling should thus be undertaken diligently not only for complex cases with a complicated history with CRS, but also for patients naïve to surgery or patients with seemingly minor disease. It is crucial that these patients understand that ESS is by no means an “easy fix”, that long-term positive outcomes are often contingent on continuous topical therapy, and that the process of undergoing ESS can be associated with significant discomfort and distress. A growing body of evidence suggests an important heterogeneity both in clinical phenotypes and genetic endotypes of patients with CRS [29,30,31]. A greater understanding of the pathophysiology and the molecular pathways involved has stimulated efforts in targeted treatment and personalized medicine for CRS patients [32, 33]. A recent article by Grayson et al. differentiates three different CRS phenotypes: IgE-mediated central compartment atopic disease, eosinophilic CRS and non-eosinophilic CRS. This article illustrates the distinctions in clinical presentation, endoscopic, radiologic and histopathologic findings, and in treatment. In all three subtypes, the authors recommend to consider ESS, with the distinction a Draf 3 is suggested in eosinophilic CRS [34]. Despite the arrival of biologics for the treatment of CRSwNP, ESS remains the mainstay of the treatment of CRS refractory to maximal medical therapy for most patients [35, 36]. Indeed, this surgery has been shown to be efficient and more cost-effective than continuous medical therapy alone [37,38,39,40]. That said, evidence suggests certain phenotypes of CRS tend to have more favorable surgical outcomes compared to others [41]. While decision to undergo ESS is always taken in partnership with the patient, studies suggest that certain symptoms or patient characteristics are predictive of positive or negative outcomes [42]. Patient reported outcome measures, such as the Sinonasal Outcome Test (SNOT-22), or a thorough preoperative assessment can guide clinicians during patient counselling [43,44,45,46]. The limitations of this study include the subjectivity inherent to the qualitative design. Moreover, all participants were recruited from the practice of a single surgeon working in an academic tertiary referral practice. Hence, this population may not be representative of the general CRS population. That said, it provided us with insights from patients who had undergone many ESS and had a rich experience with the disease. Since the study was conducted in Montreal (Canada), interviews were conducted in patients’ preferred language. This may have led to some aspects of the experiences described by patients being lost in translation during thematic analysis. Additionally, the median time from last surgery was 12 months among participants. It is likely that patients may have forgotten some elements of their experience with ESS, though we hope the most important ones were recalled. Although all participants were followed at the time of the interview by a single surgeon, many had previously been operated at other institutions and only then referred for refractory disease. Six patients had undergone one ESS only; thus, our sample was heterogeneous enough to capture many different levels of CRS severity, or at least different timeframes. Another important limitation of this study concerns the fact that 90% of participants were Caucasian. A recent paper shows that non-white patients tend to experience more severe CRS symptoms at baseline compared to white patients. They also seem to have more significant improvements in QoL with ESS [47]. Undoubtedly, non-white patients must have different experiences with regards to ESS. We unfortunately were not able to collect and analyze these unique perspectives. Despite these limitations, we believe this study provides important insights to otolaryngologists on the patient journey before and after ESS, patients’ objectives and expectations before surgery, and patients’ perspective on the definition of an optimal outcome after surgery. Abstract Thiago Freire Pinto Bezerra1 , Jay F. Piccirillo2 ,
Report abuse