Целесообразность радикальных методов эндоскопических хирургических вмешательств на околоносовых пазухах при полипозном риносинусите

Abstract

Treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex problem for physicians. There is basic therapy with topical glucocorticosteroids, in case of ineffectiveness of which a short course of systemic glucocorticosteroid therapy is carried out, or the question of using biological therapy with monoclonal antibodies is considered. Surgical approaches for CRSwNP have evolved over the years, ranging from simple nasal polyps to nasalization procedures. Since the introduction of functional endoscopic sinus surgery (FESS) into widespread practice, there has been a principle that surgery for CRSwNP should only be considered in patients who are refractory to pharmacological therapy. The analysis of surgical treatment of patients with CRSwNP in the departments of otorhinolaryngology of the Vladimirsky Moscow Regional Research Clinical Institute (MONIKI) and Clinical Hospital No. 1 of Department for Presidential Affairs of the Russian Federation (Volynsk Hospital) for the period 2015–2022 was carried out. In the department of the Volynsk Hospital, from 2017 to 2022, 595 people were treated with CRSwNP, of which 440 patients received surgical care, 36 patients in 2021 and 119 patients in 2022 were treated with dupilumab. The index of surgical activity in 2021 was 0.695 (30.51% of patients received conservative treatment, 69.49% of patients received surgical treatment) and 0.27 in 2022 (63% of patients received conservative treatment, 27% of patients were operated). In the department of otorhinolaryngology of MONIKI, in 2015, 144 surgeries were performed for PRS; in 2016, 94 surgeries; in 2017, 31 surgeries; in 2018, 28 surgeries; in 2019, 26 surgeries. All surgical interventions in both departments were performed in the scope of endoscopic polysinusotomy or maxillary ethmoidotomy. In parallel, since September 2015, on the basis of the surgical department with a day hospital, specialized care has been organized for patients with CRSwNP, where diagnostic measures are carried out jointly with an allergist-immunologist, treatment is carried out according to a stepwise therapy scheme for various CRSwNP phenotypes with an assessment of the dynamics of the course of the disease every 3 months. This made it possible to reduce the number of these operations in the department of otorhinolaryngology of MONIKI by almost 5 times. Surgical treatment for CRSwNP is not a panacea. Mechanical removal of pathologically altered tissue does not eliminate the etiological factors of this disease, nor does it affect any link in the development of pathogenesis. Any operation is associated with a surgical and anesthetic risk for the patient and costs. Therefore, reducing their number due to the complex treatment of patients, considering comorbid pathology, the use of biological therapy drugs along with economic efficiency and reducing the load on a round-the-clock hospital allows avoiding invasive interventions. Radical endoscopic surgery with a reboot approach, full-house functional endoscopic sinus surgery (FESS), and Draf III (frontal drillout) operations should always have strict indications since they are rather a «rescue operation» and can never become a routine surgical intervention for CRSwNP, especially since in 96.3% of patients with CRSwNP relapse occurs within 3 years after surgery. Schemes for the management of patients with CRSwNP in the departments of otorhinolaryngology of MONIKI and the Volynsk Hospital can improve the quality of life of these patients, achieve drug control of the disease, and reduce the number of surgical interventions while increasing the total number of patients with CRSwNP treated in these institutions.