Impact of Topical Levofloxacin Rinses on Chronic Rhinosinusitis.

BackgroundChronic rhinosinusitis (CRS) can be difficult to treat medically secondary to crusting and biofilms resistant to oral antibiotics. Treatment with topical antibiotics has grown in popularity due to their ability to administer a high local drug concentration while mitigating systemic effects. Published literature on topical antibiotic efficacy for CRS is mixed and sparse.ObjectiveTo describe the efficacy of postoperative topical mupirocin rinses in reducing objective and subjective markers of CRS disease severity.MethodsPatients with suspected biofilm formation following functional endoscopic sinus surgery who were treated with mupirocin 15 mg or 30 mg rinses twice daily between 2018-2023 were included. These patients' symptoms and endoscopic findings were refractory to high-volume steroid irrigations and oral antibiotics. Data collected involved comorbidities, rinse duration, concurrent therapies, Lund-Kennedy (LK) scores, sino-nasal outcome test-22 (SNOT) scores, and adverse effects. LK and SNOT scores were compared across 3 time points (preoperative, 3-month-postoperative-prerinse, postrinse) using one-way analysis of variance and Wilcoxon rank sum for pairwise comparisons.ResultsThirty patients were included. Average age was 63.3 years, 66.7% of patients were female, and 60% had nasal polyposis. There was a statistically significant decrease in LK scores between the 3-month-postoperative-prerinse period and the postrinse period (-0.92 ± 1.25; P-value = .01) whereas the SNOT-22 score reduction was not significantly different (P-value = .62). One patient reported a "burning sensation" and stopped after 4-weeks of treatment; no other adverse events were reported.ConclusionTopical mupirocin rinses may result in improvement of CRS burden on endoscopy without a significant reduction in symptoms. Additional studies are necessary to delineate the safety and appropriate duration and dosing of mupirocin rinses as well as to compare mupirocin to standard saline irrigations for treatment of recalcitrant CRS.

Chronic rhinosinusitis (CRS) is one of the most common health disorders in humans and has a major impact on health-related quality of life (HRQoL). Of the many factors contributing to the etiology of CRS, less is known about the correlation between CRS and bacterial biofilms and their impact on HRQoL. The aim of this prospective study was to investigate the relationship between biofilm-producing bacteria and patients' objective findings and HRQoL. Forty-eight patients with CRSwNP were enrolled in a 12-month prospective study. The Lund-Mackay (LM) CT and endoscopic Lund-Kennedy (LK) scores were obtained before endoscopic sinus surgery (ESS), and patients completed the HRQoL instruments: the 22-item Sinonasal Outcome Test (SNOT-22), the 36-item Short Questionnaire (SF-36), and the visual analog scale (VAS). A sinus culture was obtained at ESS, bacteria were isolated, and in vitro quantification of the biofilm was performed. The LK score and HRQoL were determined postoperatively at months 1, 3, 6, and 12. The most common bacterial isolates in patients with CRSwNP were Staphylococcus aureus (28%), coagulase-negative staphylococci (52%), and Pseudomonas aeruginosa (8%). Preoperatively, the highest LM and LK scores were found in patients with strong biofilm producers. Postoperative LK scores were significantly reduced in all patients. Postoperative VAS scores were significantly reduced from month 1 to month 12 postoperatively. Patients with strong biofilm producers had significantly worse nasal blockage, secretion, headache, facial pressure and pain, and loss of smell preoperatively, compared to patients with low biofilm producers. The most significant reduction in preoperative scores SNOT-22 and SF-36 (excluding physical functioning) was seen in patients with S. aureus and P. aeruginosa. Patients with strong biofilm producers had higher LK and LM scores preoperatively, and greater improvement in LK and HRQoL scores postoperatively. Microbiologic surveillance of all CRS patients is recommended.

Chronic rhinosinusitis (CRS) is a multi-factorial disorder that causes systemic symptoms beyond rhinologic symptoms alone. A possible association between autonomic nervous system (ANS) dysfunction and CRS has been identified; however, few studies have confirmed this observation. In this study, we prospectively measured changes in ANS dysfunction symptoms following functional endoscopic sinus surgery (FESS) and explored the impact of ANS dysfunction on surgical outcomes of CRS. Patients diagnosed with CRS who consented to surgical intervention were included prospectively. All patients completed the Sino-nasal Outcome Test-22 (SNOT-22) and the 31-item Composite Autonomic Symptom Score (COMPASS 31) questionnaires before the operation and during the follow-up period. Clinical demographic data, Lund-Mackay, and modified Lund-Kennedy scores were recorded and measured. A total of 102 patients were enrolled. The median SNOT-22 and COMPASS 31 scores significantly improved following FESS from 43.0 to 14.0 and 21.0 to 11.2 (all P less than 0.001), respectively. FESS led to a significant reduction in the prevalence of various ANS dysfunction symptoms. In multivariate analyses, revision surgeries (odds ratio [OR] 5.012, 95% confidence interval [CI] 1.52416.489; P=0.008), CRS with nasal polyps (OR 4.071, 95% CI 1.454-11.40; P=0.008), and higher Pre-FESS COMPASS 31 scores (OR 1.043, 95% CI 1.003-1.084; P=0.036) were independent risk factors for uncontrolled inflammation following FESS. ANS dysfunction symptoms are prevalent in CRS and higher preoperative COMPASS 31 scores correspond with poor surgical outcomes. Following FESS, the majority of ANS dysfunction symptoms can be alleviated. Further investigations are required to explore the possible mechanism of how ANS is involved in the pathogenesis of CRS.

Steroid-eluting stent implantation after endoscopic sinus surgery (ESS) effectively alleviates postoperative symptoms and polyp recurrence in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). However, the efficacy of steroid-eluting stents for the treatment of olfactory dysfunction in CRSwNP and the influencing factors therein have not been studied. Fifty-nine patients with CRSwNP with olfactory dysfunction from Peking University Third Hospital who were hospitalized for ESS were recruited and randomly divided into a stent group (n = 30) and a control group (n = 29), and were assessed for symptom scores, olfactory function, endoscopic findings, and type 2 inflammatory mediators (IL-4, IL-5, IL-13, IL-33, eotaxin-3, periostin) expression. Postoperative olfactory Visual Analogue Scale (VAS) scores, T&T olfactometer scores, SNOT-22 scores, and Lund-Kennedy (LK) scores were reduced in patients with CRSwNP (P < .01). Postoperative olfactory VAS scores, T&T olfactometer scores, SNOT-22 scores, and LK scores, IL-5, IL-13, and periostin were significantly lower in the stent group than in the control group (P < .05). Correlation analysis was performed and found that the postoperative olfactory VAS scores were strongly correlated with IL-5 and IL-13 (r = .496, P < .001 and r = .289, P = .026), and the postoperative T&T olfactometer scores were strongly correlated with IL-5 and IL-13 (r = .553, P < .001 and r = .398, P = .002). Steroid-eluting stent implantation after ESS is an effective treatment for olfactory deficits in patients with CRSwNP and may be related to the stent's more effective reduction of local type 2 inflammatory mediators in the nasal cavity.

Objective:To evaluate the efficacy of functional endoscopic sinus surgery（FESS） and radical endoscopic sinus surgery（RESS） in eosinophilic chronic sinusitis with nasal polyps（EosCRSwNP）. Methods:A total of 44 patients diagnosed with EosCRSwNP in the Department of Otorhinolaryngology Head and Neck Surgery, Henan Provincial People's Hospital from July 1st, 2020 to August 1st, 2021 were included, the percentage of eosinophils in leukocytes in all patients included was more than 3.05%. The patients were randomly divided into FESS group and RESS group according to random number table. The visual analogue scale （VAS） score, Lund-Kennedy score and sino-nasal outcome test-22 （SNOT-22） were compared between the two groups before operation, 1 month, 3 months, 6 months and 1 year after operation. Results:At 1 year after operation, the scores of the two groups were significantly improved compared with those before operation, and the differences were statistically significant （P<0.01）. There were significant differences in nasal endoscopic score, VAS score and SNOT-22 score between the two groups（P=0.01, P=0.03, P=0.03）. The recurrence rate of RESS group was 26.09%（6/23） and that of FESS group was 61.90%（13/21）, and the difference was statistically significant（P=0.04）. Conclusion:Both RESS and FESS can improve nasal symptoms and promote olfactory recovery in EosCRSwNP patients, but RESS has more advantages in reducing recurrence and improving the prognosis of patients.

BackgroundPatients with chronic rhinosinusitis (CRS) refractory to medical management often require endoscopic sinus surgery (ESS). Oral corticosteroids (OCSs) are frequently prescribed postoperatively, but the evidence of their efficacy is limited.ObjectiveThe purpose of this study is to evaluate the efficacy of OCS use in patients with CRS following ESS.MethodsA systematic search was performed to identify studies examining the use of OCSs in patients undergoing ESS for CRS. The primary outcomes were sinonasal outcome test (SNOT) and Lund-Kennedy (LK) endoscopic scores. Secondary outcomes were visual analog scale (VAS) scores. Meta-analysis was conducted using a fixed effects model with a heterogeneity test via the I2 statistic.ResultsThe search yielded 1899 articles, and 22 were included in the qualitative analysis, 14 of which were randomized controlled trials with 793 total patients. OCS use differed based on type, dosage, and duration. Studies included in meta-analysis did not show a significant difference in SNOT (Standardized Mean Difference [SMD] -0.03, Confidence Interval [CI] -0.47-0.40, I2 0%), LK (SMD -0.20 CI -0.57-0.17 I2 58%), or VAS (SMD 0.19 CI -0.25-0.63 I2 54%) scores between steroid and non-steroid groups. Two studies that assessed OCSs in the allergic fungal rhinosinusitis (AFRS) subtype of CRS showed significant improvement in outcomes. Two additional studies examined OCS versus itraconazole in AFRS, with both groups showing improvement but neither one with greater significance.ConclusionThis study showed no significant difference in SNOT, LK, or VAS scores in patients with CRS who received OCSs following ESS. Given the limited number of studies in the analysis, further investigations are warranted before making recommendations.

Endoscopic sinus surgery (ESS) has become the gold standard for treating patients with chronic rhinosinusitis (CRS) refractory to medical therapy. It is considered a relatively safe and effective procedure in all age groups, with overall success rates ranging from 76% to 97.5%. However, failure of primary endoscopic sinus surgery (PESS) occurs at a rate ranging from 2% to 24%. Patients who are still symptomatic after PESS and optimal medical therapy are candidates for revision endoscopic sinus surgery (RESS). to study the outcomes of ESS and assess the risk factors of recurrence of nasal polyps, as well as to compare the outcomes of PESS and RESS at a tertiary care teaching hospital. A retrospective cross-sectional study. This study is conducted on patients with CRS with nasal polyps (CRSwNP) who underwent ESS at King Saud University Medical City (KSUMC) between May 2015 and December 2021. During this period, ESS was performed 470 times for CRSwNP. The Sinonasal Outcome Test 22 (SNOT-22) questionnaire, the Lund-Kennedy (LK) score, the Lund-MacKay (LM) score, and the polyp grading system were used to evaluate subjective and objective outcomes. They were scored preoperatively and from 6 to 12 months postoperatively. Out of the 470 endoscopic sinus surgeries, 321 (68.3%) were PESS and 149 (31.7%) were RESS. Asthma, aspirin sensitivity, and Samter's triad were observed more in the RESS group. The LK and LM scores were significantly different between primary and revision sinus surgeries, revealing that PESS patients had better postoperative LK and LM scores. The RESS patients had significantly worse postoperative SNOT-22 scores compared to PESS patients. Lund-MacKay, Lund-Kennedy, and SNOT-22 scores improved after ESS for both primary and revision ESS patients, with better outcomes observed after PESS compared to RESS. The presence of asthma, aspirin sensitivity, Samter's Triad, high-grade nasal polyps, and older age were identified as risk factors for CRSwNP recurrence, which may require RESS.

This study aimed to explore the utility of the eosinophil percentage in peripheral blood for guiding post-operative glucocorticoid therapy in patients with chronic rhinosinusitis with nasal polyps. Forty-four patients with chronic rhinosinusitis with nasal polyps underwent functional endoscopic sinus surgery and were randomly divided into two groups. Patients in the standard treatment group used oral and nasal spray glucocorticoids. In the biomarker treatment group, patients with peripheral blood eosinophil percentage values less than 3.05 per cent did not receive glucocorticoid treatment, whereas patients with values 3.05 per cent or above were part of the standard treatment group. Visual Analogue Scale, Sino-Nasal Outcome Test-22 scores, endoscopic Lund-Kennedy scores, eosinophils, interleukin-5 and eosinophil cationic protein in peripheral blood, and nasal secretions were measured. After functional endoscopic sinus surgery, the Visual Analogue Scale, Sino-Nasal Outcome Test-22 and Lund-Kennedy scores were significantly reduced in both groups; there were no significant differences in those indicators between the groups during the three follow-up visits. Peripheral blood eosinophil percentage offers a potential biomarker to guide post-operative glucocorticoid therapy in patients with chronic rhinosinusitis with nasal polyps.

Background and aimEtiopathogeneses of chronic rhinosinusitis are poorly understood. Recent research emphasizes culture-independent molecular sequencing to identify clusters of flora that may function as drivers of inflammation. Studies also indicate that macrolides are as effective as corticosteroids in controlling chronic rhinosinusitis. In this study, we aimed to isolate microbial cultures from the middle meatus of patients suffering from chronic rhinosinusitis and assess the isolates for similarities and antibiotic sensitivity. We also sought to identify the pathogenic species disrupting the nasal microbiome and provide appropriate antibiotics based on the least minimum inhibitory concentration (MIC) from the cultures. Disease progression and response to treatment were evaluated using the Sino-Nasal Outcome Test-22 (SNOT-22) and the Lund-Kennedy endoscopy scoring system. Specifically, diagnostic nasal endoscopy (DNE) was performed in patients with chronic rhinosinusitis without nasal polyps (CRSnNP), and the pre-treatment Lund-Kennedy score was recorded, along with subjective data collected from the SNOT-22 questionnaire. After isolating cultures from the middle meatus, antibiotic treatment was provided based on these findings. A repeat DNE was conducted to calculate the post-treatment Lund-Kennedy score and collect the post-treatment SNOT-22 score. Finally, the pre- and post-treatment scores were compared to assess any statistically significant differences.MethodsThe patients upon arrival to the hospital and diagnosed with chronic rhinosinusitis without nasal polyposis (CRSnNP) based on the joint EPOS 2020 Criterion for the same were enrolled in the study. The patients were administered an SNOT-22 Questionnaire for subjective evaluation. The patients underwent a diagnostic nasal endoscopy (DNE) to calculate the Lund-Kennedy score, take swabs from the middle meatus for culture and sensitivity, and provide objective evaluation by the assessing physicians. The scores were recorded at the first visit and on each visit till the two weeks of antibiotic treatment were completed. The patients were treated with antibiotics as per the cultured isolates. The Lund-Kennedy scores and SNOT-22 scores before and after treatment were compared to note the response to treatment.ResultsThe mean average Lund-Kennedy score and SNOT-22 scores dropped following a course of antibiotics. The patients also experienced symptomatic relief. The most commonly isolated organism among the samples evaluated was Pseudomonas aeruginosa. The best response to antibiotics was noted with aminoglycosides. Total resistance (100%) to macrolides and amoxicillin was also observed, which contradicts the antibiotic guidelines of EPOS 2020, ICAR 2021, and JTFPP 2014.ConclusionThis study found that the invasive species disrupting the local nasal microbiome of the participants consisted of various pathogenic microorganisms. It indicated that a culture-based treatment of CRSnNP will yield better results compared to empirical antibiotics. The present study also suggests revising guidelines for antibiotic use and developing personalized antibiograms for treating chronic rhinosinusitis.

To validate the discharge, inflammation, polyps/edema (DIP) scoring system for the assessment of endoscopic sinus surgery (ESS) outcomes in patients with chronic rhinosinusitis (CRS). Thirty patients with CRS were included in this prospective study. All patients were evaluated before and 2 months after surgery. Baseline measures and postoperative outcomes were evaluated using sino-nasal outcome test-20 (SNOT-20), visual analogue scale (VAS) symptom score and Lund-Mackay CT score (in baseline only). All endoscopic videos were recorded before surgery and in the end of follow-up. All videos were scored blindly by two rhinologistis using the DIP and Lund-Kennedy system for investigating the inter-rater and test-retest reliability, as well as the correlations with the existing subjective and objective scoring systems.SPSS17.0 software was used to analyze the data. The average scores of VAS, SNOT-20, Lund-Kennedy, and DIP before and after surgery were listed below. Baseline, 29.73 ± 13.05, 24.43 ± 13.76, 7.70 ± 3.25 and 32.67 ± 13.48. Post-surgical, 13.60 ± 8.67, 10.40 ± 7.45, 5.03 ± 2.04 and 16.97 ± 8.37. All scores were declined significantly from baseline (t value were 7.43, 6.49, 6.88 and 10.93, all P < 0.001). The DIP system showed a higher inter-rater and rest-rest reliability than Lund-Kennedy system (interclass coefficient,ICC > 0.75). The Pearson analysis revealed that VAS scores were significantly correlated with SNOT-20 scores both in baseline and post-surgical assessments (r = 0.518 6, P = 0.003, and r = 0.546 7, P = 0.000). Before surgery, Lund-Kennedy scores were significantly correlated with DIP and Lund-Mackay CT scores (r = 0.937 5, P = 0.000 and r = 0.748 0, P = 0.000). DIP scores were significantly correlated with Lund-Mackay CT scores (r = 0.712 2, P = 0.000). After surgery,DIP scores were significantly correlated with Lund-Kennedy scores (r = 0.869 6, P = 0.000). But there were no significant correlations between subjective scores (VAS and SNOT-20) and objective scores (Lund-Kennedy, DIP and Lund-Mackay CT), (all P > 0.05). The DIP scoring system shows substantial inter-rater and test-retest reliability.It is also significantly correlated with existing objective scoring parameters. It is suitable and reliable to use.

Objectives : To determine the outcome of Functional Endoscopic Sinus Surgery (FESS/ESS) and improvement in quality of life using symptom score and sinonasal outcome test (SNOT) score in patients with chronic rhinosinusitis Study design : Prospective cross sectional study. Materials&Method : Between June 2011-June 2013, 42patients (65 sides) diagnosed to have chronic rhinosinusitis (CRS) underwent FESS. At the conclusion of the FESS/ESS operation, cotton ribbon gauge piece soaked with 1 ml Mitomycin-C (0.4 mg/ml) was placed in right/left/ both middle meati for a period of 4 minutes. Following application, nasal cavity was irrigated with sterile normal saline. Patients were examined weekly for 1 month after surgery. Additional examinations were done at the end of 2nd and 3rdmonth post-operatively. At the end of 3 months follow up the outcome was assessed subjectively comparing symptoms scores, sinonasal outcome test (SNOT) score dividing into four domains. Results : At the end of 3 months follow up a significant decrease (80%) in symptom scores was observed (6.64± 1.80, p<0.001). Similarly in SNOT score we observed a significant reduction (71%) in scores (17.76± 8.17, p<0.001) and 3.1% cases showed adhesions. Conclusions : CRS patients have remarkable improvement in their symptoms and quality of life after FESS.

Background Nasal irrigation with normal saline and topical steroid spray forms the mainstay of treatment in post endoscopic sinus surgery patients. However nasal sprays may not deliver optimum dosage of drug to the paranasal sinus mucosa. Budesonide nasal irrigation solves this problem by delivering drugs in a high-volume high-pressure system. Objective The main objectiveof this study will provide insight into the efficacy of budesonide nasal irrigation following functional endoscopic sinus surgery (FESS) surgery and will help to establish new protocols in future. Method Forty-four patients were included and divided into 2 groups of 22 each. One arm received normal saline nasal irrigation and the other arm received budesonide nasal irrigation (1 mg in 500 ml) twice daily. Patients were followed up at 1st post-operative week and 10th post-operative week and on each visit Sino-Nasal Outcome Test (SNOT) 22 and Lund Kennedy Endoscopic scores (LKES) were assessed. Result The mean scores in the first visit was SNOT 22 : 15.73 + 8.897 vs 12.73 + 16.110 (p < 0.05) and LKES : 2.82 + 1.097 vs 1.77 + 1.52 (p > 0.05) in the saline and budesonide groups respectively. The mean scores in the second visit was SNOT 22 : 7.09+3.87 vs 3.73 + 8.70 (p < 0.05) and LKES : 1.64 + 0.790 vs 0.18 + 0.501 (p < 0.05) in the saline and budesonide groups respectively. Thus the budesonide arm had statistically significantly better scores when compared to the normal saline group. Conclusion Budesonide nasal irrigation with a positive pressure high volume device was found to have better efficacy when compared to normal saline irrigation. Budesonide nasal irrigation may be used in the post-operative management of endoscopic sinus surgery patients.

Functional endoscopic sinus surgery (FESS) is a standard treatment modality for patients with chronic rhinosinusitis (CRS) who have failed appropriate medical therapy. However, FESS entails modification of the upper airway tract that may alter phonatory resonance and produce voice changes. The effects of FESS on postoperative voice characteristics in patients with CRS have yet to be quantitatively assessed. Patients with severe CRS who underwent FESS at a tertiary care referral center between May and October 2017 were prospectively enrolled. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and the Voice Handicap Index (VHI) were used to quantitatively evaluate voice characteristics and quality of life, respectively. Preoperative and postoperative CAPE-V and VHI scores were compared with postoperative scores for each patient. Sino-Nasal Outcome Test (SNOT-22) scores were also obtained to assess changes in patient symptoms. 18 CRS patients undergoing FESS were enrolled. The average preoperative Lund-Mackay score was 14, indicating baseline severe CRS. Postoperative assessments demonstrated a statistically significant decrease in CAPE-V (45-27, p = .005) and VHI (10-4.7, p < .001) scores. These correlated with a statistically significant decrease in SNOT-22 scores (42-13, p < .001). Patients with CRS experience a significant improvement in voice characteristics and vocal quality of life following FESS. Furthermore, this appears to correlate with a significant decrease in self-reported disease severity. These findings may augment the discussion of potential benefits of FESS to a new potential domain for voice quality.

Chronic rhinosinusitis (CRS) significantly affect the quality of life (QoL) of patients. The study was conducted in CRS patients who were treated with functional endoscopic sinus surgery (FESS) after failure of medical treatment to analyze clinical outcome using prospectively collected data through a symptom-based rhinosinusitis outcome measure, the Sino-nasal Outcome Test-22 (SNOT-22). The aim of the study was to evaluate and compare the QoL in patients of chronic rhinosinusitis pre-operative and after FESS by SNOT-22. The prospective study was conducted on 40 patients of chronic rhinosinusitis with or without nasal polyposis. Demographic, clinical, diagnostic nasal endoscopy and radiological findings were recorded. Visual analogue scoring and SNOT-22 questionnaire scoring were done preoperatively and at 3rd and 6th months post-operatively. These scores were compared and a value of p < 0.01 was considered statistical significant. Nasal obstruction (80%) was the most commonly reported disabling condition followed by rhinorrhea (75%), facial pain-pressure (72.5%), headache and sneezing. The mean preoperative nasal endoscopy score was 8.08 ± 3.65. The mean preoperative Lund Mackay CT scan score was 11.725 ± 3.64. The mean preoperative SNOT-22 score was 46.25 ± 20.44. After FESS, nasal discharge was improved in 86% patients. Average VAS scores showed significant postoperative improvement at 6months (p < 0.01). The mean postoperative diagnostic nasal endoscopy score improved to 2.80 ± 1.64 at 6months (p < 0.01). The mean postoperative SNOT-22 scores decreased at postoperative follow up visits at 3 and 6months to 14.58 ± 4.90 at 3months and 22.38 ±7.93 at 6months (p < 0.01). CRS patient refractory to medical treatment showed statistical significant improvement after FESS. The SNOT-22 scoring was easy to use scoring used for QoL assessment showed significant improvement after FESS.

In uncomplicated chronic rhinosinusitis (CRS), a consensus regarding appropriate medical therapy (AMT) before surgical intervention has been published in the form of "appropriateness criteria" for endoscopic sinus surgery (ESS). We sought to determine why tertiary surgeons may deviate from the suggested criteria and evaluated whether those deviations result in change in outcomes. Patients with uncomplicated CRS were prospectively enrolled over the course of 1 year. The 22-item Sino-Nasal Outcomes Test (SNOT-22), a general health outcome out of 100, and a physician form, indicating management pathway and decision making, was completed at each visit over a 6-month follow-up period. A descriptive analysis was used to quantify reasons for veering from the "appropriateness criteria," and repeated linear regression modeling was used to measure whether compliance impacted SNOT-22, general health, and Lund-Kennedy (LK) scores over the period of study. One hundred fifty-five patients were enrolled. Sixty-eight percent followed the appropriate management pathway based on their presentation and the suggested criteria. Disparate reasons were documented for deviation in the other 32%, and, despite establishing several predictive categories, "other" was the most common reason, with various explanations well documented. SNOT-22, general health, and LK scores were not statistically impacted by compliancy status (p > 0.05). The suggested "appropriateness criteria" predict a management pathway for the majority of CRS patients. However, in a tertiary sinus center, surgeons may deviate from that model with a significant minority of their patients, for multiple reasons, without causing a change in outcomes.