Surgical Adequacy in ESS for Primary Diffuse CRS: Expert Consensus Recommendations

Objective: Surgical treatment represents an adjunct to medical therapy in the management of primary diffuse chronic rhinosinusitis (CRS). Despite advancement in endoscopic sinus surgery (ESS), there are currently no established guidelines delineating the appropriate surgical extent for defining adequate ESS in cases of primary diffuse CRS. Methods: Through a modified Delphi technique, 33 statements regarding the extent of surgery for each paranasal sinus were drafted following a literature review and submitted to an expert panel composed of 15 internationally recognized ESS experts. A consensus meeting was held to discuss the results for each iteration. An additional statement was added during the meeting, and a total of 34 statements were voted on during the last round. Results: Consensus was reached in 17 statements out of 34. Type 1 medial maxillary antrostomy, bilateral anteroposterior ethmoidectomy, and at least DRAF I frontal sinusotomy should be performed in all cases of primary diffuse CRS, with a particular focus on mucosal sparing, regardless of the likelihood of subsequently needing biologic therapy. DRAF III frontal sinusotomy should not be considered as a first-line approach even in patients with risk factors for recurrence. Treatment of the sphenoid sinus might be avoided in cases where it is not involved by the pathology. Conclusion: This document outlines a consensus on the appropriate surgical approach for primary diffuse CRS, aiming to promote standardization while preserving individual clinical judgment.