Sinus Surgery: When Is Earlier Intervention Beneficial?

Research is showing the effects of earlier surgical referral for patients with chronic rhinosinusitis.

By
October 13, 2026
5 min

Keck Medicine of USC

At a Glance

Category	Detail
Condition	Chronic rhinosinusitis (CRS)
Key Mechanisms	CRS can impair health-related quality of life. Prolonged untreated disease may contribute to more severe inflammation and permanent sinus changes, according to Kevin Hur, MD.
Target Population	Adults with CRS whose symptoms persist despite adequate intranasal corticosteroid and saline irrigation therapy.
Care Setting	Otolaryngology care, including medical management, referral for endoscopic sinus surgery (ESS), and postoperative follow-up.

Key Highlights

In the MACRO trial, 514 adults with CRS were randomized to ESS, clarithromycin, or placebo; all received intranasal corticosteroids and saline irrigations.
At six months, the ESS group had a mean SNOT-22 reduction 20.44 points greater than placebo, exceeding the stated minimum clinically important difference of 8.9 points.
The trial found no significant benefit of clarithromycin over placebo.
A UK retrospective analysis found greater postoperative healthcare utilization among patients who underwent ESS five or more years after diagnosis than among those treated within 12 months.
ESS is performed through the nostril without facial incisions; most patients go home the same day and may return to normal activities within about a week.

Guideline-Based Recommendations

Diagnosis

Management

Consider early referral for ESS when CRS symptoms persist despite adequate intranasal corticosteroid and saline irrigation therapy.
Do not use long-term macrolide antibiotics routinely, according to the article's account of recent evidence and Kevin Hur, MD.
After ESS, use postoperative management including saline irrigations and steroid therapy to help prevent scar tissue and recurrence.

Monitoring & Follow-up

Continue postoperative care and follow-up; some patients may require revision surgery.

Risks

The article notes that some patients may require revision surgery.
The article reports that prolonged untreated disease may cause more severe inflammation and more permanent sinus changes, as described by Kevin Hur, MD.

Patient & Prescribing Data

Adults with chronic rhinosinusitis; the MACRO trial enrolled 514 adults.

In the MACRO trial, all groups received intranasal corticosteroids and saline irrigations. ESS produced a greater six-month SNOT-22 reduction than placebo, while clarithromycin did not significantly outperform placebo. The article describes same-day discharge for most patients and return to normal activities within about a week.

Clinical Best Practices

Assess symptom persistence after adequate intranasal corticosteroid and saline irrigation therapy when considering referral for ESS.
Discuss the MACRO trial findings on ESS and clarithromycin with patients when reviewing treatment options.
Explain that ESS uses an endoscope through the nostril to open sinus drainage pathways, remove diseased tissue, and provide access for topical medications.
Emphasize postoperative saline irrigations and steroid therapy as part of care to help prevent scar tissue and recurrence.