Saydy et al.

Journal of Otolaryngology - Head and Neck Surgery (2021) 50:34

https://doi.org/10.1186/s40463-021-00515-z

ORIGINAL RESEARCH ARTICLE Open Access

Patient perspectives on endoscopic sinus

surgery for chronic rhinosinusitis
Nadim Saydy1 , Sami Pierre Moubayed2 and Martin Desrosiers1*

Abstract
Background: Through shared decision-making, physicians and patients can elect endoscopic sinus surgery (ESS)
when maximal medical therapy fails in patients with chronic rhinosinusitis (CRS). In this study, we aim to explore
the most important themes with regards to patients’ perspectives on ESS. Our objective was to define the patient
experience and ensure that we have congruent physician and patient goals for obtaining success.
Methods: Semi-structured face-to-face interviews were conducted with 22 patients at a tertiary-care institution in
Montreal. Three themes were established a priori: living with CRS, objectives and expectations and criteria for
success. This thematic approach allowed the identification, analysis and reporting of patterns found across the data
set. A phenomenological methodological orientation was used. Interviews were audio-recorded and transcribed
verbatim for continuous analysis. These were coded by hand by a single coder who read the transcripts multiple
times and relistened to the recordings.
Results: Exploration of themes on patients’ perspectives on ESS for CRS yielded multiple anecdotal findings, and
some recurring patterns. There is a tendency for patients to focus on one principal symptom that drives their
decrease in QoL. Headaches and nasal congestion seemed to impact patients’ QoL the most amongst rhinologic
symptoms. Hyposmia was rarely spontaneously by patients but was often a significant source of distress when
prompted during interviews. Objectives and expectations seemed to be inversely proportional to number of
previous surgeries and severity of symptoms preoperatively. There was a clear association between preoperative
expectations and postoperative satisfaction. There was no clear pattern in the improvement magnitude or time
improved postoperatively for patients to consider the surgery a success.
Conclusions: Patients’ level of satisfaction postoperatively and with their care in general is multifactorial. We
believe the topic of goals and expectations regarding ESS should be discussed preoperatively for every patient with
CRS. This includes patients with seemingly minor disease and patients naive to surgery, as can sometimes have
exceedingly high expectations. Preoperative counselling must also include an assessment of what symptom is the
most cumbersome to that particular patient, as patients tend to focus a lot on one or two symptoms.
Postoperatively, we encourage clinicians to be attentive to the change in each patient’s principal complaints within
the context of a personalized approach and to refer back to patients’ preoperative goals in their assessment of
operative success.
Keywords: Chronic rhinosinusitis, Endoscopic sinus surgery, Patient-centered care, Qualitative research

* Correspondence: [email protected]
1
Division of Otolaryngology – Head & Neck Surgery, Centre Hospitalier de
l’Université de Montréal, University of Montreal, 1051 Sanguinet Street,
Montreal, QC H2X 3E4, Canada
Full list of author information is available at the end of the article

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Saydy et al. Journal of Otolaryngology - Head and Neck Surgery (2021) 50:34 Page 2 of 8

Introduction been improving. That said, there remains a small subset

Chronic rhinosinusitis (CRS) is characterized by inflam- of patients who do not experience a significant improve-
mation of the nose and paranasal sinuses. Its diagnosis is ment in their CRS symptoms postoperatively, or who
incumbent upon both subjective complaints and object- only get a short-lived improvement in their QoL [10].
ive findings (endoscopy or CT scan). The EPOS 2012 An in-depth understanding of patients’ experiences and
Position Paper on Rhinosinusitis and Nasal Polyps de- views is paramount to the patient-physician partnership.
fines CRS as two or more of the following symptoms for Being familiar with patients’ journey would help clini-
at least 12 weeks: nasal blockage/congestion/obstruction, cians improve their therapeutic relationships with pa-
nasal discharge, facial pain/pressure, hyposmia/anosmia tients, identify causes for dissatisfaction and predict
(with the presence of at least either nasal blockage, con- post-operative disappointment. This study aims to
gestion, obstruction or nasal discharge) [1]. These rhino- broadly further our understanding of patients’ experi-
logic symptoms are often an important burden on ences and views on CRS and ESS.
patients’ quality of life (QoL). Beyond these symptoms,
multiple studies link CRS with sleep disturbances, fa- Methods
tigue, depression, anxiety and an overall decrease in Study design
quality of life [2–5]. While rhinologic symptoms are suf- A qualitative research methods was chosen for this
ficient for the clinical diagnosis of CRS, non-rhinologic study. Gallo et al. state that “this type of research has
complaints remain an important part of the clinical por- the potential to enhance the understanding of surgeons’
trait. A recent study has shown that patients with de- and patients’ preferences, attitudes and beliefs, as well as
pression have an increased sino-nasal disease burden assess how these may change with time” [11]. Study
and pain compared to non-depressed patients. In fact, methodology and findings are reported in accordance
surgical outcomes appear less favorable in the former with the Consolidated Criteria for Reporting Qualitative
group [6]. A thorough understanding of patients’ per- Research (COREQ) [12]. A phenomenological methodo-
spectives and experiences with CRS and endoscopic logical orientation was used; namely, the focus of the
sinus surgery (ESS) is likely to favor patient-physician study was on individual subjective experiences. Three
collaboration and improve shared decision-making. themes were identified a priori and incorporated into
The Quality Improvement Committee of the American the interview template: living with CRS, objectives and
Rhinologic Society identified CRS as a priority in the de- expectations and criteria for success. Informed written
velopment of quality measures for rhinologic diseases consent was obtained from all participants before entry
[7]. One significant obstacle in all aspects of the manage- into the study. This study was approved by the Univer-
ment of CRS remains the ability to have universal, sity of Montreal Healthcare Center Institutional Review
patient-centered definitions of commonly used terms. Board and was conducted following study protocol and
For example, there is no clear definition of what an opti- the principles of the Declaration of Helsinki.
mal surgical outcome after ESS is, partly because even
experienced clinicians do not fully understand each pa- Setting
tient’ perspective and overall experience. There is also Twenty-two participants were recruited from a single
no unique agreed-upon definition for an “acute exacer- surgeon’s tertiary care practice (Rhinology & Skull Base
bation” of CRS, as Wu et al. showed in their systematic Surgery) between August 2018 and January 2019 at the
review published last year [8]. It is exceedingly complex University of Montreal Healthcare Center (CHUM)
to perfectly pinpoint why each patient wishes to undergo clinic of Otolaryngology – Head & Neck Surgery. Partic-
surgery for CRS, but perhaps there are common themes. ipants were adult patients (≥ 18 years old) with either
More and more, effort in research in put towards defin- CRSwNP (Chronic Rhinosinusitis with Nasal Polyposis)
ing important concepts in Rhinology and developing or CRSsNP (Chronic Rhinosinusitis without Nasal
clinical recommendations based on evidence. Last year, Polyposis) who had undergone at least one ESS. Patient
the Rhinology Subspecialty group of the Canadian Society charts were accessed before the start of clinic to deter-
of Otolaryngology – Head & Neck Surgery published rec- mine eligibility. Participants were purposively
ommendations for the diagnosis and treatment of acute approached face-to-face before their scheduled appoint-
rhinosinusitis and nasal fracture through the Choosing ment in the waiting room. Interviews were conducted ei-
Wisely Canada campaign [9]. This initiative is primarily ther before or after their visit, depending on clinical
aimed at reducing unnecessary tests and treatments, by workflow. Before initiating interviews, the interviewer
giving clinicians the tools to assist patients in shared explained to patients he had training as a physician but
decision-making. was not part of the medical team. Short-term and long-
With improving surgical techniques and novel medical term objectives of our study were explained to partici-
therapy, the outcomes of CRS patients have steadily pants; it was stated that data would be used for scientific
Saydy et al. Journal of Otolaryngology - Head and Neck Surgery (2021) 50:34 Page 3 of 8

research, rather than for internal audit purposes. A total Results

of 27 patients were approached, only 3 declined to par- The average interview time was 13.3 min (range: 8–25).
ticipate. In all 3 cases, it was because their schedule did The median age was 53 years old (range: 19–79) and
not permit it. there 14 male participants (64%). The median number
previous ESS was 2 (range: 1–7). Seventeen patients had
CRSwNP (77%). Many patients had severe forms of CRS,
Interview with recurring disease despite surgical intervention and
Interviews were conducted in a semi-structured, face-to- maximal therapy. Patients had many comorbidities in-
face manner by NS (male), who at the time of the study cluding asthma, aspirin intolerance and atopy. One pa-
held a Medical Degree and was enrolled in a full-time tient had a concurrent diagnosis of common variable
Masters’ Degree in Biomedical Science (Clinical Re- immune deficiency. Most patients were not active
search) at the University of Montreal. Interviews were smokers (77%) and the majority of patients were Cauca-
scheduled to last 15 min. Based on a review of literature, sian (90%). Demographic data and disease characteristics
an interview template composed of 8 open-ended ques- for interviewed participants are presented in Table 1.
tions was produced [13–16]. An iterative process was
conducted throughout interviews to remove low-yield Living with CRS
questions or add prompts; the final version is shown in Many patients reported nasal congestion as the most
Appendix 1. Specific prompts were added to stimulate bothersome symptom. They also reported secondary
discussion and provide a structure. Moreover, this sleep disturbances, as well as an impact on activities of
allowed participants to provide impressions they had not daily living (including sports). According to them, these
spontaneously mentioned. Each question was evaluated were consequences of the nasal congestion. Patients with
by the senior author (MD); items were subtracted, and diagnosed sleep apnea who were dependent on a CPAP
wording was modified to ensure that concerns com- machine reported difficulty using it because of their in-
monly raised by patients during clinical visits were ad- ability to breathe through their nose. One participant
dressed. Issues identified in early interviews were was a competitive weightlifter. The obstructive symp-
corrected for subsequent interviews. Whenever patients toms became so severe that he could not exercise
did not understand the question, the interviewer pro-
vided clarification or reformulated the question. Each Table 1 Participant demographic and disease characteristics
participant was interviewed once. Patients were recruited (n = 22)
until thematic saturation was achieved. All interviews Male gender; n (%) 14 (64%)
were conducted by the same interviewer. Interviews Age; median (range) 53 (19–79)
were conducted either in French or in English, depend-
CRSwNP; n (%) 17 (77%)
ing on patient preference.
Number of previous ESS; median (range) 2 (1–7)
1 9 (41%)
Analysis 2–4 12 (55%)
Data saturation was achieved after 22 interviews, which 5+ 1 (5%)
prompted us to stop the interview process. Sample size Months since last ESS; median (range) 12 (0.25–180)
in qualitative studies is determined when data saturation
Asthma; n (%) 9 (41%)
is achieved [17]. This is determined during data collec-
tion, when no new information or themes are discussed Intolerance to ASA; n (%) 6 (27%)
during interviews [18]. Thus, there is no formula or cri- Atopy; n (%) 9 (41%)
teria to determine sample size, but some authors Immune deficiency; n (%) 1 (5%)
propose 12 to 26 interviews as a general rule of thumb Ethnicity; n (%)
[19]. Interviews were audio-recorded and transcribed Caucasian 20 (90%)
verbatim for continuous analysis. Transcripts were
African American 1 (5%)
coded by hand and were not returned to patients for
comments or corrections. No data extraction software Middle Eastern 1 (5%)
was used. Feedback was not provided to participants. Smoking status; n (%)
There was one coder (NS), who listened repeatedly to Never 12 (55%)
the recordings and reread the transcripts. A thematic ap- Former 6 (27%)
proach was used to identify common patterns among Active 4 (18%)
the interviews. This allowed the identification, analysis
ASA Aspirin; CRSwNP Chronic rhinosinusitis with nasal polyposis; ESS Functional
and reporting of patterns found across the data set. endoscopic sinus surgery
Saydy et al. Journal of Otolaryngology - Head and Neck Surgery (2021) 50:34 Page 4 of 8

anymore and had to undergo surgery only to continue could not smell anything.
training. (Participant 13, female, CRSwNP)

When it was completely blocked before surgery, I Anterior and posterior nasal drip were also described
could not breathe at all. At night, my mouth got very by patients as a frustrating symptom which also has im-
dry. If I choked on food, I could not breath from the portant consequences on QoL. Some participants also
nose. described a sense of social anxiety associated with dis-
(Participant 16, male, CRSwNP) charge. Meeting new people came with the inevitability
of having to explain they were not contagious; they felt
the need to constantly justify why they were blowing
Try blocking your nose with a clothespin for 24h, I their nose, and one patient spent a significant amount of
dare you. Then imagine that for years. time going to the bathroom to clean his hands because
(Participant 16, male, CRSwNP) he was afraid of appearing unhygienic.

Patients seldom described a single symptom and most People think it’s trivial. But it is not trivial. Everyone
often had multiple rhinologic complaints before ESS. asks: “you still have that?”
They could usually identify a principal symptom mostly We have gone to the moon; how come we cannot
responsible for the decrease in QoL. In many cases, that prevent polyps from coming back?
symptom was the persistent and incapacitating head- (Participant 15, female, CRSwNP)
aches. Patients with CRSwNP were also very bothered
by the severe nasal congestion. Symptomatology and disease progression varied widely
between participants. That said, the severity of the im-
With sinusitis, it’s not only the headaches … pact on patients’ quality of life and the general feeling of
I always feel like I’m in a box, like my head is in a exasperation and desperation before seeking out surgery
box. was shared among most participants. In other words, pa-
(Participant 17, female, CRSwNP) tients seemed to elect surgery if they not only had symp-
toms, but if these symptoms prevented them from living
When asked to describe what it feels like to have CRS, a normal life.
some patients reported symptoms which are not trad-
itionally reported in CRS as being part of their disease, Objectives and expectations
such as hypoacusis, pruritus or tinnitus. As previously described, the majority of participants had
a tendency to focus on a principal symptom when de-
It’s itchiness on the nose, it’s an uncomfortable scribing the incapacity associated with CRS. With a lot
squeezing sensation. of their attention often directed towards that symptom;
It’s as if someone is lifting you from the tip of your patients’ main objective was often to correct their most
nose. bothersome symptom.
(Participant 7, male, CRSwNP)
My objective for surgery was to eliminate the head-
Hyposmia and anosmia were rarely mentioned spontan- aches. I wanted them to disappear.
eously as a symptom of CRS. Only with additional And it worked, it really worked. But the relief only
prompts did many patients describe anosmia, which lasted 1 year and 2 months.
often had a tremendous impact on their QoL. One par- (Participant 21, male, CRSsNP)
ticipant was passionate about cooking and drinking wine
and described anosmia as a “handicap”. Three patients
also mentioned being afraid of eating leftover food be- I chose to undergo surgery because I wanted to be
cause they could not tell if it was still edible without a able to breathe and smell like before.
normal sense of smell and taste. One patient also no- Now I can smell, and it has given me my life back.
ticed an association between acute sinusitis episodes and (Participant 22, male, CRSwNP)
a feeling of cacosmia.
Other participants described more general objectives.
My sinusitis greatly affected my quality of life. Even They wanted to improve their condition, get rid of the
working full-time was difficult. I could not eat; I chronic malaise, improve their QoL, or “become nor-
could not smell. I was afraid of tasting food from mal”. Patients’ objectives and expectations both appeared
fear of getting sick. I could not smell fire smoke. I inversely proportional to the amount of previous
Saydy et al. Journal of Otolaryngology - Head and Neck Surgery (2021) 50:34 Page 5 of 8

surgeries and the severity of CRS impact. In other words, Had you told me 1 month, I would have still gone
patients who had only been operated once had a ten- forth. I could not live like that anymore.
dency to describe that they hoped for (or expected) a full Prompt: How much improvement would be neces-
return to normality after ESS. Patients who had under- sary for you to consider the surgery successful?
gone many surgeries had more pessimistic expectations Even if it’s not perfect. Even a tiny improvement is
and tended to have less ambitious objectives. Further- worth it. If not for surgery, the only other solution is
more, some patients with incapacitating constant head- cortisone. And that is bad for the rest of my body.
aches or a complete incapacity to breathe from the nose (Participant 22, male, CRSwNP)
stated that any small improvement would be worth go-
ing through the ESS. Only a minority of patients (5/22) Discussion
hoped (or expected) all their symptoms would disappear. Many interviewed participants reported significant levels
Other patients hoped (or expected) and improvement in of distress before ESS. Amongst our participants, the de-
one symptom in particular, or simply hoped for an im- cision to undergo ESS was motivated by the desire to
provement in QoL. improve symptoms and QoL, which is consistent with
findings from Soler et al. [20]. Indeed, in a group of 242
The first surgery, I did not really have any objectives. patients among which 180 patients elected to have ESS
The doctor said the polyps were so big, they came rather than medical management, there was no differ-
out from the nose. The second time I wanted to ence in demographic characteristics, social support, per-
breath better, I wanted to have less infections and I sonality types or physician-patient relationship between
wanted to have a lasting relief. groups. The only difference between the surgery group
(Participant 5, male, CRSwNP) and the medical management group was a greater nega-
tive impact on disease-specific QoL in the ESS group as
assessed by SNOT-22 score (a validated measure of CRS
My goals were to need less antibiotics and cortisone. symptoms and health-related QoL) [21]. In light of this
Also, I wanted to get rid of my asthma. When I have data, it is not surprising that our group of post-ESS par-
nasal polyps, my asthma gets out of control. ticipants reported a significant preoperative impact of
(Participant 15, male, CRSwNP) CRS on their daily life.
Symptoms reported in our population pre-operatively
Criteria for success were similar to those reported in the literature. Mattos
Among participants, there was a clear association be- et al. found that preoperatively, symptoms most often
tween expectations and satisfaction. Dissatisfied patients reported by CRS patients were nasal obstruction, smell/
tended to have ambitious expectations such as a taste, discharge and sleep symptoms [22]. One notable
complete and prolonged cure after ESS. difference in our study is that we questioned participants
a posteriori rather than a priori. Despite this variation,
The goal I think is to feel better. I wanted to be 80% our overall impression was similar: these symptoms
better … or at least 60%. I think the goal is also to seem to be the ones which lead patients to seek ESS, es-
feel better for as long as possible. Ideally to feel bet- pecially in the CRSwNP group. Some patients described
ter forever, but by now I don’t really believe anymore symptoms they believed were associated with CRS, but
that it’s possible. So, I would say at least 4-5 years. which are not usually considered a part of the disease
(Participant 4, female, CRSwNP) spectrum. In these instances, they may describe unrealis-
tic goals. For example, pruritus may be due to an atopic
Only one patient reported no improvement whatsoever predisposition, which is associated with CRS; that said,
after ESS, but several participants were not entirely satisfied. one does not necessarily expect this patient to resolve
This dissatisfaction was often due to a recurrence in symp- with the control of CRS. It is imperative that patients
toms after a while. Patients were asked to determine what learn through counselling which symptoms are amen-
decrease in symptom magnitude would make the surgery able to improvement and which are not. If patients
worth it in terms of risks vs benefits. Their answers ranged undergo ESS with the goal of improving a symptom un-
from “any noticeable improvement in the main symptom” related symptoms to CRS, disappointment is inevitable.
to “a complete resolution of all symptoms”. The same ques- Even rhinologic symptoms associated with CRS do not
tion was asked for time with symptomatic control. Duration always respond to ESS. It is unclear which symptoms are
ranged from “1 month” to “forever” most improved by ESS, but certain clinical presentations
(symptom clusters) may predict overall SNOT-22 score
Prompt: How long should you be free of symptoms improvements [23]. Patient-reported outcome measures
for you to consider the surgery successful? (PROMs), such as the SNOT-22, are validated clinical
Saydy et al. Journal of Otolaryngology - Head and Neck Surgery (2021) 50:34 Page 6 of 8

tools that produce a numerical score which can be inter- Physicians should play a role in assessing – and modu-
preted as an improvement or a deterioration in disease lating if necessary – expectations because unrealistic
state. goals are often synonymous with postoperative disap-
One of the most interesting findings of this study is pointment. Moreover, open and frank discussion should
the heterogeneity of patient definitions of operative suc- be geared to the severity of patients’ disease and previ-
cess. Patient satisfaction seems to depend greatly on the ous experience with ESS. Preoperative counselling
extent to which expectations and goals are met, rather should thus be undertaken diligently not only for com-
than the actual process or quality of outcome. We be- plex cases with a complicated history with CRS, but also
lieve that patient satisfaction remains an overly simplis- for patients naïve to surgery or patients with seemingly
tic measure of success after ESS, even in the busy minor disease. It is crucial that these patients understand
clinical setting. Some participants in our study reported that ESS is by no means an “easy fix”, that long-term
that they would be content with any noticeable improve- positive outcomes are often contingent on continuous
ment, while others were expecting a complete and indef- topical therapy, and that the process of undergoing ESS
inite resolution of their symptoms. Interestingly, patients can be associated with significant discomfort and
had a tendency to have the highest expectations before distress.
their first surgery. First-time ESS patients with exces- A growing body of evidence suggests an important
sively high expectations should be proactively counselled heterogeneity both in clinical phenotypes and genetic
preoperatively, in the hopes of avoiding or mitigating endotypes of patients with CRS [29–31]. A greater un-
post-operative disappointment. Conversely, patients with derstanding of the pathophysiology and the molecular
recurrent disease did not expect to be cured with a sub- pathways involved has stimulated efforts in targeted
sequent ESS and were more realistic regarding long- treatment and personalized medicine for CRS patients
term outcomes. Counselling in these patients should [32, 33]. A recent article by Grayson et al. differentiates
focus on the increased risks of operative complications three different CRS phenotypes: IgE-mediated central
in revision ESS [24]. compartment atopic disease, eosinophilic CRS and non-
The great disparity between patients’ objectives, expec- eosinophilic CRS. This article illustrates the distinctions
tations and definitions of success emphasizes the im- in clinical presentation, endoscopic, radiologic and histo-
portance of a thorough presurgical counselling and a pathologic findings, and in treatment. In all three sub-
strong physician-patient partnership. Last year, the types, the authors recommend to consider ESS, with the
Quality Improvement Committee of the American Rhino- distinction a Draf 3 is suggested in eosinophilic CRS
logic Society published a framework termed the CRS Ap- [34]. Despite the arrival of biologics for the treatment of
propriate Presurgical Algorithm (CAPA), which relies on CRSwNP, ESS remains the mainstay of the treatment of
4 main quality metrics [25]. One of those is the occur- CRS refractory to maximal medical therapy for most pa-
rence of “a patient-centered discussion regarding treat- tients [35, 36]. Indeed, this surgery has been shown to
ment options for refractory CRS while focusing on risks be efficient and more cost-effective than continuous
and benefits, the need for long-term medical compliance medical therapy alone [37–40]. That said, evidence sug-
and understanding of patient preferences and expecta- gests certain phenotypes of CRS tend to have more fa-
tions”. Vennik et al. have recently published their exten- vorable surgical outcomes compared to others [41].
sive work on both patient and physicians’ While decision to undergo ESS is always taken in part-
(Otolaryngologists and primary care physicians) experi- nership with the patient, studies suggest that certain
ences and views on current management of CRS in the symptoms or patient characteristics are predictive of
UK [26, 27]. Previously, Erskine et al. had also explored positive or negative outcomes [42]. Patient reported out-
CRS patients’ experiences in both primary and secondary come measures, such as the Sinonasal Outcome Test
care, again in the UK [28]. A thorough understanding of (SNOT-22), or a thorough preoperative assessment can
the patient experience is essential to optimal care, espe- guide clinicians during patient counselling [43–46].
cially in chronic illnesses such as CRS. This qualitative The limitations of this study include the subjectivity
approach to the topic of ESS permitted an in-depth ex- inherent to the qualitative design. Moreover, all partici-
ploration of certain theme. This permitted us to collect pants were recruited from the practice of a single sur-
rich and granular information directly from primary geon working in an academic tertiary referral practice.
stakeholders. Hence, this population may not be representative of the
Clinicians strive to offer the best surgical treatments, general CRS population. That said, it provided us with
and to follow evidence-based recommendations. That insights from patients who had undergone many ESS
said, emphasis must also be placed on tailoring the right and had a rich experience with the disease. Since the
treatment to the right patient. As we have shown, pa- study was conducted in Montreal (Canada), interviews
tients’ goals and expectations may vary widely. were conducted in patients’ preferred language. This
Saydy et al. Journal of Otolaryngology - Head and Neck Surgery (2021) 50:34 Page 7 of 8

may have led to some aspects of the experiences de- Abbreviations

scribed by patients being lost in translation during the- CRS: Chronic rhinosinusitis; CRSwNP: Chronic rhinosinusitis with nasal
polyposis; CRSsNP: Chronic rhinosinusitis without nasal polyposis;
matic analysis. Additionally, the median time from last ET: Eustachian tube; ESS: Functional endoscopic sinus surgery; QoL: Quality of
surgery was 12 months among participants. It is likely life
that patients may have forgotten some elements of their
Acknowledgements
experience with ESS, though we hope the most import- Not applicable.
ant ones were recalled. Although all participants were
followed at the time of the interview by a single surgeon, Authors’ contributions
All authors contributed to the design of the questionnaire. NTS and MYD
many had previously been operated at other institutions recruited participants to interview. NTS compiled and analyzed the data
and only then referred for refractory disease. Six patients under supervision and guidance from MYD and SPM. NTS wrote the
had undergone one ESS only; thus, our sample was het- manuscripts, while MYD and SPM proofread and edited it. The author(s) read
and approved the final manuscript.
erogeneous enough to capture many different levels of
CRS severity, or at least different timeframes. Another Funding
important limitation of this study concerns the fact that Internal funds. No extra-mural sources of funding were obtained.
90% of participants were Caucasian. A recent paper
Availability of data and materials
shows that non-white patients tend to experience more Data used in the current study is available from the corresponding author on
severe CRS symptoms at baseline compared to white pa- reasonable request.
tients. They also seem to have more significant improve-
Declarations
ments in QoL with ESS [47]. Undoubtedly, non-white
patients must have different experiences with regards to Ethics approval and consent to participate
ESS. We unfortunately were not able to collect and This study was approved by the University of Montreal Healthcare Center
Institutional Review Board. Informed written consent was obtained from all
analyze these unique perspectives. Despite these limita- participants before entry into the study.
tions, we believe this study provides important insights
to otolaryngologists on the patient journey before and Consent for publication
Not applicable.
after ESS, patients’ objectives and expectations before
surgery, and patients’ perspective on the definition of an Competing interests
optimal outcome after surgery. There are no competing interests.

Author details
Appendix 1
Division of Otolaryngology – Head & Neck Surgery, Centre Hospitalier de
Question 1: Please describe the most important aspects l’Université de Montréal, University of Montreal, 1051 Sanguinet Street,
Montreal, QC H2X 3E4, Canada. 2Division of Otolaryngology – Head & Neck
of your experience living with CRS.
Surgery, Sacré-Coeur Hospital, University of Montreal, Montreal, Quebec,
Prompt: How would you rate them in order of Canada.
importance?
Received: 16 December 2020 Accepted: 10 May 2021
Prompt: What are the best questions to assess each of
these aspects?
Question 2: Please describe your goals before under- References
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2012: European position paper on rhinosinusitis and nasal polyps 2012. A
Question 3: Please describe your expectations before summary for otorhinolaryngologists. Rhinology. 2012;50(1):1–12. https://doi.
undergoing ESS. org/10.4193/Rhino50E2.
Question 4: Please list things you wish you knew go- 2. Tomoum MO, Klattcromwell C, DelSignore A, Ebert C, Senior BA. Depression
and anxiety in chronic rhinosinusitis. Int Forum Allergy Rhinol. 2015;5(8):
ing into surgery, if any. 674–81. https://doi.org/10.1002/alr.21528.
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