Endoscopic Extended Sinus Surgery for Patients with Severe Chronic Rhinosinusitis with Nasal Polyps, the Choice of Mucoplasty: A Systematic Review

Purpose of Review The advances in the knowledge of the molecular basis of the inflammatory response in chronic rhinosinusitis with nasal polyps (CRSwNP) have led the management of these patients towards personalized and precision medicine. Surgery has been positioned as a suitable alternative in patients who do not achieve control with appropriate medical treatment, but polypoid recurrences remain a constraint. The emergence of new surgical approaches based on patient phenotyping and the poor disease control associated with type 2 inflammatory phenotype makes it necessary to review the role of personalized and precision surgery in managing the disease. Recent Findings Surgical approaches based on wide resection of bony sinus structures and the treatment of mucosa lining the sinonasal cavity have been analyzed and compared with other techniques and seem to offer more favorable surgical outcomes and improved quality of life (QoL), in addition to lower relapse rates. The innovations with new complementary surgical techniques, such as reboot surgery adding an extended autologous mucosal graft from the nasal floor (mucoplasty), may benefit endoscopic and QoL outcomes in the most severe CRSwNP patients with type 2 phenotype. Summary Using bilateral endonasal mucoplasty as a complementary technique to reboot surgery is a suitable technical choice that has improved short- and medium-term QoL and endoscopic outcomes for patients with severe CRSwNP. These results are likely due to a combination of the extension of reboot and the inherent inflammatory and healing properties of mucoplasty. We propose this technique as a valuable surgical resource, although more robust clinical studies are needed to evaluate its long-term benefits comprehensively. Supplementary Information The online version contains supplementary material available at 10.1007/s11882-023-01113-x.

The most complete resection possible of the non-olfactory ethmoid mucosa from the underlying periosteum based on the evo-devo theory To address the affected sinuses (computed tomography images), irrespective of the presence of specific sinusrelated symptoms Aims to maximally remove all sinus mucosa and enables healthy reepithelialization from the preserved nasal mucosa to treat type 2 inflammation To place mucosa from a nonpolyposis donor site to promote re-epithelialization of the excised mucosa with a tissue of lesser polyposis potential

Objective
Removal of varying amounts of nasal and sinus respiratory epithelium to widen the natural sinus ostia to restore ventilation and mucociliary clearance of the nasal sinuses damage to the surrounding tissue To perform a wide marsupialization of the ethmoid, maxillary, sphenoid, and frontal sinuses into the nasal cavities Removal of all offending ethmoidal lamellae can prevent unintended obstruction and simplifies ongoing diagnostics and therapeutics in the postoperative patient To accomplish a total clearance of all affected mucosa from all sinuses, leaving the periosteum where possible To place mucosa from a nonpolyposis donor site to promote re-epithelialization from the graft

Mucosa
Targeted removal of disease from key areas of the anterior ethmoid and middle meatus Ethmoid mucosa complete removal.The mucosa on the walls of the large sinuses and around the frontal ostia is preserved The basal lamella is perforated to enter the posterior ethmoid cells and the opening is enlarged The basal lamella is perforated to enter the posterior ethmoid cells and the opening is enlarged The basal lamella is perforated to enter the posterior ethmoid cells and the opening is enlarged The basal lamella is perforated to enter the posterior ethmoid cells and the opening is enlarged 8 Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process.Page 5 (Lines 108-120)

Data collection process
9 Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process.
Page 5 (Lines 108-120) Data items 10a List and define all outcomes for which data were sought.Specify whether all results that were compatible with each outcome domain in each study were sought (e.g. for all measures, time points, analyses), and if not, the methods used to decide which results to collect.Page 5 (Lines 112-120) 10b List and define all other variables for which data were sought (e.g.participant and intervention characteristics, funding sources).Describe any assumptions made about any missing or unclear information.
Pages 5-6 (Lines 112-120) and Table S1 Study risk of bias assessment 11 Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.
Pages 5-6 (Lines 122-127), Figure 2 and Table S4 Effect measures 12 Specify for each outcome the effect measure(s) (e.g.risk ratio, mean difference) used in the synthesis or presentation of results.Page 5 (Lines 112-120)

Synthesis methods
13a Describe the processes used to decide which studies were eligible for each synthesis (e.g.tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)).
Page 5 (Lines 100-111) and Table S3 13b Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions.
Page 6 (Lines 129-142) 13c Describe any methods used to tabulate or visually display results of individual studies and syntheses.Page 6 (129-133) 13d Describe any methods used to synthesize results and provide a rationale for the choice(s).If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used.Page 6 (129-133) 13e Describe any methods used to explore possible causes of heterogeneity among study results (e.g.subgroup analysis, meta-regression).Not applicable 13f Describe any sensitivity analyses conducted to assess robustness of the synthesized results.Not applicable

Reporting bias assessment
14 Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases).

Certainty assessment
15 Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome.Figure 2 and Table S4 Supplementary Table S2.PRISMA checklist fulfilled for this systematic review (continue).

Item # Checklist item
Location where item is reported

Study selection 16a
Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram.Figure 1 16b Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded.Page 5 (100-106) Figure 1 and Table S3 Study characteristics 17 Cite each included study and present its characteristics.Tables 1 and 2 Risk of bias in studies 18 Present assessments of risk of bias for each included study.
Figure 2 and Table S4 Results of individual studies 19 For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g.confidence/credible interval), ideally using structured tables or plots.Table 2 Results of syntheses 20a For each synthesis, briefly summarise the characteristics and risk of bias among contributing studies.Table 1, Figure 2 and Table S4 20b Present results of all statistical syntheses conducted.If meta-analysis was done, present for each the summary estimate and its precision (e.g.confidence/credible interval) and measures of statistical heterogeneity.If comparing groups, describe the direction of the effect.Not applicable 20c Present results of all investigations of possible causes of heterogeneity among study results.Tables 1 and 2 20d Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results.S3

Vertical plate of the basal lamella of the middle turbinate
Provide registration information for the review, including register name and registration number, or state that the review was not registered.Page 3 (Lines 73-74) 24b Indicate where the review protocol can be accessed, or state that a protocol was not prepared.Page 4 (Lines 82-98) and TableS324c Describe and explain any amendments to information provided at registration or in the protocol.Not applicable Support 25 Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the review.Report which of the following are publicly available and where they can be found: template data collection forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review.Table2 and Table