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Originally published September 2, 2026
Last updated September 2, 2026
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For the community otolaryngologist, the question of optimal timing for endoscopic sinus surgery (ESS) in chronic rhinosinusitis (CRS) patients is a critical one. While medical management remains the first-line approach, emerging evidence suggests that delaying surgical intervention may impose a greater long-term burden on patients — and the healthcare system — than previously appreciated.
Kevin Hur, MD, is a board-certified otolaryngologist with the USC Sinus and Nasal Disorders Program, part of the USC Caruso Department of Otolaryngology – Head and Neck Surgery of Keck Medicine of USC, who specializes in endoscopic sinus surgery. He offers a compelling perspective on the benefits of earlier surgical referral.
For patients with CRS whose symptoms persist despite optimal medical therapy, the stakes are high. Studies have shown that patients with CRS experience impairment in health-related quality of life comparable to other serious chronic conditions such as COPD, kidney failure requiring dialysis, congestive heart failure and cancer-related pain. Social functioning scores for CRS patients are lower than for most other chronic diseases.
“You feel stuffy, like you have a cold all the time. It really affects your daily activities as well as how you sleep,” Hur says. “It has a very strong impact on quality of life.” However, he notes that because symptom onset is often gradual, “a lot of people just tolerate it,” adapting to a diminished baseline until surgery provides immediate, eye-opening (and nose-opening) improvement.
Newer research indicates that offering sinus surgery earlier in the treatment pathway when symptoms do not respond to intranasal medications may be beneficial.
The MACRO trial, a £3.2 million UK-based study published in The Lancet in 2025, provided the most definitive evidence to date. The study randomized 514 adults with CRS into three arms: ESS, clarithromycin or placebo — all while receiving intranasal corticosteroids and saline irrigations. At six months, the surgical group demonstrated significantly superior outcomes, with a mean SNOT-22 score reduction of 20.44 points compared to placebo, far exceeding the minimum clinically important difference of 8.9 points. Crucially, the trial found no significant benefit from clarithromycin over placebo, challenging the routine use of long-term macrolide antibiotics.
Beyond the MACRO trial, retrospective data further informs timing. A UK analysis using the Clinical Practice Research Datalink compared patients who underwent ESS within 12 months of diagnosis versus those who waited five years or more. The late cohort required significantly more postoperative healthcare utilization, meaning more physician visits and prescriptions per patient per year.
Hur explains the clinical rationale: “When you don’t treat disease for a longer period of time, it can cause chronic, more severe inflammation and more permanent changes in the sinuses.”
He emphasizes that while surgery remains beneficial regardless of timing, the magnitude of improvement appears larger when performed earlier. He says that many patients who undergo surgery after suffering for years express regret, telling him, “I wish I did this 10 or 15 years ago.”
ESS is performed using a small endoscope through the nostril with no facial incisions. The surgeon opens the natural drainage pathways of the sinuses, removes diseased tissue and creates access for topical medications. Recovery is typically manageable; most patients go home the same day and can return to normal activities within about a week.
As Hur notes, postoperative management, including saline irrigations and steroid therapy, is critical to preventing scar tissue and recurrence. Some patients may require revision surgery, but the goal is to maximize symptom relief and reduce overall healthcare utilization.
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