Reg-ent Registry Insights: Chronic Rhinosinusitis
An analysis using the Reg-ent database to explore trends in the diagnosis and treatment of chronic rhinosinusitis in adults.
Characterized by symptoms such as nasal congestion, facial pressure, nasal discharge, and hyposmia or anosmia, CRS significantly impairs patients’ quality of life and places a substantial burden on healthcare systems worldwide.1 Endoscopic sinus surgery (ESS) is a well established treatment option for patients with CRS, with about 14% of patients undergoing ESS nationwide from 2010 to 2012.3 ESS, a minimally invasive procedure, has been widely adopted in the United States as the standard surgical approach for managing CRS. Given the prevalence of CRS and the complexity of its management, there has been a growing need for standardized, evidence-based guidance to inform clinical practice.
The American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) developed a comprehensive clinical practice guideline focused on the surgical management of adult CRS with the goal to identify opportunities for quality improvement, and to provide clinicians with trustworthy, evidence-based recommendations to enhance patient outcomes, reduce practice variation, and ensure safe, effective care.
Based on the key action statements recommended in the guideline, the Academy’s Reg-ent team conducted a deeper analysis of Reg-ent registry data to examine trends in the prevalence of CRS and its treatment patterns, specifically focusing on ESS use and antibiotic therapy.
Materials and Methods
The initial analytic cohort was derived from the Reg-ent database and comprised patients aged 18 years and older diagnosed with CRS, which totaled 515,504 patients. To define CRS, we used a comprehensive set of diagnostic codes, including ICD-9 and 10, which encompassed both acute and chronic forms of sinusitis, including site-specific classifications such as maxillary, frontal, ethmoidal, sphenoidal, and pansinusitis. The data spanned the years 2019 to 2023.
Results
Coding and Treatment Pathways
We identified the 36 diagnosis codes applicable to CRS from our database. From the Reg-ent dataset, the most frequently documented ICD-10 code was J32.0, corresponding to chronic maxillary sinusitis, with 135,004 patients (approximately 30.3% of the cohort) assigned to this diagnosis. Additionally, the ICD-9 code 473.9, representing unspecified chronic sinusitis, accounted for 18.6% of all CRS diagnoses. Other commonly charted diagnosis codes included ICD-9 and ICD-10 classifications for acute and recurrent sinusitis, and site-specific conditions such as sphenoid and maxillary sinusitis.
From the initial CRS population, we further stratified patients based on treatment pathways and identified 40,857 patients who underwent ESS. Within that ESS cohort, 22,288 patients were prescribed antimicrobial therapy as part of the perioperative regimen.
Patient Demographics
Our preliminary analysis of CRS trends revealed that individuals aged 60–69 years had the highest rate of diagnosis within the Reg-ent dataset, accounting for 20.5% of the total patient population. This was followed by the 50–59-year age group at 17.9%. In terms of sex distribution, most patients diagnosed with CRS were identified as male (59.7%), versus female (40.3%). Patients diagnosed with CRS in Reg-ent were identified by race as follows: 67.5% (335,129) White, 7.8% (40,055) Black or African American, 2.5% (13,038) other races, 2.4% (12,479) Asian, 1.5% (7,483) American Indian or Alaskan Native, 0.1% (482) Native Hawaiian or other Pacific Islander, and 0.1% (424) multiracial. Patients diagnosed with CRS in Reg-ent were identified by ethnicity as follows: non-Hispanic or Latino at 63% (324,678), Hispanic or Latino at 4.7% (24,292) and other ethnicity at 1.2% (6,383).
Regional Prevalence of CRS Diagnosis
Regionally, the distribution of patients diagnosed with CRS in the Reg-ent dataset was as follows: Mid-Atlantic (32.4%), South Atlantic (28.2%), South Central (18.7%), Midwest (8.1%), Pacific (5.4%), New England (3.6%), and Mountain (2.7%). Notably high concentrations of CRS diagnoses were observed at the state level in New York and New Jersey (Mid-Atlantic), Texas (South Central), California (Pacific), South Carolina, and Florida (both South Atlantic).
Note: the Reg-ent registry receives data from participating EHR systems with patient demographic information occasionally incomplete or unavailable, which may result in demographic percentages not adding to 100%.
Endoscopic Sinus Surgery (ESS)
ESS is commonly used to treat CRS. Our analyses were designed to address the research needs identified in the CPG to enhance knowledge of the CRS disease profile, as well as explore patterns of antibiotic use during CRS treatment. Out of the 515,504 patients who were diagnosed with CRS, we identified 40,857 patients that had undergone ESS procedures. We analyzed our cohort using CPT codes for ESS procedures, including nasal/sinus endoscopy with partial or total ethmoidectomy, maxillary antrostomy with or without tissue removal, sphenoidotomy, and frontal sinus exploration.
From 2019 to 2023, the rate of ESS procedures performed peaked in 2019 (11% of all diagnosed CRS patients), followed by a progressive decline to 6.1% by 2023, despite a relatively stable CRS diagnosis rate averaging approximately 10,000 patients per year over this period.
ESS Patient Demographics
CRS patients who went on to receive ESS procedures were identified by race as follows: White patients at 67.5% (26,569), Black or African American patients at 7.1% (2,889), Asian patients at 2.7% (1,120), other races at 2.5% (1,039), American Indian or Alaskan Native patients at 0.7% (281), and Native Hawaiian or other Pacific Islander and multiracial patients at 0.1% each (42 and 22, respectively).
To examine potential disparities within each racial group, we calculated the proportion of patients in the initial CRS cohort who underwent ESS: 9.0% of Asian patients, 8.7% of Native Hawaiian or other Pacific Islander patients, 8.2% of White patients, 8.0% of other race patients, 7.2% of Black or African American patients, 5.2% of multiracial patients, and 3.8% of American Indian or Alaskan Native patients received ESS.
Among those who underwent ESS procedures, non-Hispanic or Latino patients comprised 62.3% of ESS recipients, Hispanic or Latino patients accounted for 5% (2,021), and other ethnicity patients made up 1.7% (700).
To explore potential disparities by ethnicity, we determined the proportion of each group in the initial CRS cohort who received ESS. We found that 11% of other ethnicity patients, 8.3% of Hispanic or Latino patients, and 7.8% of non-Hispanic or Latino patients underwent ESS.
ESS Patient Regional Distribution
Geographic distribution indicated that the South Atlantic region observed the highest ESS prevalence at 29.4%, followed by South Central (24.9%), Mid-Atlantic (21.2%). The New England, Mountain, and Pacific regions had the lowest prevalence rates for ESS, accounting for 4.9%, 3%, and 0.5%, respectively.
Cavities Treated During ESS Procedures
Among all configurations of ESS procedures, the maxillary sinus treated alone emerged as the most common, accounting for 36.1% of all procedures. In contrast, the combination involving the frontal, maxillary, and sphenoid sinuses represented the least common pattern, occurring in just 0.1% of cases. We further used the ESS cohort to identify the number of sinus cavities treated on a single procedure date. Single cavity procedures were the majority with 78.2% of the total procedures followed by two (17.8%), three (3.7%), and four (0.3%) combinations of cavities.
Antibiotic Prescription in ESS Patients
The observation window for antibiotic prescriptions was defined as up to 13 weeks to encompass preoperative, intraoperative, and postoperative prescriptions.
Within the ESS cohort, 22,288 patients were identified as having received antibiotic prescriptions. Detailed analysis revealed a positive correlation between the number of sinus cavities treated and the rate of antibiotic use. Procedures involving a single sinus cavity like maxillary, ethmoid, sphenoid, or frontal were associated with an average antibiotic prescription rate of 51.9%. Antibiotic rates were elevated in multi-cavity procedures. The highest antibiotic prescription rate, 78.4%, was observed in cases involving all four sinus cavities: ethmoid, frontal, maxillary, and sphenoid.
Between 2019 and 2023, we observed a notable trend in antibiotic prescription rates associated with ESS procedures. Antibiotic usage rose from 52.2% in 2019 to 56.5% in 2020, followed by a gradual decrease to approximately 55.1% by 2023.
Antibiotic Timing and Types Prescribed
Antibiotic use was further categorized based on timing of administration: preoperative, intraoperative, postoperative, and overall usage.
Preoperatively, amoxicillin was the most commonly prescribed antibiotic, followed by sulfamethoxazole/trimethoprim and doxycycline. Ciprofloxacin had the lowest preoperative prescription rate. Preoperative antibiotic use was higher than intraoperative and postoperative use across both single and multi-cavity procedures. Amoxicillin was also the most frequently prescribed antibiotic in the intraoperative setting, followed by cefazolin and doxycycline. In the postoperative period, doxycycline was the most prescribed antibiotic.
Across all time points, we identified the ten most typically prescribed antibiotics from our dataset, with amoxicillin ranking first, followed by doxycycline and sulfamethoxazole/trimethoprim. Azithromycin had the lowest prescription rate over the entire study period.
Repeated Procedures and Antibiotic Prescription
Finally, we evaluated documented reoperative rates among patients who had antibiotics ordered within 13 weeks of their ESS procedure. Our ESS cohort, drawn from the larger CRS cohort, comprised 40,857 patients, of whom 22,288 (54.6%) had at least one antibiotic order recorded in the peri-operative period. To assess whether antibiotic receipt was associated with reoperation, we first examined procedure counts across the entire cohort.
A total of 38,183 patients (93.5%) underwent only a single ESS procedure. Within this group, 20,624 (54%) had received antibiotics and 17,559 (46%) had not. We then analyzed the 2,674 patients (6.5%) who underwent two or more ESS procedures during the study period. For these patients, we identified any antibiotic orders in the preoperative, intraoperative, or postoperative setting within a 13-week window surrounding each procedure date.
Discussion
CRS is an increasingly significant health concern both in the United States and globally. In the U.S., approximately 11.5% of adults report symptoms consistent with CRS.^4,5 Beyond its high prevalence, CRS has a significant impact on quality of life, being equally burdensome as other chronic conditions. It is also associated with increased healthcare costs and reduced overall productivity.1
In response to these challenges, the Reg-ent team conducted an in-depth analysis to explore trends in CRS prevalence and treatment patterns and evaluate research gaps identified in the recently published CPG guidelines using data collected from the Reg-ent registry database. The CPG specifically highlighted critical areas where further research is needed, particularly in relation to patient demographic characteristics, treatment outcomes, and the comparative effectiveness of different surgical and medical treatment options over time.
As indicated in the results section, our analysis revealed that ESS was the most widely accepted and used treatment for CRS, along with medical therapy. While it has been established as an important step in managing CRS, the overall trend in surgeries performed over time shows a decline post-pandemic. Several factors may explain this decline. During the post-pandemic period, several physicians saw a significant reduction in ESS procedures. In a survey of rhinologists,7 60% of respondents (n = 277) indicated they had performed no endoscopies during the initial phases of the pandemic. The authors also noted fewer than 20% of the pre-pandemic nasal endoscopies were performed in the post-pandemic period.6
The heterogeneity of CRS with multiple phenotypes and endotypes, such as milder or nonpolypoid CRS, may be effectively managed with nonsurgical options such as topical saline irrigations, intranasal corticosteroids, and other medical therapies. The increasing use of biological therapies has demonstrated enhanced efficacy in reducing polyp burden, improving symptoms, and reducing the need for revision surgery. It is also important to note that the study cohort was limited to outpatient data, which may have contributed to the observed reduction in procedural volumes and prescriptions.
A parallel decline in antibiotic prescriptions was also observed during this period. Regarding antibiotic utilization, amoxicillin was the most frequently prescribed agent, which aligns with its favorable pharmacologic profile, broad-spectrum coverage, and established efficacy in CRS management. However, our analysis also revealed a notable level of doxycycline use in postoperative settings. Although not considered a first-line agent for all CRS cases, doxycycline offers a clinically valuable alternative to macrolides, particularly in patients with macrolide intolerance or resistance, or in scenarios where its anti-inflammatory properties may benefit postoperative recovery. Antibiotic stewardship in CRS perioperative care is vital to balance the risks and benefits of antibiotic use.
Conclusions and Looking Ahead
As CRS continues to represent a significant and growing public health concern, understanding how treatment patterns correlate with patient outcomes is critical to ensuring that treatment strategies continue to be effective and efficient. Evaluation of the long-term effectiveness of surgical interventions and the appropriateness and impact of various antibiotic regimens is critical. Extensive, longer-term prospective studies are required to analyze and identify gaps in CRS care and treatment. Owing to variability in practice, further rigorous research is needed to clarify the use of antibiotics to optimize patient outcomes and combat antimicrobial resistance.
Although this study primarily analyzed observed data trends, our team’s future work will focus on a detailed evaluation of the cohort to address questions outlined in the CPG. Specifically, we aim to assess the efficacy of targeted antibiotics, the impact of biologic therapies, and the role of imaging findings in influencing surgical outcomes.
The Reg-ent team aims to work with our member practices and clinicians to integrate our insights into an evidence-based framework to promote more personalized and value-driven care for patients, while supporting broader public health goals and advancing our specialty.
If you’re attending the AAO-HNSF 2025 Annual Meeting & OTO EXPOSM, be sure to visit the Research and Quality booth to interact with the surgical management of chronic rhinosinusitis dashboard, compare results to balloon sinuplasty, as well as other intriguing analyses!
Note: The data presented in this study are derived from the Reg-ent clinical data registry, which collects clinical information from participating private practices and academic medical centers. As such, the dataset may not reflect a comprehensive or nationally representative sample. Patient demographics and counts may be disproportionately influenced by the geographic distribution and characteristics of participating sites. Therefore, the findings should be interpreted as trends observed within the Reg-ent dataset and not as indicative of broader, nationwide patterns.
References
- "Surgical Management of Chronic Rhinosinusitis." Otolaryngology–Head and Neck Surgery 00, no. 00 (2025): 1–47. doi:10.1002/ohn.1287. http://otojournal.org.
- Centers for Disease Control and Prevention. "Sinus Infection (Sinusitis)." U.S. Department of Health & Human Services. Published 2020. Accessed April 19, 2024. https://www.cdc.gov/nchs/fastats/sinuses.htm.
- Denneny JC III, Cyr DD, Witsell DL, Brereton J, Schulz KA. "A Pathway to Value‐Based Care of Chronic Rhinosinusitis Using a Claims Database." Laryngoscope Investigative Otolaryngology 4, no. 1 (2019): 193–206. doi:10.1002/lio2.232.
- Centers for Disease Control and Prevention. "FastStats—Sinus Conditions." Published January 27, 2022. Accessed April 19, 2024. https://www.cdc.gov/nchs/fastats/sinuses.htm#print.
- National Center for Health Statistics. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2012. Published 2014.
- Patel R, Huang A, Lin A, et al. "COVID-19 and Rhinological Surgery." Operative Techniques in Otolaryngology–Head and Neck Surgery 33, no. 2 (2022): 103–111.
- Papagiannopoulos P, Ganti A, Kim YJ, et al. "Impact of COVID-19 Pandemic on Ambulatory and Operating Room Rhinology Practice in the US." American Journal of Rhinology & Allergy 35 (2021): 441–448. doi:10.1177/1945892420961962.
