Sinus Surgery Shown More Effective Than Antibiotics for Chronic Sinus Disease: Landmark UK MACRO Trial Sparks Changes in Treatment Guidelines

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A major new clinical trial led by University College London (UCL) and published in The Lancet has found that sinus surgery is significantly more effective than prolonged antibiotic use for treating chronic rhinosinusitis (CRS), a debilitating condition affecting up to 1 in 10 adults in the UK and millions worldwide. This groundbreaking study, part of the MACRO programme, tracked more than 500 patients across 20 UK sites, testing the effectiveness of surgery versus antibiotics and placebo in improving patients’ symptoms and quality of life.

Key Findings

Patients who received sinus surgery reported sustained relief from CRS symptoms, including improvements in breathing, reduced facial pain, and regained sense of smell, with 87% noting improved quality of life after six months.
Those assigned to antibiotic therapy (three months of low-dose antibiotics) experienced no statistically significant benefit over the placebo group.
All groups continued standard care practices such as nasal steroid sprays and saline rinses.
The findings address longstanding uncertainty about the medical value of sinus surgery, showing robust evidence that surgery outperforms antibiotics when local treatments fail.

Expert Commentary

Professor Carl Philpott (UEA Norwich Medical School), a lead investigator on the MACRO trial, explained, “Chronic rhinosinusitis causes the spaces inside the nose and head, called sinuses, to become inflamed… Surgery was effective at reducing symptoms six months on, while taking a course of antibiotics seemed to make little difference. Until now, there was no trial-based evidence that sinus surgery works better than medical treatment. This could be a game-changer for sufferers worldwide.”

Professor Claire Hopkins (Guy’s Hospital, London) added, “The MACRO trial highlights the significant improvement in quality of life that many patients experience after surgery and should give primary care doctors and patients more confidence in seeking treatment.”

Professor Anne Schilder (UCL Ear Institute and NIHR UCLH Biomedical Research Centre) emphasized, “Here we provide robust evidence that surgery is effective for CRS when local treatments have failed—a welcome result for many with the condition.”

Context and Background

Chronic rhinosinusitis is a persistent inflammation of the sinus cavities, often resulting in blocked noses, facial pain, fatigue, reduced smell, and worsened asthma symptoms. The global prevalence varies but can reach up to 12% in some regions, with roughly 5-10% of adults in Europe and North America affected. CRS management typically begins with nasal steroids and saline rinses, which can help subgroups of patients.

Until now, sinus surgery has been reserved for cases where these treatments fail, partly due to limited evidence and concerns around surgery’s effectiveness and recurrence risk. The new MACRO trial findings directly address these concerns and potentially shift clinical priorities.

Implications for Public Health

The MACRO trial’s results have immediate practical implications for both physicians and patients:

Faster access to effective treatment: Streamlining care pathways could reduce unnecessary medication use and help patients gain relief sooner.
Improved quality of life: Surgical treatment can restore sense of smell and alleviate symptoms, which, as patient advocate Jim Boardman noted, “removes a whole dimension of everyday experience and enjoyment”.
Reduced inappropriate antibiotic use: Given rising antibiotic resistance, limiting ineffective prescriptions is vital for both individual and public health.
Potential changes to clinical guidelines: Healthcare systems may revise protocols to prioritize surgery over long courses of antibiotics for suitable CRS patients.

Potential Limitations and Counterarguments

Recurrence after surgery: Expert reviews and guidelines acknowledge that even after successful sinus surgery, there is a 40–50% chance of CRS symptoms returning within a few years, especially among those with nasal polyps or severe disease.
Risks of surgery: As with any operation, sinus surgery carries risks, including bleeding, infection, or adverse effects, albeit rare.
Emergence of biologics: For some CRS patients, especially those with frequent recurrence or comorbid asthma, newer medications like monoclonal antibody biologics (such as dupilumab or omalizumab) are proving valuable, often reducing need for surgery and improving quality of life.
Cost-effectiveness and long-term data: The MACRO research group is continuing follow-up to assess both the economic feasibility and the durability of surgical benefits.
Global differences: Access to surgery and newer medications varies widely, so findings may not immediately translate in resource-limited settings.

Practical Implications

What does this mean for daily health decisions?

Individuals diagnosed with CRS should discuss surgical options with an ENT specialist if symptoms persist after standard therapies, rather than expecting significant improvement from antibiotics alone.
Physicians may increasingly recommend earlier consideration of sinus surgery for eligible patients, improving clinical outcomes and patient satisfaction.
Routine use of nasal steroids and saline rinses remains foundational to management.

Balanced Reporting

This evidence-based shift does not mean all CRS patients should immediately undergo surgery. Optimal care demands a personalized approach, considering severity, recurrence risk, comorbid conditions, and patient preferences. For some, emerging biologic therapies may offer effective non-surgical alternatives.

Medical Disclaimer

Medical Disclaimer: This article is for informational purposes only and should not be considered medical advice. Always consult with qualified healthcare professionals before making any health-related decisions or changes to your treatment plan. The information presented here is based on current research and expert opinions, which may evolve as new evidence emerges.