Assessing Surgical Extent in Endoscopic Sinus Surgery: A Scoping Review of Scoring Systems

BACKGROUND: Endoscopic sinus surgery (ESS) varies substantially in the extent of surgical dissection performed, even when described under the same procedural label. In chronic rhinosinusitis, this heterogeneity may influence postoperative outcomes, revision rates, and response to biologic therapies. This review aimed to identify and characterize available instruments for assessing surgical extent after ESS. METHODS: Scoping review following PRISMA-ScR guidelines with systematic search of PubMed/MEDLINE, Scopus, and Web of Science. RESULTS: Twenty-one studies describing 11 instruments were included: spanning computed tomography (CT)-based scores (Amsterdam Classification of Completeness of Endoscopic Sinus Surgery ACCESS, Completion of Surgery Index CoSI, Sinus Surgery Completeness Score SSCS, and Residual Ethmoid Cell REC score), intraoperative classifications (Lamella-Ostium-Extent-Mucosa LOEM, complete vs. targeted, and Japanese Rhinologic Society JRS), radiologic-surgical concordance metrics, and study-specific tools. A key conceptual distinction emerged between surgical extent (the procedure performed) and surgical completeness (the anatomical result achieved). CT-based instruments primarily assess completeness, whereas intraoperative classifications capture extent. Because similar procedures may yield different anatomical results, these dimensions are not interchangeable. Among CT-based instruments, CoSI demonstrated the most consistent outcome associations, with incomplete prior surgery predicting greater benefit from revision ESS. ACCESS showed preliminary utility in biologic response prediction. LOEM is the only intraoperative system with reported outcome associations, although evidence is limited to a single group. Overall, evidence across instruments remains limited and predominantly retrospective. CONCLUSIONS: CT-based and intraoperative instruments capture different dimensions of prior surgery and should be selected according to the clinical or research question. Notably, structured scoring consistently reveals that many patients meeting guideline criteria for prior surgery have varying anatomical dissection. Given the association between surgical extent, postoperative outcomes, and biologic therapy response, its standardized assessment warrants evaluation for integration into clinical decision making. However, prospective validation is urgently needed.