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Reprinted by permission of Int Forum Allergy Rhinol. 2014; 4(7):525-532.

OR I G I NAL ART I CLE

The fate of chronic rhinosinusitis sufferers a er maximal medical therapy Campbell Baguley, MD 1,2 , Amanda Brownlow, MD 2 , Kaye Yeung, BSc 2,3 , Ellie Pratt, BA, BSc 2 , Raymond Sacks, MD 2,4 and Richard Harvey, MD 2

Background: Many chronic rhinosinusitis (CRS) treatment regimes revolve around “one-off” maximal medical ther- apy (MMT) protocols, and although many patients initially respond, long-term control is unpredictable. The value of imaging, endoscopy, and patient progress a er MMT for CRS is assessed. Methods: Symptomatic CRS patients with computed to- mography (CT)-confirmed disease were recruited at a ter- tiary rhinology clinic. All patients received at least a 3-week oral prednisone course as part of their MMT. Pretreatment and pos reatment nasal symptoms scores (NSS), quality of life (22-item SinoNasal Outcomes Test [SNOT-22]), and CT (Lund-Mackay [LM]) scores were recorded along with post- MMT endoscopy status. Results: A total of 86 patients (38% female, age 46 ± 13 years) met inclusion criteria. Pre-MMT and post-MMT LM scores were 10.9 ± 5.3 and 8.3 ± 5.5 (change 2.6 ± 3.8, p < 0.001). Median follow-up a er their initial post-MMT assessment was 6.3 (interquartile range [IQR] 17) months. At initial post-MMT review, 43 (50%) were symptomatic with persistent radiologic disease (“symptomatic CRS”), 12 (14%) were asymptomatic with no radiologic disease (“re- solved CRS”), 21 (24%) were asymptomatic with persis- M any descriptions of response to medical therapy for chronic rhinosinusitis (CRS) imply an endpoint is reached with a number of patients avoiding surgery. Subse- quent progress is less well studied. CRS cases present along a spectrum of chronic airway disease with relapses, much 1 Dept of Otolaryngology, Wellington Hospital, Wellington, New Zealand; 2 Applied Medical Research Centre, St. Vincent’s Hospital, Sydney, Australia; 3 Faculty of Medicine, University of NSW, Sydney, Australia; 4 Australian School of Advanced Medicine, Macquarie University, Sydney, Australia Correspondence to: Campbell Baguley, MD, Wellington Hospital, Riddiford St, Newtown, Wellington 6021, New Zealand; e-mail: campbell.baguley@ccdhb.org.nz

tent radiologic disease (“asymptomatic CRS”), and 10 (12%) were symptomatic with no radiologic disease (“alternate di- agnosis”). Pre-MMT NSS and SNOT-22 were similar among groups. The “asymptomatic CRS” group had the highest age (52 ± 11 years, p = 0.07). The “alternate diagnosis” group had the lowest initial LM scores (5.2 ± 2.9, p = 0.001). Of the “asymptomatic CRS” patients, 43% relapsed between 3 and 23 months (median 6; IQR 4.4 months) post-MMT and 29% eventually underwent surgery. Conclusion: AlthoughMMT for CRS achieved symptomatic relief in 38%patients, objective evidence of disease was as- sociated with clinical relapse. The concepts of “response” to medical therapy and the need to “control” long-term inflammatory burden need to be balanced. C 2014 ARS- AAOA, LLC. Key Words: sinusitis; treatment; imaging; endoscopy; recurrence How to Cite this Article: Baguley C, Brownlow A, Yeung K, Pra E, Sacks R, Harvey R. The fate of chronic rhinosinusitis sufferers af- ter maximal medical therapy. Int Forum Allergy Rhinol. 2014;4:525–532. like asthma, and are managed initially by combinations of topical and sometimes systemic therapy. The reported response to a round of maximal medical therapy (MMT) varies between patient groups. This is from 37.5% at a tertiary rhinology clinic 1 to as much as 90% of patients treated through an asthma center with Lund- Mackay (LM) scores of 10.9 ± 4.8. 2 Considering the variable chronicity of inflammation of the airway, more recent publications, such as the Euro- pean Position Paper on Rhinosinusitis, discuss the manage- ment of CRS as a condition to be “controlled” with ongo- ing medical therapy, similar to other chronic lower airway diseases. 3 Simple intranasal corticosteroids and saline irri- gations, with intermittent systemic therapy, often form the basis of ongoing therapy. This presents a clinical conun- drum, as the philosophy suggests that a period of MMT will have an endpoint of symptom relief for an unspecified duration of time, rather than a cure. For many CRS patients

Potential conflict of interest: R.S. is a consultant for Medtronic. Received: 23 August 2013; Revised: 7 January 2014; Accepted: 30 January 2014 DOI: 10.1002/alr.21315 View this article online at wileyonlinelibrary.com.

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