2016 Section 5 Green Book

Baguley et al.

post-MMT, the presence of residual radiological and/or en- doscopic disease despite symptomatic control may increase risk of symptom relapse. 4 The presence or degree of disease burden post-MMT may play a critical role in determining chronicity and whether further treatment is required, in- dependent of symptom status. The influence of post-MMT symptoms and their correlation to radiological appearance post-MMT are assessed. Patients and methods A retrospective cohort of patients treated at a tertiary rhi- nology clinic was assessed. All data were collected prospec- tively. The study had prior institutional ethics review ap- proval from St Vincent’s Hospital. Population Inclusion criteria were radiologic confirmation of diffuse mucosal disease and a history consistent with major or mi- nor CRS symptoms 5 or fulfilling the current European Po- sition Paper < on Rhinosinusitis and Nasal Polyps (EPOS) classification. 3 Atopic status (by history or blood/skin prick test), history of asthma, smoking, previous surgery, and aspirin-sensitive airways disease (ASAD) were recorded. Pa- tients with suspected comorbidities such as migraine, atypi- cal facial pain, and allergic rhinitis were included as long as they met the inclusion criteria of both radiologically con- firmed mucosal changes and CRS symptoms. Patients with clear indications for surgery, such as mucoceles, extensive fungal disease, and uncinate atelectasis, and those with iso- lated sinus disease (eg, sphenoid or odontogenic sinusitis) were excluded. Patients who had recently had prednisone courses and remained symptomatic and requested surgery rather than further medical treatment were also excluded. MMT MMT consisted of oral prednisone for 3 weeks (1 week each of 25 mg/day, 12.5 mg/day, and 5 mg/day), topi- cal steroids in spray or irrigation form, and saline irriga- tion. Antibiotics were given whenever discolored discharge from the middle meatus was observed and in these cases swabs were taken from the middle meatus with endoscopic guidance. Amoxicillin/clavulanic acid was prescribed for 20 days and the antibiotic was altered if indicated by sub- sequent culture. Atopic patients were not offered oral an- tihistamines or antileukotrienes. For the included group follow-up was arranged in 4 to 6 weeks (later if requested by the patient) to assess response to medical therapy. Clinical outcomes Patient-reported outcomes consisted of nasal symptom scores (NSS), and disease specific quality of life (QOL) scores (22-item SinoNasal Outcomes Test [SNOT-22]). 6 Nasal symptoms were nasal obstruction, rhinorrhea, post- nasal discharge, loss of smell, and facial pain/pressure, each

scored on a scale of 0 to 5. SNOT-22 scores were tallied both initially and post-MMT and reported as means. Clinically reported status of CRS post-MMT was de- fined as “controlled” if symptoms had resolved or were not bothersome. 3 This was recorded post-MMT only because all patients were symptomatic for CRS initially. Endoscopic outcomes Endoscopic images were captured digitally at both pre- MMT and post-MMT visits with archived images from the latter visits assessed using the Lund-Kennedy scor- ing system as well as EPOS 2012 definitions of “positive endoscopy.” 3,7 Radiological outcomes CT scans were performed with a Xoran miniCAT TM low- dose cone-beam scanner (Xoran Technologies Inc., Ann Arbor, MI), which delivers an equivalent radiation dose of 0.17 mSv per sinus CT series. CT scans were scored as described by Lund and Mackay 8 and were given a clinician- assigned category of “resolved” or “persistent inflamma- tion.” Mucosal cysts and minor isolated thickening of the maxillary sinus floor were considered neither to represent CRS nor to influence the LM scores. Patients were thus grouped according to the presence or absence of both ongoing symptoms and objective evidence of inflammation (see Fig. 1, results). Patients were followed as required to assist with ongoing therapy and asked to represent should symptoms recur after discharge. Statistical analysis Data were analyzed using IBM SPSS Statistics v20 (IBM Corp., Chicago, IL). Descriptive data are presented as per- centages with mean ± standard deviation (SD) for para- metric data and median and interquartile range (IQR) for nonparametric data. Chi-square tests were used for categorical variables with the Fisher exact test for cell counts < 5. Parametric data were compared with 1-way analysis of variance (ANOVA) and nonparametric data with the Mann-Whitney U test or Kruskal-Wallis test for 3 or more independent samples. Statistical significance was reported for alpha of 0.05. Results A total of 86 patients (38% female, age 46 ± 13 years) met inclusion criteria and had post-MMT CT scans avail- able for review. Nasal polyposis was evident in 31%, al- lergy/atopy in 37%, asthma in 28%, and ASAD in 2%; 13% were smokers and 10% had undergone previous sinus surgery. MMT consisted of a 3-week course of prednisone with daily intranasal corticosteroids and saline irrigation for all patients with antibiotic treatment given to 53% patients, usually amoxicillin/clavulanic acid for 20 days. The median

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