2016 Section 5 Green Book

The fate of CRS sufferers after MMT

FIGURE 1. Allocation of patient groups after MMT. MMT = maximal medical therapy.

TABLE 1. Characteristics of post-MMT groups

Symptom relapse

Post MMT group n Age (years) Gender (%F) CRSwNP Pre-NSS Pre-SNOT-22 Post-NSS Post-SNOT-22 Pre-CT

Post-CT

Symptomatic CRS 43 45 ± 12

26% 33% 2.5 ± 0.9 1.9 ± 0.9 1.9 ± 1.0 1.4 ± 0.8 11.6 ± 5.2 10.5 ± 4.5 n/a 58% 17% 2.0 ± 1.0 1.7 ± 0.9 0.6 ± 0.3 0.5 ± 0.3 8.2 ± 3.9 2.75 ± 2.0 0 43% 52% 2.7 ± 1.1 2.2 ± 1.1 1.1 ± 0.9 0.8 ± 0.7 12.1 ± 6.3 11.1 ± 3.5 9 60% 0% 2.2 ± 1.1 1.9 ± 0.8 1.9 ± 1.3 1.7 ± 1.0 5.2 ± 2.9 0.7 ± 1.6 0

Resolved CRS

12 42 ± 11

Asymptomatic CRS 21 52 ± 11 Alternate diagnosis 10 42 ± 20

p a

0.02

< 0.01

< 0.01

< 0.01

< 0.01

< 0.01

0.07

0.07

0.42

0.54

a Bold values are significant. CRS = chronic rhinosinusitis; CT = computed tomography; MMT = maximal medical therapy; NSS = nasal symptom scores; pre/post CT = Lund-Mackay CT scores before/after MMT; n/a = not applicable; SNOT-22 = 22-item SinoNasal Outcome Test.

TABLE 2. Post-MMT groups and CRS phenotype

time of MMT was 46 days (IQR 24) and did not differ between the patient groups outlined in the next paragraph ( p = 0.94). Although the post-MMT CT scan was always performed at the post-MMT visit, there was variation in the interval between the 2 scans being compared (median 63 days, IQR 78). At the post-MMT visit, patients were categorized into 4 groups: 43 (50%) were symptomatic with persistent ra- diologic disease (“symptomatic CRS”); 12 (14%) were asymptomatic with no radiologic disease (“resolved CRS”); 21 (24%) were asymptomatic with persistent radiologic disease (“asymptomatic CRS”); and 10 (12%) were symp- tomatic with no radiologic disease (“alternate diagnosis”) (Fig. 1). Pretreatment factors affecting response to MMT Age was highest in the “asymptomatic CRS” group (52 ± 11 years, p = 0.07) (Table 1). The proportion of pa- tients with nasal polyposis was highest in the “symptomatic CRS” (33%) and “asymptomatic CRS” groups (52%), and lowest among those with alternate diagnoses (0%, p = 0.018). Table 2 shows percentages of patients within each group, when separated for CRS phenotype (with vs without polyps). There were 2 patients with ASAD. One ended up with “symptomatic CRS” and 1 with “asymptomatic CRS.” Pre- viously operated patients (n = 9) were fairly evenly split

Post-MMT groups

Symptomatic CRS

Resolved CRS

Asymptomatic CRS

Alternate diagnosis

CRS phenotype

With polyps (n = 27) Without polyps (n = 59)

52% 7% 41% 0%

49% 17% 17% 17%

CRS = chronic rhinosinusitis; MMT = maximal medical therapy.

between the “symptomatic CRS” (4) and “asymptomatic CRS” groups (5), with none of these patients having reso- lution of CT changes after MMT ( χ 2 7.26, p = 0.06). Pre-MMT NSS and SNOT-22 were similar across the 4 groups. This included pre-MMT facial pain scores ( p = 0.64). Pre-MMT and post-MMT LM scores for the entire study group were 10.9 ± 5.3 and 8.3 ± 5.5 (change 2.6 ± 3.8, p < 0.001). The interval between pretreatment and posttreatment scans did not differ significantly between groups ( p = 0.82). The “alternate diagnosis” group had the lowest LM scores initially ( p = 0.001, Fig. 2) and was more likely to score facial pain highly after treatment ( p = 0.028). This group had other reasons for their per- sistent symptoms, such as migraine, rhinitis, mucus recir- culation, postviral hyposmia, and postviral cough, despite having evidence of CRS on radiology at initial assessment.

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