2016 Section 5 Green Book

Baguley et al.

FIGURE 4. Time to symptom relapse among asymptomatic patients with CT inflammation. CT = computed tomography.

objective measures of inflammation and predicting early and long-term response to medical therapy. The current study has shown that the knowledge of both the radiologic and endoscopic status of the sinuses after medical therapy can help with management decisions, potentially avoiding unnecessary surgery for some patients and predicting the likelihood of symptomatic relapse for other patients. MMT included the use of saline irrigation and topical steroid sprays, as is well supported by evidence. 3,9,10 Most patients were prescribed mometasone 100 μ g twice daily to both nostrils. Patients with some open sinus ostia after previous surgery were prescribed high-volume steroid ir- rigation, using either betamethasone 1 mg or budesonide 1 mg, per 240-mL bottle, daily. 11 Specific details of com- pliance were not recorded. Our practice is to offer all CRS patients (with and without polyps) systemic steroids pro- vided there are no contraindications. We accept that the evidence supporting their use for CRS without nasal poly- posis (CRSsP) patients is weaker than for CRS with nasal polyposis (CRSwP). 12 However, the systemic route guar- antees some delivery to the sinuses compared to simple nasal sprays. Culture-directed antibiotics were used only when purulence was observed endoscopically rather than longer term antibiotics alone that may have specific anti- inflammatory actions. 13–15 CT scanning has a well-established role in confirming the diagnosis of CRS when symptoms are persistent after

TABLE 4. Progress after MMT and endoscopy for patients with “asymptomatic CRS”

CRS symptoms relapsed after MMT

No

Yes

Total

Post-MMT endoscopic examination No evidence of sinus inflammation

5

0

5

Evidence of sinus inflammation

7

8

15

Total

12

8

20

CRS = chronic rhinosinusitis; MMT = maximal medical therapy.

Within the group with “asymptomatic CRS” (with radi- ologic evidence of CRS), none of the 5 patients with neg- ative endoscopy suffered symptom relapse before the most recent clinic visit (median 8, IQR 21 months after post- MMT visit) whereas 8 of 15 (53%) did if their endoscopy was abnormal ( p = 0.035, Table 4). Discussion Among the challenging aspects of CRS patient manage- ment are the difficulties correlating patient symptoms with

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