2016 Section 5 Green Book

The fate of CRS sufferers after MMT

medical treatment, assessing disease extent, ruling out other pathologies, and assessing anatomy prior to surgery. Pa- tients in this study frequently presented after some form of medical therapy, with CT scans. Others underwent imag- ing at the initial visit to clarify the presence and extent of disease, given the availability of a low-radiation-dose in- office scanner. CT is less well studied as a tool to monitor response to medical therapy. Imaging was with an in-office scanner with a low ra- diation dose of 0.17 mSv per scan. This compares with 0.96 mSv for a conventional sinus CT scan 16 and around 2 mSv for a standard head CT. Even the higher radiation dose associated with head CT appears not to have any cataractogenic effect, based on an Australian study of pa- tients undergoing detailed eye examinations. 17 The findings of this study were in contrast with a prior report that found a moderate positive association between head CT scan his- tory (conventional scanner) and cataract presence. 18 For this and other reasons protocols should always exist to prevent indiscriminate CT scan use and thus radiation exposure. Changes in CT findings have previously been reported after medical treatment of CRS. In a group of patients with nasal polyps and higher initial LM scores (mean 18.2), Benitez et al. 19 found that oral prednisone followed by topical budesonide achieved a reduction in LM scores of around 3. These authors point out that the improvement in CT scores compared with symptoms is small and follow- up CT is probably not indicated in nonsurgical patients. Subramanian et al. 2 reported that mean LM scores im- proved from 10.9 to 5.4 after prednisone and antibiotics plus topical therapy and 90% of their patients achieved symptom control after MMT. This study also evaluated symptom relapse. It occurred in 14 of 40 patients, up to 8 weeks after medical treatment. There was a positive asso- ciation between symptom relapse and the presence of nasal polyps and a history of previous surgery, but not persistent ostiomeatal unit (OMU) obstruction on CT. The higher response in this group to medical therapy may relate to the treatment setting (allergy center as opposed to tertiary rhinology clinic). Finally Wei et al. 20 assessed the effec- tiveness of once-daily saline and antibiotic irrigation in the treatment of pediatric CRS and found that both saline and topical antibiotic irrigation led to an improvement in CT LM scores of around 8 on average. Our data revealed an average improvement in LM score of 2.6 after medical therapy. One-half of the patients were surgical candidates after MMT. Only 14% percent were successfully treated in terms of symptomatic and radiologic response with none re-presenting with CRS. Importantly, 24% were not bothered by their symptoms but had per-

sistent CT changes and these patients were likely (43%) to suffer symptom relapse, usually within 9 months. Al- though repeat imaging may not be necessary in every case, knowledge of the radiologic status of a patient’s sinuses af- ter initial response to MMT has some prognostic value and can help guide ongoing treatment. The value of endoscopy in this setting is discussed below. Other diagnoses to explain nasal symptoms existed in 12% of patients, who despite remaining symptomatic had no persistent disease on CT scans. Careful analysis of pa- tient symptoms and their response to systemic steroids along with endoscopic findings often alerts the clinician to alternate diagnoses to CRS. Some still require imaging for clarification given the generally poor correlation between symptomatology and CT findings. 21,22 Endoscopy as an objective measure of inflammation has previously been compared with CT and its role recently summarized. 23–26 Although generally specific (76–95%) for confirming the presence of radiologic inflammation in symptomatic patients, most studies including ours demon- strate a poor NPV for endoscopy (50–70%). This infor- mation, along with our data, suggest that repeat imaging could be avoided for some who appear to be clear surgical candidates with abnormal endoscopy after medical treat- ment, assuming the extent of residual radiologic disease will not influence the extent of ESS performed. For many others though follow-up CT scans provide additional useful information. Endoscopy may provide prognostic information in addi- tion to CT scanning. More severe endoscopic changes have been associated with failure of medical therapy. 27 In the current study, asymptomatic patients with persistent radi- ologic changes post-MMT and with abnormal endoscopy were more likely to suffer symptom relapse than those with normal endoscopy (53% vs 0%, p = 0.035). The potential of endoscopy to define the “active” state of mucosal inflam- mation as opposed to radiologic mucosal thickening/edema might better define those at risk of relapse. Conclusion Although MMT achieved symptomatic control of CRS for 38% patients, over one-half of this number had persis- tent radiologic disease, which was frequently associated with symptom relapse. Twelve percent, although still symp- tomatic, had normal scans and other diagnoses to explain their symptoms. Future discussions of “response” to medi- cal therapy should acknowledge the chronicity of this con- dition, the behavior of which relates in part to the underly- ing inflammatory burden within the sinuses.

References 1. Young LC, Stow NW, Zhou L, Douglas RG. Effi- cacy of medical therapy in treatment of chronic rhi- nosinusitis. Allergy Rhinol (Providence) . 2012;3:e8– e12.

2. Subramanian HN, Schechtman KB, Hamilos DL. A retrospective analysis of treatment outcomes and time to relapse after intensive medical treatment for chronic sinusitis. Am J Rhinol . 2002;16:303–312.

3. Fokkens WJ, Lund VJ, Mullol J, et al. European Posi- tion Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl . 2012;(23):3 p preceding table of con- tents, 1–298.

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