2016 Section 5 Green Book

Cardinal symptom improvement in CRS treatment

TABLE 4. Improvement in mean cardinal symptom scores over time *

Cardinal symptoms

Baseline

Follow-up

Improvement

p

Total cohort (n = 342)

“Thick nasal discharge”

3.0 (1.5)

1.6 (1.5)

− 1.4 (1.7) − 1.3 (1.5) − 1.0 (1.8) − 1.7 (1.9) − 0.6 (1.4) − 0.5 (1.2) − 0.5 (1.9) − 0.6 (1.8) − 1.6 (1.7) − 1.5 (1.5) − 1.1 (1.8) − 2.0 (1.7)

< 0.001

“Facial pain/pressure”

2.6 (1.5)

1.3 (1.4)

< 0.001

“Sense of smell/taste”

2.8 (1.8)

1.9 (1.7)

< 0.001

“Blockage/congestion of nose”

3.5 (1.4)

1.8 (1.5)

< 0.001

Medical management (n = 69) “Thick nasal discharge”

2.9 (1.5)

2.2 (1.6)

0.001

“Facial pain/pressure”

2.3 (1.7)

1.8 (1.7)

0.002

“Sense of smell/taste”

2.8 (1.8)

2.3 (1.9)

0.044

“Blockage/congestion of nose”

3.2 (1.5)

2.6 (1.6)

0.009

Endoscopic sinus surgery (n = 273) “Thick nasal discharge”

3.0 (1.4)

1.5 (1.5)

< 0.001

“Facial pain/pressure”

2.7 (1.5)

1.2 (1.4)

< 0.001

“Sense of smell/taste”

2.9 (1.8)

1.8 (1.7)

< 0.001

“Blockage/congestion of nose”

3.6 (1.3)

1.6 (1.4)

< 0.001

*Values are mean (SD). SD = standard deviation.

TABLE 5. Comparison of average and relative score improvement between treatment modalities

Medical management (n = 69)

Endoscopic sinus surgery (n = 273)

Cardinal symptoms

Improvement mean (SD)

Relative improvement (%)

Improvement mean (SD)

Relative improvement (%)

p

“Thick nasal discharge”

− 0.6 (1.4) − 0.5 (1.2) − 0.5 (1.9) − 0.6 (1.8)

24.1

− 1.6 (1.7) − 1.5 (1.5) − 1.1 (1.8) − 2.0 (1.7)

50.0

< 0.001

“Facial pain/pressure”

21.7

55.6

< 0.001

“Sense of smell/taste”

17.9

37.9

0.007

“Blockage/congestion of nose”

18.8

55.6

< 0.001

SD = standard deviation.

standard of complete resolution of symptoms, although an extremely high standard, carries no ambiguity, and allows for determination of OR between treatment modalities (Table 7). These ORs are easily articulated to patients and help translate CRS outcomes research to clinical care when counseling patients with CRS. An important caveat to these ORs is that they were derived from a sampling of patients spanning several academic referral centers and care should be taken when applying these findings to individual patients. Furthermore, our regression models were built to isolate the impact of treatment modality on outcomes, not to identify other clinical factors which could potentially skew the probability of success for an individual. The present study represents the largest prospective co- hort study to investigate the impact of different therapies on the cardinal symptoms of CRS. The current available literature investigating individual symptom scores is dom-

inated by smaller cohort studies at single institutions. A meta-analysis of these prior studies demonstrated that ESS successfully improves all cardinal symptoms. 8 Interestingly, patient-reported olfactory dysfunction improved less than the other cardinal symptoms. The shortcomings of available interventions for olfaction may result from an irreversible olfactory neuron end-organ damage that has been described in the presence of long-standing inflammation. 18 Recover- ing durable olfactory function may require more than just control of inflammation in patients with impaired olfac- tion using available treatment modalities. The focus of this study was to investigate patient-based clinical responses to different treatment modalities because quantifiable, objec- tive measures of olfaction are cost prohibitive and rarely employed in standard clinical practice for this patient pop- ulation. Additionally, subjectively measured olfaction cor- relates only weakly with objective measures of olfaction

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