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OR I G I NAL ART I CLE
The fate of chronic rhinosinusitis sufferers a er maximal medical therapy
Campbell Baguley, MD
1,2
, Amanda Brownlow, MD
2
, Kaye Yeung, BSc
2,3
, Ellie Pratt, BA, BSc
2
,
Raymond Sacks, MD
2,4
and Richard Harvey, MD
2
Background:
Many chronic rhinosinusitis (CRS) treatment
regimes revolve around “one-off” maximal medical ther-
apy (MMT) protocols, and although many patients initially
respond, long-term control is unpredictable. The value of
imaging, endoscopy, and patient progress a er MMT for
CRS is assessed.
Methods:
Symptomatic CRS patients with computed to-
mography (CT)-confirmed disease were recruited at a ter-
tiary rhinology clinic. All patients received at least a 3-week
oral prednisone course as part of their MMT. Pretreatment
and pos reatment nasal symptoms scores (NSS), quality of
life (22-item SinoNasal Outcomes Test [SNOT-22]), and CT
(Lund-Mackay [LM]) scores were recorded along with post-
MMT endoscopy status.
Results:
A total of 86 patients (38% female, age 46
±
13 years) met inclusion criteria. Pre-MMT and post-MMT
LM scores were 10.9
±
5.3 and 8.3
±
5.5 (change 2.6
±
3.8,
p
<
0.001). Median follow-up a er their initial post-MMT
assessment was 6.3 (interquartile range [IQR] 17) months.
At initial post-MMT review, 43 (50%) were symptomatic
with persistent radiologic disease (“symptomatic CRS”), 12
(14%) were asymptomatic with no radiologic disease (“re-
solved CRS”), 21 (24%) were asymptomatic with persis-
tent radiologic disease (“asymptomatic CRS”), and 10 (12%)
were symptomatic with no radiologic disease (“alternate di-
agnosis”). Pre-MMT NSS and SNOT-22 were similar among
groups. The “asymptomatic CRS” group had the highest age
(52
±
11 years,
p
=
0.07). The “alternate diagnosis” group
had the lowest initial LM scores (5.2
±
2.9,
p
=
0.001). Of
the “asymptomatic CRS” patients, 43% relapsed between
3 and 23 months (median 6; IQR 4.4 months) post-MMT and
29% eventually underwent surgery.
Conclusion:
AlthoughMMT for CRS achieved symptomatic
relief in 38%patients, objective evidence of disease was as-
sociated with clinical relapse. The concepts of “response”
to medical therapy and the need to “control” long-term
inflammatory burden need to be balanced.
C
2014 ARS-
AAOA, LLC.
Key Words:
sinusitis; treatment; imaging; endoscopy; recurrence
How to Cite this Article:
Baguley C, Brownlow A, Yeung K, Pra E, Sacks R,
Harvey R. The fate of chronic rhinosinusitis sufferers af-
ter maximal medical therapy.
Int Forum Allergy Rhinol.
2014;4:525–532.
M
any descriptions of response to medical therapy for
chronic rhinosinusitis (CRS) imply an endpoint is
reached with a number of patients avoiding surgery. Subse-
quent progress is less well studied. CRS cases present along
a spectrum of chronic airway disease with relapses, much
1
Dept of Otolaryngology, Wellington Hospital, Wellington, New
Zealand;
2
Applied Medical Research Centre, St. Vincent’s Hospital,
Sydney, Australia;
3
Faculty of Medicine, University of NSW, Sydney,
Australia;
4
Australian School of Advanced Medicine, Macquarie
University, Sydney, Australia
Correspondence to: Campbell Baguley, MD, Wellington Hospital,
Riddiford St, Newtown, Wellington 6021, New Zealand;
e-mail:
campbell.baguley@ccdhb.org.nzPotential conflict of interest: R.S. is a consultant for Medtronic.
Received: 23 August 2013; Revised: 7 January 2014; Accepted:
30 January 2014
DOI: 10.1002/alr.21315
View this article online at
wileyonlinelibrary.com.like asthma, and are managed initially by combinations of
topical and sometimes systemic therapy.
The reported response to a round of maximal medical
therapy (MMT) varies between patient groups. This is from
37.5% at a tertiary rhinology clinic
1
to as much as 90%
of patients treated through an asthma center with Lund-
Mackay (LM) scores of 10.9
±
4.8.
2
Considering the variable chronicity of inflammation of
the airway, more recent publications, such as the Euro-
pean Position Paper on Rhinosinusitis, discuss the manage-
ment of CRS as a condition to be “controlled” with ongo-
ing medical therapy, similar to other chronic lower airway
diseases.
3
Simple intranasal corticosteroids and saline irri-
gations, with intermittent systemic therapy, often form the
basis of ongoing therapy. This presents a clinical conun-
drum, as the philosophy suggests that a period of MMT
will have an endpoint of symptom relief for an unspecified
duration of time, rather than a cure. For many CRS patients
International Forum of Allergy & Rhinology, Vol. 4, No. 7, July 2014
Reprinted by permission of Int Forum Allergy Rhinol. 2014; 4(7):525-532.
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