2016 Section 5 Green Book

Baguley et al.

post-MMT, the presence of residual radiological and/or en-

doscopic disease despite symptomatic control may increase

risk of symptom relapse.

The presence or degree of disease

burden post-MMT may play a critical role in determining

chronicity and whether further treatment is required, in-

dependent of symptom status. The influence of post-MMT

symptoms and their correlation to radiological appearance

post-MMT are assessed.

Patients and methods

A retrospective cohort of patients treated at a tertiary rhi-

nology clinic was assessed. All data were collected prospec-

tively. The study had prior institutional ethics review ap-

proval from St Vincent’s Hospital.

Population

Inclusion criteria were radiologic confirmation of diffuse

mucosal disease and a history consistent with major or mi-

nor CRS symptoms

or fulfilling the current European Po-

sition Paper

on Rhinosinusitis and Nasal Polyps (EPOS)

classification.

Atopic status (by history or blood/skin prick

test), history of asthma, smoking, previous surgery, and

aspirin-sensitive airways disease (ASAD) were recorded. Pa-

tients with suspected comorbidities such as migraine, atypi-

cal facial pain, and allergic rhinitis were included as long as

they met the inclusion criteria of both radiologically con-

firmed mucosal changes and CRS symptoms. Patients with

clear indications for surgery, such as mucoceles, extensive

fungal disease, and uncinate atelectasis, and those with iso-

lated sinus disease (eg, sphenoid or odontogenic sinusitis)

were excluded. Patients who had recently had prednisone

courses and remained symptomatic and requested surgery

rather than further medical treatment were also excluded.

MMT

MMT consisted of oral prednisone for 3 weeks (1 week

each of 25 mg/day, 12.5 mg/day, and 5 mg/day), topi-

cal steroids in spray or irrigation form, and saline irriga-

tion. Antibiotics were given whenever discolored discharge

from the middle meatus was observed and in these cases

swabs were taken from the middle meatus with endoscopic

guidance. Amoxicillin/clavulanic acid was prescribed for

20 days and the antibiotic was altered if indicated by sub-

sequent culture. Atopic patients were not offered oral an-

tihistamines or antileukotrienes. For the included group

follow-up was arranged in 4 to 6 weeks (later if requested

by the patient) to assess response to medical therapy.

Clinical outcomes

Patient-reported outcomes consisted of nasal symptom

scores (NSS), and disease specific quality of life (QOL)

scores (22-item SinoNasal Outcomes Test [SNOT-22]).

Nasal symptoms were nasal obstruction, rhinorrhea, post-

nasal discharge, loss of smell, and facial pain/pressure, each

scored on a scale of 0 to 5. SNOT-22 scores were tallied

both initially and post-MMT and reported as means.

Clinically reported status of CRS post-MMT was de-

fined as “controlled” if symptoms had resolved or were not

bothersome.

This was recorded post-MMT only because

all patients were symptomatic for CRS initially.

Endoscopic outcomes

Endoscopic images were captured digitally at both pre-

MMT and post-MMT visits with archived images from

the latter visits assessed using the Lund-Kennedy scor-

ing system as well as EPOS 2012 definitions of “positive

endoscopy.”

3,7

Radiological outcomes

CT scans were performed with a Xoran miniCAT

low-

dose cone-beam scanner (Xoran Technologies Inc., Ann

Arbor, MI), which delivers an equivalent radiation dose

of 0.17 mSv per sinus CT series. CT scans were scored as

described by Lund and Mackay

and were given a clinician-

assigned category of “resolved” or “persistent inflamma-

tion.” Mucosal cysts and minor isolated thickening of the

maxillary sinus floor were considered neither to represent

CRS nor to influence the LM scores.

Patients were thus grouped according to the presence or

absence of both ongoing symptoms and objective evidence

of inflammation (see Fig. 1, results).

Patients were followed as required to assist with ongoing

therapy and asked to represent should symptoms recur after

discharge.

Statistical analysis

Data were analyzed using IBM SPSS Statistics v20 (IBM

Corp., Chicago, IL). Descriptive data are presented as per-

centages with mean

standard deviation (SD) for para-

metric data and median and interquartile range (IQR)

for nonparametric data. Chi-square tests were used for

categorical variables with the Fisher exact test for cell

counts

5. Parametric data were compared with 1-way

analysis of variance (ANOVA) and nonparametric data

with the Mann-Whitney U test or Kruskal-Wallis test for

3 or more independent samples. Statistical significance was

reported for alpha of 0.05.

Results

A total of 86 patients (38% female, age 46

13 years)

met inclusion criteria and had post-MMT CT scans avail-

able for review. Nasal polyposis was evident in 31%, al-

lergy/atopy in 37%, asthma in 28%, and ASAD in 2%;

13% were smokers and 10% had undergone previous

sinus surgery.

MMT consisted of a 3-week course of prednisone with

daily intranasal corticosteroids and saline irrigation for all

patients with antibiotic treatment given to 53% patients,

usually amoxicillin/clavulanic acid for 20 days. The median

International Forum of Allergy & Rhinology, Vol. 4, No. 7, July 2014