2016 Section 5 Green Book

Baguley et al.

FIGURE 4.

Time to symptom relapse among asymptomatic patients with CT inflammation. CT

computed tomography.

TABLE 4.

Progress after MMT and endoscopy for patients

with “asymptomatic CRS”

CRS symptoms

relapsed after

MMT

Yes

Total

Post-MMT endoscopic examination

No evidence of sinus inflammation

Evidence of sinus inflammation

Total

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 (

0.035, Table 4).

Discussion

Among the challenging aspects of CRS patient manage-

ment are the difficulties correlating patient symptoms with

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

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.

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).

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

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