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

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.

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.

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.

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.

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.

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.

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%,

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

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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.

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