Efficacy of Medical Therapy in Treatment of Chronic Rhinosinusitis

Abstract

Uncomplicated chronic rhinosinusitis (CRS) is generally treated with medical therapy initially and surgery is contemplated only after medical therapy has failed. However, there is considerable variation in the medical treatment regimens used and studies defining their efficacy are few. The aim of this study was to determine the proportion of patients treated medically who responded sufficiently well so that surgery was not required. Subgroup analysis to identify clinical features that predicted a favorable response to medical therapy was also performed. Eighty patients referred to the Otorhinolaryngology Clinic at North Shore Hospital were treated with a standardized medical therapy protocol (oral prednisone for 3 weeks, oral antibiotics and ongoing saline lavage and intranasal budesonide spray). Symptom scores were collected before and after medical therapy. Clinical features such as presence of polyps, asthma, and aspirin hypersensitivity were recorded. Failure of medical therapy was defined as the persistence of significant CRS symptoms, and those patients who failed medical therapy were offered surgery. Follow-up data were available for 72 (90%) patients. Of this group, 52.5%, (95% CI, 42.7%, 62.2%) failed to respond adequately to medical therapy and were offered surgery. The remaining patients (37.5%) were successfully treated with medical therapy and did not require surgery at the time of follow-up. The premedical therapy symptom scores were significantly higher than the postmedical therapy symptom scores (p < 0.01). The symptom scores of those patients postmedical therapy who proceeded to have surgery were significantly higher than the group who responded well to maximum medical therapy (MMT) and did not require surgery (p < 0.0001). There were no significant differences in the proportion of patients with asthma, aspirin sensitivity, or polyps between the groups failing or not failing MMT. In approximately one-third of patients with CRS, medical therapy improved symptoms sufficiently so that surgical therapy was avoided. Patients with more severe symptoms tended not to respond as well as those with less severe symptoms. Long-term follow-up is required for the group of responders to determine how many will eventually relapse.

International Consensus Statement on Allergy and Rhinology: Rhinosinusitis

“…CRSwNP and previous sinus surgery were predictors of relapse. In contrast, Young et al 1146 found no significant deterioration in the symptom scores of medical responders from the end of a 3-month treatment period to 5 months (mean) of further follow-up. Ongoing medical treatment was not defined in either study.…”

“…728,729,[1144][1145][1146] It is accepted that CRS has a chronic relapsing course, but the long-term fate following a successful trial of medical therapy is not well reported. Subramanian et al 729 found a relapse rate of 47.5% in those initially responding to medical therapy trial prior to surgery, requiring a further course of medical treatment.…”

The impact of medical therapy on cognitive dysfunction in chronic rhinosinusitis

“…First, greater than one third of our study cohort did not achieve an MCID of SNOT‐22 scores, suggesting that, although pre‐ and posttreatment symptom scores were statistically significantly different, many patients may not have noted a clinically detectable benefit. In addition to the significantly higher SNOT‐22 score of the posttreatment cohort as compared with healthy controls, the posttreatment scores in this study were nearly 2 MCIDs higher than the literature reported mean SNOT‐22 scores of control patients, which can serve as a surrogate for CRS patients with a return to “normal.” Finally, although heterogeneous in nature, several studies have suggested that medical therapy confers a variable rate of success after AMT ranging from 14% to 65%, with success defined by either patients not requiring operative intervention or binary patient‐reported symptom improvement . With this in mind, if the cohort in this study was followed longitudinally, one could expect that a subset of this medically treated group would ultimately require surgical intervention.…”

Rhinosinusitis in Children

“…When appropriate, maximal medical therapy fails or with associated anatomic aberrations, surgical interventions are contemplated in rhinosinusitis. About 2/3rd of patients of CRS fail maximal medical therapy and need to go ahead with surgery [122]. Almost universally, children with diagnosis of AFS need operative intervention, postoperative medical management, and close long-term monitoring and followup [123].…”