It is generally accepted that CRS is treated initially with medical therapy with the aim of reducing symptoms, improving quality of life, and preventing disease progression or recurrence.3,17
Many different medical protocols have been used but none have been universally accepted.
The medical therapy prescribed for an individual patient may be influenced by previous treatments, patient referral patterns, and local bacterial sensitivities.1
In the present study, the standardized medical protocol consisted of doxycycline or roxithromycin for a minimum of 3 weeks, oral prednisone tapering over 3 weeks, and intranasal corticosteroid spray and saline lavage using the sinus rinse device continued until review. We found that medical therapy reduced symptoms sufficiently so that nearly 40% of patients felt they did not need surgical intervention after 3 months follow-up.
Other combinations of medical therapy have yielded variable results. In one series of 200 patients, with 9% <18 years of age, treated with 4 weeks of oral cefuroxime or amoxicillin/clavulanate, intranasal steroids, nasal irrigation, and topical decongestants, nasal mucosal swelling and purulent secretion were reduced markedly and only 6% of patients required surgery.18
In a retrospective study of 40 patients, symptoms and CT changes were assessed after oral prednisone for 10 days, (40 mg daily for 5 days followed by 20 mg daily for 5 days), broad-spectrum antibiotics for 4–8 weeks, nasal saline irrigation, and intranasal steroid. A relapse rate of 47.5% was observed at 3 months evaluation postmedical therapy requiring reinstitution of antibiotics and/or steroids. A 10% failure rate was reported, necessitating surgery.5
Association of nasal polyposis and previous sinus surgery were found to be linked with earlier relapse of sinusitis symptoms.5
A more recent study reported 145 patients treated with 4 weeks of clarithromycin or amoxicillin-clavulanate, a tapering course of oral steroids over 12 days, nasal saline irrigation, intranasal steroid, and topical decongestants. In just over one-half of the patients, there was complete resolution of symptoms at 2 months posttherapy, with no requirement for surgery in 69% of the patients.4
Facial pressure or pain, mucosal inflammation, and higher endoscopic severity grade were identified to be associated with failure of medical therapy.4
Several factors may contribute to the difference seen in our series and that of existing studies. The majority of our patients were referred by their primary care physicians, often with a long history of symptoms that had been resistant to previous trials of medical therapy. In this preselected group, the failure of medical therapy would be expected to be higher than self-referred patients.
Direct comparison between studies is challenging because of different study design variables including doses, duration, and inclusion of additional agents; follow-up period; and definitions of what constitutes failure of medical therapy. The majority of American Rhinologic Society members surveyed (61.0%) consider that medical failure was disease on CT scan with persistent symptoms, and many (41.9%) regarded medical failure was disease with improved but persistent symptoms.
Nasal polyposis has been previously reported to be an important predictor of sinusitis relapse.5
We found a tendency toward polyp patients being more likely to require surgery after a trial of medical therapy (p
In our study patient group there was no association between Lund-Mackay score and symptom score severity (p
= 0.34), a finding consistent with several other reports.4,5,18
Relatively younger age, male gender, presence of asthma, and positive endoscopic and CT findings () were correlated with severity of symptom scores and were predictive of a need for surgery.
Our study has some limitations. Compliance with medical therapy was not measured, and poor compliance would presumably reduce efficacy. Follow-up data were not available for 10% of patients.
The decision to proceed to surgery was largely based on the patients' perspective that their response to medical therapy was not adequate. It is very difficult to objectify the basis of this decision, and it is vulnerable to patient and surgeon biases. However, the framework of the consultation was similar in all cases and the patients were asked how they wished to proceed in an open manner.
A longer period of follow-up especially in patients whose symptoms have improved sufficiently after the medical therapy so that surgery was not indicated, would offer a superior insight into the longevity of the medical therapy effect. For practical reasons we were limited to a period of several months to maximize completeness of follow-up.
The majority of the study patients with Samter's triad had not been desensitized at the time of their taking medical therapy. Aspirin desensitization has been shown to improve nasal congestion, sense of smell, and reduction in sinus infections. This effect is independent of maximal medical therapy, and may confound the result.19
The majority (52.5%) of our patients failed to achieve what they regarded as adequate control of their symptoms with medical therapy and therefore required sinus surgery. The combination of medical therapy and surgery shares a synergistic relationship in providing long-term disease control.
The challenge is to offer a medical therapy regimen that is effective while remaining safe and well tolerated by patients. Medical therapy for CRS will continue to evolve as our understanding of the disease process and pharmacotherapy advances.