CMT Does Not Improve CRS after Adequate Medical Therapy Fails

Does continued medical therapy (CMT) benefit patients with medically refractory chronic rhinosinusitis (RCRS) prior to endoscopic sinus surgery (ESS)?

Background: Patients with RCRS have shown improvement in symptom scores and quality of life (QoL) scores after ESS. Studies differ on whether patients who fail adequate medical therapy have continued beneficial effects from CMT.

Study design: Prospective observational study.

Setting: University of Calgary, Alberta, Canada.

Synopsis: The study included 31 adult patients with a diagnosis of CRS (by American Academy of Otolaryngology-Head and Neck Surgery Rhinosinusitis Task Force guidelines) who failed medical therapy, defined as a three-month minimum course of topical intranasal steroids, had at least seven days of systemic steroids, were given a +/- two-week course of broad spectrum antibiotics, and subsequently elected to undergo ESS. Due to the long wait time for elective surgeries in the Canadian healthcare system, there was a mean of 7.1 months of CMT between the point at which medical therapy was deemed to have failed and ESS was performed. CMT consisted of antihistamines, leukotriene receptor antagonists, and prolonged macrolide therapy, along with saline irrigations (+/- steroids), steroid sprays, and systemic antibiotics and steroids as needed. At the end of the period of CMT, just prior to ESS, this patient group experienced a statistically significant decline in disease-specific QoL (as measured by the SNOT-22) and Lund-Kennedy scores, p = 0.006 and p = 0.002, respectively. There was also an increase of 3.6 lost work days and an increase in use of high-volume steroid irrigations, while the use of topical steroid sprays was reduced, specifically to provide stronger topical therapy. A shortcoming of the study was that this period of CMT was not standardized.

Bottom line: Although there is still debate on what constitutes maximal medical therapy prior to proceeding to ESS, this study indicates that QoL measures and endoscopic scores do not improve with continued medical therapy for RCRS after failure of adequate medical therapy.

Citation: Smith KA, Rudmik L. Impact of continued medical therapy in patients with refractory chronic sinusitis. Int Forum Allergy Rhinol. 2014;4:34-38.