Ragab, Sameh Mostafa; (2002) Evaluation of the medical and surgical treatment of chronic rhinosinusitis and its effect upon the lower airways. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Chronic rhinosinusitis (CRS) is a prevalent disease that has marked effects on the society. Its definition, pathophysiology, microbiology and treatment are still a source of debate. Likewise, there is still considerable confusion in the literature concerning the relationship and the effect of therapy of CRS upon the concomitant asthma. The aims of the thesis were: To conduct the first prospective randomised controlled trial, evaluating and comparing the medical and surgical treatment of CRS and its subgroups; to study whether the presence of nasal polyps serves as a poor prognostic factor for the efficacy of CRS therapy; to study whether asthma serves as a poor prognostic factor for the efficacy of CRS therapy; to elucidate the relationship between upper and lower airway diseases, considering specifically the relationship between CRS and asthma; to conduct the first prospective randomised study evaluating and comparing the effect of the medical and surgical treatment of CRS and its subgroups upon asthma, applying a range of subjective and objective parameters, and including exhaled NO as an easy and sensitive detector of inflammation; to study whether the presence of nasal polyps serves as a poor prognostic factor tor asthma control in CRS patients; to study the effect of medical and surgical therapy of CRS upon nasal NO levels; to investigate the value of nasal NO as an objective indicator of the effect of therapy on CRS. 2. Subjects were 90 patients with CRS, of whom 43 were asthmatics. Patients were randomised either to medical or surgical therapy of CRS. All patients underwent pre and post-treatment assessments of visual analogue score (VAS), chest score, overall asthma control score, use of anti-asthma medication, hospitalisation tor asthma, the Sinonasal Outcome Test-20, the Short Form 36 Health Survey (SF-36), nitric oxide (NO), acoustic rhinometry, saccharine clearance time, spirometry, and nasal examination including anterior rhinoscopy and endoscopy. 3. Both the medical and surgical treatment of CRS significantly improved almost all the subjective and objective parameters of CRS (P<0.01), with no significant difference being found between the medical and surgical groups (P>0.05) except for total nasal volume in CRS (P<0.01) and CRS without polyposis (P<0.01) groups in which the surgical treatment demonstrated greater changes.. 4. Both the medical and surgical treatment significantly improved almost all the subjective and objective parameters of CRS in asthmatic patients (P<0.01 in total groups and <0.05 in subgroups), with no significant difference being found between the surgical and medical groups. 5. The asthmatic surgical groups showed a general trend for improvement in the subjective and objective lower airway measurements. However, this did not reach a statistical significance except for use of bronchodilator inhalers (P<0.05), use of oral corticosteroids (P<0.05), hospitalisation (P<0.05), overall asthma control score (P<0.05), exhaled NO (P<0.05) and FEV1% (P<0.05) in the total surgical group of CRS. The medical groups showed higher significance values than the corresponding surgical groups. However, the difference between the medical and surgical groups did not reach a statistical significance except for exhaled NO (P<0.05) and FEVl% (P<0.05) measurements in CRS with polyposis. On the other hand, no significant difference was found between the surgical groups of CRS without and with polyposis, although CRS without polyposis tended to show higher improvement percentage values in the subjective and objective lower airway measurements. 6. Nasal NO increased significantly with medical (P<0.01) and surgical (P<0.01) treatment of CRS. The surgical groups experienced higher levels of improvement, although not significant (P>0.05), than the medical groups. Nasal NO correlated inversely with VAS (P<0.001), SCT (P<0.001), endoscopic score (P<0.001), polyp grade (P<0.01) and CT score (P<0.001). 7. Chronic rhinosinusitis should be targeted with maximal medical therapy in the first instance, with surgical treatment being reserved for cases refractory to medical therapy. Neither presence of nasal polyps nor asthma serves as a poor prognostic factor for the efficacy of CRS therapy. The evidence of the link between CRS and asthma is too striking to be denied. Both medical and surgical therapy of CRS improve the clinical course of asthma, with the medical treatment being superior to the surgical, especially in CRS with polyposis. On the other hand, it seems that sinus surgery can trigger or aggravate asthma in a subgroup of CRS patients. Finally, nasal NO is a valuable objective measurement in monitoring medical and surgical therapy for CRS.

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