Multimodality approach to sinus and nasal disorders: results of treatment as determined by a patient survey.

Abstract

Patients with sinus and nasal disorders whose symptoms persist despite primary care may benefit from a referral to a dedicated nose and sinus center where all treatment modalities are available. The essential principle of a multimodality approach is that medical therapy, allergy treatment, and surgery are all important and useful tools. While various medical and surgical treatments of sinus and nasal disorders have been well described in the literature, overall assessments of comprehensive treatment are uncommon. For more than 7 years, the office practice of the senior author (D.G.B.) has been dedicated to the treatment of sinus and nasal disorders. In an effort to assess the results of the multimodality approach to therapy delivered there, we mailed questionnaires to 1,800 patients who had been treated at this practice over a 3-year period. Responses from 222 of these patients revealed that patients required less medication following treatment with a multimodality approach and that they expressed a high degree of satisfaction with the comprehensive care they received. In addition, most patients with asthma experienced relief of their asthma symptoms following treatment for sinonasal disease. We conclude that a stepwise, multimodality, specialty-center approach to treatment is beneficial for patients with persistent sinonasal disorders.

Introduction

Until recently, sinusitis has been an undertreated disease. Its drastic negative effect on quality of life has been generally underappreciated. Some studies have shown that patients may consider certain consequences of chronic sinus disease, such as bodily pain and impaired social functioning, to be more debilitating than angina, congestive heart failure, emphysema, chronic bronchitis, lower back pain, and other diseases and conditions. (1,2)

Both nasal and oral agents can be used to treat patients with nasal symptoms and mucosal disease. Typical agents include steroids, saline sprays, mucolytics, antihistamines, decongestants, and antibiotics. When inhalant allergies are a significant contributory factor, immunotherapy is an option. To date, no standardized, universally accepted treatment protocol that constitutes "maximum medical therapy" has been developed. The selection of the appropriate medication depends on the specific diagnosis and varies from patient to patient.

Surgical intervention for sinusitis is considered when medical management fails to relieve symptoms. Functional endoscopic sinus surgery (FESS) has become the most widely accepted approach for patients who require surgical management of sinusitis. The goal of surgery is to return the sinuses to as near a normal anatomic state as is possible and to correct conditions that impede mucociliary clearance, especially through the ostiomeatal complex. The use of powered instrumentation (i.e., microdebriders and soft-tissue shavers) during FESS offers several potential advantages, including less trauma and bleeding, shorter surgical time, more rapid healing, and a better overall recovery. (3-8)

Computer-assisted surgery, also known as image-guided surgery, was initially developed in an effort to improve the accuracy of localizing lesions, anatomic landmarks, and surgical instruments during neurosurgical procedures. (4,8-10) In the paranasal sinuses, the surgeon is usually able to localize the tip of a surgical instrument to within 2 mm on coronal, axial, and sagittal computed tomography (CT). Computer-assisted FESS may be most useful in cases where surgical landmarks have been altered by previous surgery, dense scarring, or extensive disease.

Patients with sinus and nasal disorders whose symptoms persist despite standard office care--particularly by primary care physicians--may benefit from a referral to a dedicated nose and sinus center where all treatment modalities are available. The essential principle of a multimodality approach to sinusitis is that medical therapy, allergy treatment, and surgical therapy are all important and useful tools.

For more than 7 years, the office practice of the senior author (D.G.B.) has been dedicated to the treatment of sinus and nasal disorders. In an effort to assess the results of the stepwise, multimodality approach to therapy delivered there, we mailed questionnaires to a large group of patients who had been treated at this practice over a 3-year period. In this article, we describe the results of our survey.

Patients and methods

We searched a database that included the records of all patients who had been seen by the senior author from January 1999 through December 2001. We mailed a 6-page questionnaire and a postage-paid return envelope to 1,800 of these patients, and we received 247 replies (13.7%). Of the 247 respondents, 25 had been seen for purely nonsinus issues, leaving us with 222 usable replies.

Patients were asked to list the functional problems for which they had sought treatment and to indicate whether their definitive treatment had been medical or surgical or if they had required a combination of both to achieve a cure. They were also asked to select from a list of medications those that they had used both before and after they received treatment and to rate the effectiveness of each medication on a scale of 1 (completely ineffective) to 10 (completely effective). In addition, respondents who had been diagnosed with asthma were asked whether treatment of their sinonasal pathology had helped relieve their asthma symptoms. Finally, all patients were asked to rate the overall effectiveness of treatment in relieving sinonasal symptoms on the same rating scale.

Results

Type of treatment. Of the 222 patients, 99 (44.6%) had responded to medical treatment and required no further intervention (medical group) (table 1). Initial medical treatment had failed in 57 patients (25.7%), but they responded to subsequent surgical treatment without the need for further medication (surgical group). A combination of medical and surgical treatment was required to effectively treat 66 patients (29.7%) (combined group).

Medication use. Prior to treatment, the most commonly used drugs were nasal steroid sprays (147 patients [66.2%]), oral antihistamines (126 [56.8%]), and nasal saline sprays (121 [54.5%]). The least-used drugs were the bronchodilator montelukast (12 [5.4%]) and the nasal antihistamine azelastine (17 [7.7%]). Following treatment, there was a substantial decline in overall medication use (table 2). The most significant change was seen in the use of the nasal decongestant oxymetazoline, which declined by 78.7%. The smallest change was seen in the use of nasal steroid sprays, but even this declined by 25.2%. As was the case prior to therapy, the most commonly used drugs following treatment were nasal steroid spray s (110 patients [49.5%]), oral antihistamines (81 [36.5%]), and nasal saline sprays (73 [32.9%]).

Medication effectiveness. On the 10-point scale, patients rated oral prednisone (mean score: 7.91) and antibiotics (mean: 7.83) as the most effective drugs (table 3). The lowest mean scores were given to azelastine (5.00), oral decongestants (5.97), montelukast (6.13), and nasal saline sprays (6.17).

Asthma. Thirty-five patients (15.8%) reported that they had asthma--12 in the medical group, 9 in the surgical group, and 14 in the combined group (table 4). Relief of asthma symptoms was reported by 7 (58.3%), 6 (66.7%), and 8 patients (57.1%), respectively. In all, 21 of the 35 asthma patients (60.0%) reported relief of asthma symptoms.

Overall treatment effectiveness. A total of 165 patients had responded to medical therapy, either alone (n = 99) or in combination with surgery (n = 66) (medical/combined group). Of this group, 144 rated the overall effectiveness of medical treatment. Likewise, 123 patients had responded to surgery alone (n = 57) or in combination with medical treatment (n = 66) (surgical/combined group), and 114 of them rated the overall effectiveness of surgery. On the 10-point scale, the mean effectiveness score for medical therapy was 7.19 and the mean score for surgery was 7.96; the overall score was 7.53 (table 5). No patient indicated that symptoms worsened after treatment.

Among the 144 respondents in the medical/combined group, 109 (75.7%) rated the effectiveness of their treatment with a score of 6 or more. In the surgical/combined group, a rating of 6 or more was given by 96 of 114 respondents (84.2%). Overall, a rating of 6 or more was given by 205 of the 258 respondents (79.5%), and a rating of 5 or more by 222 (86.0%).

Discussion

The data collected from these questionnaires warrant critical analysis. Most notable are the percentage of patients who responded to medical therapy alone and the percentages who required surgery or combined therapy.

Medical therapy. Careful, directed sinus and nasal histories and physical examinations allowed the senior author to develop a tailored medical regimen that was successful in 99 of the 222 patients (44.6%). These patients, the vast majority of whom had been previously treated by primary care physicians, required no further therapy.

Surgical therapy. When symptoms could not be controlled by medical therapy alone, surgical intervention was undertaken when appropriate. Fifty-seven of the 222 patients (25.7%) who did not improve adequately with medical treatment were successfully treated with subsequent surgery. The data presented here suggest that correction of fixed structural blockage had a positive effect on symptoms, as evidenced by not only patients' positive evaluations of treatment, but by their decreased need for posttreatment medication.

Combined therapy. Sixty-six patients (29.7%) required both medical and surgical treatment for significant symptom relief. This highlights the effectiveness of a stepwise, multimodality approach in which all aspects of a patient's sinus and nasal problem are evaluated at a specialty center.

Medication use. Most patients treated for sinonasal disease had used some form of intranasal or oral medication. The most common were nasal steroid sprays (e.g., fluticasone and triamcinolone), oral antihistamines, nasal saline sprays, antibiotics, and oral decongestants; others included oxymetazoline, mucolytics, saline irrigations, oral prednisone, azelastine, and montelukast. Our survey revealed a posttreatment decrease in the use of every type of medication listed.

There are specific areas where the senior author believes his concerted efforts led to a decrease in the need for certain medications. For instance, the senior author urges patients to reduce their use of oral decongestants as a routine medication because of the risk of chronic systemic vasoconstriction; the use of oral decongestants, which had been taken by 103 patients (46.4%), declined by 68.9%. Also, the routine use of nasal decongestant sprays is strongly discouraged because overuse leads to rhinitis medicamentosa; the need for oxymetazoline, which had been used by 61 patients (27.5%) prior to treatment, decreased by 78.7% posttreatment. The fairly common use of oxymetazoline prior to treatment may be attributable to its quick onset of action, its efficacy over the first few days of use, and its over-the-counter availability; in addition, it is reasonable to assume that some percentage of these patients were chronic users who were "hooked" on oxymetazoline as a result of its tendency to cause rebound rhinitis when used for more than a few days. The fact that large percentages of patients discontinued oral and nasal decongestants suggests that the senior author's approach was successful.

The senior author also routinely informs patients that the prophylactic use of nasal steroid sprays, nasal saline sprays, antihistamines, mucolytics, and other adjunctive medications can decrease the risk of infections and thereby lessen the need for antibiotics. Indeed, the use of antibiotics by 112 of the 222 patients (50.5%) declined by 76.8% posttreatment. Some patients may need to take these adjunctive medications at the first signs of symptoms, while others may need to follow a tailored dally medical regimen. The three most commonly used pretreatment agents--nasal steroid sprays, oral antihistamines, and nasal saline sprays--remained the most frequently used substances following treatment. The continued use of these agents may be attributable to their relative efficacy and safety. We infer from our data that regardless of treatment modality, nasal steroids, oral antihistamines, and nasal saline sprays play an important role in maintaining control of sinonasal disease after medical, surgical, or combined treatment.

Medication effectiveness. It was quite revealing that patients rated oral prednisone and antibiotics as the most effective drugs (mean scores: 7.91 and 7.83, respectively). We can speculate that these agents "worked the best" because they are typically used in the setting of an acute exacerbation of symptoms; it is understandable that patients would highly regard an agent that effects a timely resolution of an acute episode.

It is also interesting to note that while nasal saline sprays were one of the most commonly used agents pre- and posttherapy, they received one of the lowest effectiveness ratings (6.17). Possible reasons for the low rating include the facts that nasal saline sprays (1) are typically used as a maintenance therapy, (2) are rarely used as a monotherapy, and (3) typically offer little subjective relief during an acute episode. Even so, the numerous benefits of nasal saline sprays (e.g., loosening nasal secretions and improving the mucosal penetration of nasal steroid sprays) should not be overlooked by physicians, even if they are not apparent to patients. Oral decongestants received the second-lowest effectiveness score (5.97), possibly because of their side effects (e.g., increased heart rate and jitteriness).

Asthma. The subjective improvement in asthma status reported by 21 of the 35 asthmatics (60.0%) was fairly consistent regardless of the type of treatment. Although improvement was not based on measurements such as pulmonary function tests, it is nevertheless consistent with reports of other studies in which control of sinonasal disease resulted in an improvement in asthma status. (11-13)

Study limitations. A few limitations attended to our questionnaire and subsequent evaluation of data. Patients were not asked to specify the total length of time they had used each medication, the daily dosing regimen, or the subtype of medication (e.g., sedating or nonsedating antihistamine or the specific class of antibiotic, etc.), our analysis might have revealed slightly different trends had these factors been accounted for. However, the objective of our survey was to assess general trends with regard to the care rendered at the senior author's practice. Those trends reflected a high degree of patient satisfaction, as 75.7% of medically treated patients and 84.2% of surgically treated patients rated their care as a 6 or more on the 10-point scale. No patient indicated that symptoms were worse after treatment.

Finally, it is important to point out that the patients in this study were seen by the senior author at a tertiary care center. Prior to those encounters, a significant number of these patients had undergone specialty evaluation and treatment, including sinus surgery, elsewhere. It is possible that their problems were more severe than those seen in a community practice, yet their degree of satisfaction with comprehensive, multimodality, specialty-center approach to sinonasal disease was high.

References

(1.) Gliklich RE, Metson R. The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg 1995;113:104-9.

(2.) Gliklich RE, Hilinski JM. Longitudinal sensitivity of generic and specific health measures in chronic sinusitis. Qual Life Res 1995;4:27-32.

(3.) Setliff RC III, Parsons DS. The hummer: New instrumentation for functional endoscopic sinus surgery. Am J Rhinol 1994;8:275-8.

(4.) Gross CW, Becker DG. Advances in sinus and nasal surgery. Otolaryngol Clin North Am 1997;30(3):xiii-xiv.

(5.) Gross WE. Soft-tissue shavers in functional endoscopic sinus surgery (standard technique). Otolaryngol Clin North Am 1997;30: 435-41.

(6.) Setliff RC III. The small-hole technique in endoscopic sinus surgery. Otolaryngol Clin North Am 1997;30:341-54.

(7.) Becker DG. Technical considerations in powered instrumentation. Otolaryngol Clin North Am 1997;30:421-34.

(8.) Becker DG. Powered instrumentation and intraoperative image guidance in endoscopic sinus surgery. Jpn J Rhinol 2001;40: 79-83.

(9.) Anon JB, Klimek L, Mosges R, Zinreich SJ. Computer-assisted endoscopic sinus surgery. An international review. Otolaryngol Clin North Am 1997;30:389-401.

(10.) Fried MP. Intraoperative computerized imaging for endoscopic sinus surgery. Nashville, Tenn.: Vanderbilt University Newsletter, Spring 1997.

(11.) Batra PS, Kern RC, Tripathi A, et al. Outcome analysis of endoscopic sinus surgery in patients with nasal polyps and asthma. Laryngoscope 2003; 113:1703-6.

(12.) Palmer JN, Conley DB, Dong RG, et al. Efficacy of endoscopic sinus surgery in the management of patients with asthma and chronic sinusitis. Am J Rhinol 2001; 15:49-53.

(13.) Senior BA, Kennedy DW, Tanabodee J, et al. Long-term impact of functional endoscopic sinus surgery on asthma. Otolaryngol Head Neck Surg 1999;121:66-8.

Paul V. Lanfranchi, DO; Laurie A. Brigandi, DO; Samuel S. Becker, MD; Daniel G. Becker, MD, FACS

From the University of Medicine and Dentistry of New Jersey School of Medicine/Kennedy Health System, Stratford, N.J. (Dr. Lanfranchi and Dr. Brigandi), the University of Virginia Medical Center, Charlottesville (Dr. S.S. Becker), and the Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania School of Medicine, Philadelphia (Dr. D.G. Becker).

Reprint requests: Daniel G. Becker, MD, Becker Nose and Sinus Center, 400 Medical Center Dr., Suite B, Sewell, NJ 08080. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

Table 1. Type of treatment

Treatment   No. (%) patients

Medical     99 (44.6)

Surgical    57 (25.7)

Combined    66 (29.7)

Total       222 (100.0)

Table 2. Decline in medication use by the 222 patients

                      No. (%) patients    No. (%) patients
                      taking medication   taking medication   Pct. of
Medication            pre-Tx              post-Tx             decline

Oxymetazoline          61 (27.5)           13 (5.9)           78.7
Antibiotic            112 (50.5)           26 (11.7)          76.8
Azelastine             17 (7.7)             4 (1.8)           76.5
Oral decongestant     103 (46.4)           32 (14.4)          68.9
Mucolytic              53 (23.9)           24 (10.8)          54.7
Oral prednisone        29 (13.1)           14 (6.3)           51.7
Saline irrigation      34 (15.3)           17 (7.7)           50.0
Montelukast            12 (5.4)             6 (2.7)           50.0
Nasal saline spray    121 (54.5)           73 (32.9)          39.7
Oral antihistamine    126 (56.8)           81 (36.5)          35.7
Nasal steroid spray   147 (66.2)          110 (49.5)          25.2

Table 3. Subjective medication effectiveness scores

Medication            No. patients   Mean score *

Oral prednisone            22            7.91
Antibiotic                 47            7.83
Oxymetazoline               5            7.50
Oral antihistamine         85            7.00
Nasal steroid spray       123            6.56
Saline irrigation          25            6.44
Mucolytic                  35            6.43
Nasal saline spray         87            6.17
Montelukast                 8            6.13
Oral decongestant          40            5.97
Azelastine                  9            5.00

* Based on a scale of 1 (completely ineffective) to 10
(completely effective). Some patients did not answer all survey
questions.

Table 4. Effect of treatment on asthma symptoms in patients with asthma

Treatment   No.         No. (%)
group       patients    improves

Medical     12           7 (58.3)
Surgical     9           6 (66.7)
Combined    14           8 (57.1)
Total       35          21 (60.0)

Based on a scale of 1 (completely ineffective) to 10 (completely
effective). Some patients did not answer all survey questions.

Table 5. Subjective overall treatment effectiveness scores

Treatment   No.
group       responses   Mean score *

Medical/    144         7.19
combined

Surgical/   114         7.96
combined

Total       258         7.53