Regular readers of the newsletter we send to Fifth Sense members will have seen that a major study of the treatment of CRS has been funded by the NHS and is now in its pilot phase – the MACRO programme. However, not everyone will be familar with this, so to explain in a little more detail:
One aspect of the study looks at the effectiveness of endoscopic sinus surgery (ESS) as a treatment relative to the currently recommended first line treatment of sinus rinsing and steroid nasal spray. Teams working with Prof Carl Philpott have recently published two papers about CRS, which, although not relating to its effect on the sense of smell, will be of interest to our CRS suffering members.
The first paper (ref 1) looks at the benefits reported by those CRS patients who report ear pain and fullness after undergoing ESS. The data had been collected from a questionnaire about various aspects of sinus symptoms, known as the SNOT-22, filled in by 131 patients at the time of their ESS procedure and again around four months later.
Other data was collected with the same form from 251 similar people without CRS for comparison. The questionnaire contained two questions about ear pain and “fullness”, which asked the respondent to rate their symptoms on a 6 point scale from 0 (no problem), through 1 (very mild) to 3 (moderate problem) to 5 (as bad as it can be).
Analysis of all the data showed that for ear “fullness” 61% of CRS patients reported some degree of problem before surgery whereas the figure for non-CRS was 18%. For ear pain the corresponding figures were for CRS 30% and non-CRS 13%. This would indicate that ear discomfort and some possible effect on hearing is a significantly greater problem for CRS sufferers than for the general population.
Looking at the results four months after surgery, most (79%) of those patients who had reported ear “fullness” reported an improvement with their score for that question reduced by an average (mean) of 2.5, while a small number (7.6%) reported a deterioration.
Similarly, most (73%) of those patients who had reported ear pain reported an average score improvement of 2.2, while a small number (10%) reported a deterioration. For those showing an improvement, the result four months after surgery was very similar to that for the non-CRS respondents, with the size of the improvements corresponding to a change from moderate/severe (2.5) or moderate (2.2) to very mild (1).
This would indicate that many CRS patients undergoing ESS will experience significant improvements in ear discomfort, apart from hoped for improvements in sinus and nasal symptoms, including smell.
The second paper (ref 2) collected information from 1243 CRS patients at the time of their first consultation with an ENT specialist after referral by their GP. It used a questionnaire about their prescribed medication and other treatments, and their adherence to the instructions for use.
The current advice for CRS treatment, after being seen by the GP, is to start nasal saline rinses and a topical steroid nasal spray, which should be reviewed at 12 weeks for effectiveness. If no, or limited, benefit is seen at this time, referral to an ENT specialist should be considered.
The study found very little current use of nasal rinsing (1%) and only limited use of nasal steroid spray (15%). Oral steroid and antibiotic use was very low. No significant differences were found between geographical regions or social groups. The low use of CRS medication may reflect poor prescribing (including advice on how to best use topical treatments) or poor adherence to the prescription. It may also reflect the fact that sprays and rinses are more burdensome to use than taking tablets.
Interviews done along with the questionnaires suggest that in some cases they are not seen as “proper” medications as they are sprays not tablets. However, it may simply be, as other interviews suggested, that patients have tried this medical therapy but failed to derive significant benefit or suffered side effects, so have stopped taking them. The controlled trials in the MACRO programme aim to investigate and clarify these issues so that clear and evidence based advice on treatments is available to both patients and their doctors.
Ref 1 Eustachian tube symptoms are frequent in chronic rhinosinusitis and respond well to endoscopic sinus surgery: Rhinology 56: 0-0, 2018 https://doi.org/10.4193/Rhino17.165
Ref 2 Current use of baseline medical treatment in chronic rhinosinusitis: Data from the National Chronic Rhinosinusitis Epidemiology Study (CRES) DOI: 10.1111/coa.13012