title: A randomized trial examining the effect of pretreatment point-of-care computed tomography imaging on the management of patients with chronic rhinosinusitis symptoms.
abstract: BACKGROUND
  Recent consensus statements on the diagnosis of chronic rhinosinusitis (CRS) now require endoscopic or radiographic evidence of paranasal sinus inflammation. The timing of point-of-care (POC) computed tomography (CT) scan in the workup of these patients remains to be elucidated, particularly when endoscopy is negative. The objective of this research was to prospectively evaluate 2 algorithms for the initial management of patients with symptoms of CRS who manifest a normal nasal endoscopic examination.
  
  
  METHODS
  A total of 40 such patients were randomized to 1 of 2 pathways: POC-CT at the initial visit followed by medical therapy based upon CT results (pre-CT group; n = 20), or empiric medical therapy (EMT) followed by POC posttreatment CT if symptoms persisted (EMT group; n = 20).
  
  
  RESULTS
  The 2 groups were demographically and symptomatically similar with regard to 2003 Task Force major criteria. Otolaryngology follow-up was recommended in 11 of 20 pre-CT patients, all of whom (100%) returned. In contrast, only 10 of 20 EMT patients (50%) followed up as instructed (p < 0.05). Radiographic confirmation of CRS was found in 8 of 20 pre-CT patients, and only 2 of 9 patients after EMT (p = 0.61). EMT patients received more antibiotic prescriptions (relative ratio [RR], 2.50; 95% CI, 1.46-4.27), while pre-CT patients received more CT scans (RR, 2.22; 95% CI, 1.37-3.61). Overall prescriptions costs were similar to the EMT group ($253 vs $218; p = 0.37) and the overall number of otolaryngology visits was similar.
  
  
  CONCLUSIONS
  In patients with symptoms of CRS but negative endoscopy, POC at initial presentation results in substantially less unnecessary antibiotic prescriptions and significantly greater compliance with otolaryngology care but does result in a higher utilization of radiographic imaging.
authors.affiliation: Department of Otolaryngology, Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. btan@nmff.org
authors.forename: Bruce K
authors.initials: BK
authors.lastname: Tan
authors.forename: Rakesh K
authors.initials: RK
authors.lastname: Chandra
authors.forename: David B
authors.initials: DB
authors.lastname: Conley
authors.forename: Robin Smolak
authors.initials: RS
authors.lastname: Tudor
authors.forename: Robert C
authors.initials: RC
authors.lastname: Kern
mesh_terms: D000305:Adrenal Cortex Hormones / Q000191:economics / Q000627:therapeutic use; D000328:Adult; D000465:Algorithms; D000900:Anti-Bacterial Agents / Q000191:economics / Q000627:therapeutic use; D002908:Chronic Disease; D004724:Endoscopy / Q000706:statistics & numerical data; D005260:Female; D006633:Histamine Antagonists / Q000191:economics / Q000627:therapeutic use; D006801:Humans; D020024:Leukotriene Antagonists / Q000191:economics / Q000627:therapeutic use; D008297:Male; D019095:Point-of-Care Systems; D055553:Prescription Drugs / Q000191:economics; D011306:Prescription Fees; D054328:Proton Pump Inhibitors / Q000191:economics / Q000627:therapeutic use; D012220:Rhinitis / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000191:economics; D012852:Sinusitis / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000191:economics; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data*
chemical_list: D000305:Adrenal Cortex Hormones; D000900:Anti-Bacterial Agents; D006633:Histamine Antagonists; D020024:Leukotriene Antagonists; D055553:Prescription Drugs; D054328:Proton Pump Inhibitors