Otolaryngology–Head and Neck Surgery (2007) 137, 555-561
ORIGINAL RESEARCH—SINONASAL DISORDERS
The Lund-Mackay staging system for chronic
rhinosinusitis: How is it used and what does
it predict?
Claire Hopkins, DM, John P. Browne, PhD, Rob Slack, FRCS,
Valerie Lund, FRCS, and Peter Brown, FRCS, London, Bath,
Buckinghamshire, UK
OBJECTIVES: The Lund-Mackay score is widely used in as-
sessment of chronic rhinosinusitis. We aimed to describe its rela-
tionship to other measures of pre- and post-treatment health status.
STUDY DESIGN: Multicenter prospective study of 1840 pa-
tients undergoing surgery for chronic rhinosinusitis in the UK.
RESULTS: There was no absolute threshold for surgery, but
patients with higher Lund-Mackay scores underwent more exten-
sive surgery. There was no correlation between Lund-Mackay and
SNOT-22 scores. The Lund-Mackay increased with increasing
grade of polyposis. The Lund-Mackay score was associated with
symptom reduction (coefficient ⫽ 0.24, P ⫽ 0.02) complication
rates (odds ratio, 1.08, 95%CI 1.06 to 1.1), and revision rates (odds
ratio, 1.03, 95% CI 1.001 to 1.06).
CONCLUSIONS: The Lund-Mackay score measures a differ-
ent aspect of disease to “subjective” symptom scores. However, it
correlates well with other markers of disease severity, the nature of
surgery offered, and its outcome.
SIGNIFICANCE: This demonstrates the strengths and limita-
tions of a commonly used staging system.
© 2007 American Academy of Otolaryngology–Head and Neck
Surgery Foundation. All rights reserved.
C hronic rhinosinusitis (CRS) is a common problem that
results in significant impairment of quality of life.
Associated symptoms drive a patient to seek medical opin-
ion. Although the definition of chronic rhinosinusitis is
based on the occurrence and duration of symptoms,1 many
clinicians use CT scans to confirm the presence of disease,
assess severity, and aid management decisions. It is often
assumed that patients’ symptoms correlate to “objective”
scores of disease severity. However, the relationship between
radiologic findings and symptoms at presentation in sinus-
itis remains controversial. The predictive value of radio-
logic scores in terms of symptomatic improvement after
surgical intervention is also unknown. If radiologic findings
do not correlate with either pretreatment symptoms or the
outcome of treatment, it may be wrong to base treatment
Received November 27, 2006; accepted February 5, 2007.
0194-5998/$32.00 © 2007 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
doi:10.1016/j.otohns.2007.02.004
decisions on findings that do not reflect the patient’s symp-
tom load.
There are several systems available to stage disease se-
verity in CRS. The Lund-Mackay staging system was de-
veloped as a simple assessment tool to facilitate treatment
decisions in the mid-1980s.2 It includes symptom scores,
radiologic staging, and endoscopy scores; however, it is the
radiologic score that has become widely used. The interpre-
tation of the CT scan does not require radiology training and
is unambiguous; each group of sinuses is judged on cross-
sectional images to be completely clear, partly opaque, or
completely opaque, which results in a simple numeric score.
As a result it has be shown to have high interobserver
reliability.3 The Task Force on Rhinosinusitis4 has recom-
mended the Lund-Mackay scoring system for future out-
come research. From inception, there was never any expec-
tation that it would correlate with symptom severity, merely
that it would confirm (and quantify) the presence of inflam-
mation and thereby act as an inclusion criterion for clinical
studies. To this end, the score has been used as an inclusion
criterion in a number of our clinical studies.5-7 The mean
“normal” Lund-Mackay score in patients who undergo im-
aging for nonrhinologic symptoms has been found to be
4.3.8 It has therefore been proposed that patients submitted
to endoscopic sinus surgery for CRS should have a mini-
mum score of 4.
Symptom severity may be measured with global or dis-
ease-specific tools. Several instruments have been designed
and validated to measure disease-specific quality of life in
CRS. We have used the 22-question Sinonasal Outcome
Test (SNOT-229), a derivative of the SNOT-20,10 to which
the symptoms of nasal obstruction and loss of taste and/or
smell have been added.
With data collected from a large prospective study of pa-
tients who underwent sinonasal surgery, we set out to evaluate
how the Lund-Mackay score is currently used in clinical
practice. Specifically, we examined whether a threshold
556 Otolaryngology–Head and Neck Surgery, Vol 137, No 4, October 2007
exists below which patients are not submitted for surgery
and whether the extent of disease on cross-sectional imag-
ing influences the extent of surgery performed. We also
aimed to describe the relationship between the Lund-
Mackay score and other measures of the patients’ pre- and
post-treatment health status. First, we evaluated the associ-
ation between the Lund-Mackay score and other markers of
disease severity. We then examined the ability of the Lund-
Mackay to predict postoperative complications, symptom
reduction, and revision surgery rates.
METHODS
The National Comparative Audit of Surgery for Nasal Pol-
yposis and Chronic Rhinosinusitis was set up by a collab-
oration of the Comparative Audit Group of the British
Association of Otorhinolaryngologists–Head and Neck Sur-
geons and the Clinical Effectiveness Unit at The Royal
College of Surgeons of England. All patients who were to
undergo procedures to treat nasal polyposis and/or CRS
(including polypectomy, antral washout, or any surgery
entering the sinuses) from April to September during 2000
in 87 participating NHS Hospitals in England and Wales
were eligible for inclusion. Data collection at some Trusts
was extended until May 2001. Patients were followed-up for
three years. A full report of the methods and results of this
audit is available elsewhere.9
Patients were asked to complete a preoperative question-
naire about their current health status/symptoms, allergic
status, and previous treatments for sinonasal conditions.
Surgeons completed a clinical data proforma for each op-
eration performed in the audit. Patients who had consented
to follow-up were sent outcome questionnaires for comple-
tion at three, 12, and 36 months after surgery.
Disease-specific quality of life in sinonasal conditions
was measured with the SNOT-22. This produces a score on
a scale that ranged from 0 to 110, with higher scores rep-
resenting poorer health-related quality of life.
Polyp extent was graded on the basis of a 3-point clas-
sification system (1, confined to middle meatus; 2, below
level of middle turbinate but not causing total obstruction; 3,
causing total obstruction).
The CT findings were summarized with the Lund-
Mackay score. This score ranges from 0 (complete lucency
of all sinuses) to 24 (complete opacity of all sinuses).3
Comorbidity was scored according to the American So-
ciety Anesthesiologists (ASA) score. An ASA score of 1
represents a normal healthy patient, 2 a patient with mild
systemic disease, 3 a patient with a severe systemic disease
that limits activity, and 4 a patient with an incapacitating
systemic disease that is a constant threat to life.11
The extent of surgery performed has been summarized
by the most distal group of sinuses entered during the
procedure. The complication rate was determined by the
occurrence of any reported complication; this included both
Table 1
Distribution of Lund-Mackay scores and mean
SNOT-22 scores
Lund-Mackay Mean
score No. % SNOT22 95% CI
0-4 385 20.9 41.8 39.7-43.9
5-9 469 25.5 43.5 41.5-45.5
10-14 515 28.0 42.8 41.0-44.7
15-24 471 25.6 45.5 43.6-47.4
major and minor complications. Revision surgery was iden-
tified on the basis of information provided by the patient at
12 and 36 months. The change in SNOT-22 score from
baseline was calculated for each individual patient to deter-
mine how much symptom improvement was achieved.
Multicenter Research Ethics Committee Approval for
this study was received from the London region. Fast-track
Local Research Ethics Committee Approval was then re-
ceived from all participating NHS Trusts.
Statistical analyses were performed as follows. When the
correlation between Lund-Mackay and the SNOT-22 scores
was examined, we used Pearson’s correlation coefficient.
When the association between Lund-Mackay scores and
ordinal variables such as extent of polyposis and extent of
surgery was examined, we used 1-way analysis of variance.
We used logistic regression when we examined the power
of the Lund-Mackay score to predict perioperative compli-
cations or revision surgery, and linear regression when we
examined for continuous variables (SNOT-22 scores). To
account for possible clustering of patient outcomes within
hospitals, we used robust standard errors in all regression
analyses.
Regression analyses were repeated to include the allergic
status of the patient. This did not alter the associations with
the Lund-Mackay score reported, and the allergic status of
the patient was therefore not included in the analyses per-
formed.
All P values are 2-sided and P values lower than 0.05
were considered a statistically significant result. Stata soft-
ware (Release 8) was used for all calculations.
RESULTS
Patient Characteristics
Lund-Mackay scores were recorded in 1840 patients. The
mean Lund-Mackay score was 11 (SD 6.5); the range was 0
to 24. The distribution of Lund-Mackay scores is given in
Table 1. A total of 3128 patients were included in the study;
1288 patients did not undergo a preoperative CT scan, and
therefore could not be assigned a Lund-Mackay score. Pa-
tients for whom no Lund-Mackay score was recorded had
undergone limited surgery or simple polypectomy only; in
Hopkins et al The Lund-Mackay staging system for chronic . . . 557

Table 2
Patient characteristics

Nasal polyps CRS only All patients

(N ⫽ 992) (N ⫽ 848) (N ⫽ 1840) Missing data
N % N % N % N

Male 656 66.1 368 43.4 1024 55.7 3

Previous sinonasal surgery 481 53.3 280 36.3 761 45.4 176
Previous steroid treatment 900 90.7 740 87.3 1640 89.1 0
Symptoms began within last year 55 6.1 53 6.9 108 6.5 14
Smoker 161 18.2 194 25.4 355 21.5 190
Asthma 356 39.4 167 21.6 523 31.2 177
Patient-reported allergy 350 36.5 298 35.7 648 36.1 47
Aspirin sensitivity 65 6.6 9 1.1 74 4.0 0
ASA grade 3 or 4 39 3.9 20 2.3 59 3.2 69
Polyp grade 15
I 322 32.9 — — — —
II 368 37.7 — — — —
III 287 29.4 — — — —
Mean age in years (range) 49.4 (17-84) 44.8 (16-82) 47.2 (16-84) 5
Mean Lund-Mackay score (SD) 13.6 (6.3) 7.0 (4.7) 10.6 (6.5) 0
Mean preoperative SNOT-22 (SD) 43.0 (20.0) 44.1 (20.4) 43.5 (20.2) 187

the UK it is not common practice to perform a preoperative in terms of extent of surgery were compared, a 1-way of
CT scan in these cases. analysis of variance revealed a highly significant between
Patient characteristics are presented in Table 2. Accord- group effect (F ⫽ 46.66; df ⫽ 2; P ⬍ 0.00001). Patients
ing to patient-reported data, 36% of patients were allergic. who underwent the least extensive surgery had the lowest
Allergic patients reported higher rates of revision surgery at Lund-Mackay scores (mean, 4.2, 95% CI 3.6 to 4.7) and
three years (13.8% versus 9.9%), but other outcomes were these were significantly lower than patients submitted to
not related to allergic status. anterior ethmoidectomy (mean, 6.2, 95% CI 5.8 to 6.6) and
Seven percent of patients underwent simple polypectomy, those who underwent the most extensive surgery (mean, 8.4,
50% underwent proximal sinus surgery that extended as far as, 95% CI 7.8 to 9.0).
but not beyond the anterior ethmoids, and the remaining 44%
underwent distal sinus surgery that extended into or beyond the
posterior ethmoids. Operative characteristics are presented in Table 3
Table 3. Outcomes are reported in Table 4. A complication Mean Lund-Mackay scores by extent of surgery,
was reported in 7.6% of cases; the most common was excess polyp grade, and preoperative SNOT-22 score
perioperative hemorrhage. The revision surgery rate at 12
N Mean LM 95% CI
months was 3.7% and increased to 11.2% at 36 months. The
mean change in SNOT-22 scores at 12 months postoperatively Distal extent of surgery
was 13.5 (SD 20.5) and was 13.2 (SD 22.1) at 36 months. performed
Polypectomy 120 11.7 10.2-13.2
Is there a threshold Lund-Mackay score below which Antral washout 44 8.8 6.4-11.1
MMA/uncinectomy 222 7.4 6.6-8.3
patients are not submitted to surgery? Twenty-one percent
Ant. ethmoidectomy 637 8.5 8.1-8.9
of patients had a score of 4 or less (Table 1). Post. ethmoidectomy 468 12.6 12.2-13.2
Sphenoid sinus 117 14.7 13.6-15.8
Is there an association between Lund-Mackay score and All sinuses 77 17.3 16.0-18.6
extent of surgery? Comparing mean Lund-Mackay score Frontal sinus 138 11.3 10.3-12.3
Extent of polyposis
with distal extent of surgery performed suggests that in No polyps 717 6.5 6.2-6.8
current practice there is an association between the extent of 1 432 10.6 10.1-11.0
sinus surgery and the severity of disease on cross-sectional 2 380 13.5 12.9-14.0
imaging (Table 3). Polyp patients were excluded from fur- 3 296 16.8 16.0-17.5
ther 1-way analysis of variance between extent of surgery Preoperative SNOT-22
0-25 337 10.0 9.3-10.6
and Lund-Mackay score, as we had demonstrated an asso- 26-40 437 10.9 10.3-11.5
ciation between increasing polyp grade and increasing 41-60 530 10.5 9.9-11.0
Lund-Mackay score that might confound the results. When 61⫹ 523 10.7 10.2-11.3
the Lund-Mackay scores of patient groups known to differ
558 Otolaryngology–Head and Neck Surgery, Vol 137, No 4, October 2007

Table 4
Complication rate, revision surgery rate, and change in SNOT-22 score by Lund-Mackay score

Revision surgery Change in SNOT-22 score

rates (%) (mean, 95% CI)
LM score Complication rate (%) 12-month 36-month 12-month 36-month

0-4 3.1 4.1 9.7 11.3, 8.8-13.8 10.3, 7.2-13.4

5-9 5.5 2.5 10.9 13.4, 11.1-15.8 12.7, 9.9-15.6
10-14 7.6 4.1 9.6 14.1, 12.1-16.1 13.4, 11.0-15.9
15⫹ 13.2 4.1 14.0 14.5, 12.4-16.7 15.2, 12.6-17.8

Is there an association between Lund-Mackay scores and
other markers of disease severity? When we compared the
Lund-Mackay scores of patient groups known to differ in
terms of polyp extent, a 1-way of analysis of variance
revealed a highly significant difference between group ef-
fect (F ⫽ 100.25; df ⫽ 2; P ⬍ 0.00001). Patients with grade
I polyps had the lowest Lund-Mackay scores (mean, 10.6,
95% CI 10.1 to 11.0) and these were significantly lower
than patients with grade II polyps (mean, 13.5, 95% CI 12.9
to 14.0) and those with grade III polyps (mean, 16.8, 95%
CI 16.0 to 17.5). Patients with grade II polyps also had
significantly lower Lund-Mackay scores than those with
grade III polyps (Table 3).
There is a weak association between preoperative
SNOT-22 scores and Lund-Mackay scores (r ⫽ 0.058); for
every point increase in the Lund-Mackay score, there is a
very small incremental rise in the mean SNOT-22. Al-
though this reaches statistical significance, it is not clini-
cally important; that is, the extent of measurable disease
does not correlate strongly with the severity of symptoms.
Does the Lund-Mackay score predict outcome? The com-
plication rate increased with increasing Lund-Mackay score
(Table 4). With logistic regression, this association is found
to be significant (Table 5, odds ratio [OR, for a single point
increase in Lund-Mackay score] 1.08, 95% CI for OR 1.06
to 1.11; P ⬍ 0.001). Patients with higher Lund-Mackay
scores have been shown above to undergo more extensive
surgery. Controlling for this within a multivariate analysis
confirms that the association found between complication
rates and Lund-Mackay score is independent of the extent of
surgery. With logistic regression to control for both Lund-
Mackay score and the extent of surgery, the association
between complication rates and Lund-Mackay score be-
comes stronger (Table 5, OR 1.09, 95% CI for OR 1.06 to
1.13; P ⬍ 0.001).
The changes in SNOT-22 scores at both 12 and 36
months from preoperative levels are shown in Table 4.
Linear regression found a small but significant association
between Lund-Mackay score and the change in SNOT-22
score after surgery at 12 months (coefficient 0.19, 95% CI
0.006 to 0.37; P ⫽ 0.04). This indicates that patients with
higher preoperative Lund-Mackay scores also achieve a
greater reduction in symptoms after treatment. At 36
months, the association becomes stronger (coefficient 0.24,
95% CI 0.04 to 0.44; P ⫽ 0.02).
Logistic regression found no association between Lund-
Mackay score and revision surgery rates at 12 months
(Table 5, OR 1.006, 95% CI for OR 0.96 to 1.05; P ⫽ 0.76).
At 36 months, a small but significant association is found
(OR 1.03, 95% CI for OR 1.0001 to 1.06; P ⫽ 0.046). We
do not know the nature of the revision surgery performed
for these patients.
DISCUSSION
Methodological Limitations of This Study
This study is larger than all previously published articles
that look at the relationship between symptoms, outcomes,
and radiologic staging systems. We have only looked at a
single patient-based outcome instrument, the SNOT-22, but
this has been recently recommended as the most suitable
outcome tool for CRS.12 Similar studies utilizing other

Table 5
Logistic regression results (regression performed for given variable and increasing Lund-Mackay score)

Variable Coefficient Standard error P Odds ratio 95% CI for odds ratio

Occurrence of complication 0.08 0.01 ⬍0.001 1.08 1.06-1.11

Occurrence of complication
(controlling for extent of surgery) 0.09 0.02 ⬍0.001 1.09 1.06-1.13
Revision surgery within 12 months 0.01 0.02 0.76 1.006 0.96-1.05
Revision surgery within 36 months 0.03 0.01 0.046 1.03 1.001-1.06
Hopkins et al The Lund-Mackay staging system for chronic . . .
instruments, such as the Chronic Sinusitis Survey, have
found similar results to our own.13-15 We do not think that
the relationships described between symptom scores and
outcomes are dependent on the type of symptom instrument
used.
Of the 3128 enrolled in the main study, 1288 did not
undergo preoperative CT and hence had no Lund-Mackay
score. The patients included in this group differed from the
group in whom a CT was performed in several ways; they
were on average 5 years older, there was a higher proportion
of patients with polyps (82% versus 54%), and they were
less likely to be operated on by a consultant surgeon. We do
not know the extent of sinus disease in these patients due to
the lack of imaging, but they had slightly lower symptom
scores preoperatively (39.2 versus 43.8). We cannot judge if
this introduces significant bias into this study, but as we are
looking at the relationship between disease severity and
symptoms, there is no reason to expect this group to behave
differently.
There is a potential further source of error in this study,
as completion of the SNOT-22 and polyp grading occurred
on the day of surgery and not at the time of CT imaging,
which may have occurred several months before. It is
thought that radiologic findings remain constant over time
once a chronic state refractory to medical treatment has
been reached;16 however, patients who undergo surgery for
recurrent acute sinusitis may have been scanned between
episodes of infection. The accuracy of scoring the Lund-
Mackay could not be assessed in this study, but as the
Lund-Mackay is simple to score this is unlikely to be a
significant problem.
For ethical reasons, the CT scan cannot routinely be
repeated after surgery, and therefore the Lund-Mackay
score cannot be used as an outcome measure. We are there-
fore unable to test for an association between pre- and
postoperative Lund-Mackay scores.
Is there a threshold Lund-Mackay score below which
patients are not submitted to surgery? No. Twenty-one per-
cent of patients have Lund-Mackay scores within the range
found in asymptomatic individuals. However, the mean
SNOT-22 scores in this patient group were comparable to
those with higher Lund-Mackay scores. Thus, there does not
appear to be a clear threshold in the Lund-Mackay score
below which patients are denied surgery, and other factors
such as symptom scores must influence the decision to
operate on patients with minimal disease on CT.
Is there an association between Lund-Mackay score and
extent of surgery performed? Yes. We have found that there
is an association with the extent of surgery performed. This
may be indirect, as the surgery may be tailored with the
severity of mucosal disease encountered during surgery in
keeping with the Messerklinger technique. The Messer-
klinger technique involves a step-by step progression
through the sinus compartments, targeted to the extent of
559
disease identified during dissection.17 However, more ex-
tensive disease on CT imaging may also directly encourage
the surgeon to undertake more extensive surgery.
Does the Lund-Mackay capture the extent of disease and
symptom severity? There is a strong correlation between
extent of disease on cross-sectional imaging and polyp ex-
tent, both objective markers of disease severity. This sug-
gests that the Lund-Mackay has good construct validity; that
is it does measure disease severity.
We found a small, but clinically nonsignificant associa-
tion between the Lund-Mackay and SNOT-22 scores; the
incremental rise in SNOT-22 with increasing Lund-Mackay
is not clinically important. This concurs with several previ-
ous small studies that found that CT findings do not corre-
late with the severity of sinonasal symptoms at the time of
presentation.13-15
It may be that disease and obstruction of a single sinus
complex may cause such significant symptoms that involve-
ment of additional sinuses does not have the added impact
on symptoms that might be expected. However, another
recent study also failed to demonstrate a correlation be-
tween the RSOM-31 and either total Lund-Mackay scores
or opacification of individual sinuses.18 Some of the pa-
tients, particularly those with low Lund-Mackay scores,
may have been wrongly diagnosed as having chronic rhi-
nosinusitis. The differential diagnoses include several con-
ditions, such as facial migraine, where symptom severity
would not be expected to correlate with mucosal changes in
the sinuses. Another subgroup may have been undergoing
surgery for recurrent acute episodes of sinusitis. In this
group, both symptom severity and radiologic findings will
vary, and again no correlation can be expected unless both
are measured concurrently.
The relationship between biological, physiologic, and
radiologic variables and symptoms is complex. Physiologic
variables can be profoundly abnormal in some asymptom-
atic patients, whereas others may report severe symptoms in
the absence of change in biological markers of disease.
Studies in many medical specialties demonstrate that pa-
tient-reported measures of symptoms are poorly correlated
with clinical measures. In studies of benign prostatic hyper-
trophy, there was no association between urodynamic in-
dexes of obstruction and obstructive symptoms.19 In a study
of rheumatoid arthritis, significant reductions in the eryth-
rocyte sedimentation rate and rheumatoid factor levels were
not correlated with changes in joint symptoms or stiffness.20
Studies of asthma and COPD have found little or no corre-
lation between subjective dyspnoea and FEV1.21 In osteo-
arthritis, the correlation between radiographic disease se-
verity and symptom severity is often poor.22
It has been proposed that patients’ symptoms and quality
of life are the result of an interaction between many factors
in which biological or physiologic variables are only a piece
of the final jigsaw (Fig 1).23 Clinicians probably overesti-
mate the impact that these measurable biological variables
have on symptoms and functioning. It is therefore not sur-
560 Otolaryngology–Head and Neck Surgery, Vol 137, No 4, October 2007
Figure 1 Relationships between physiologic variables of disease and patients’ symptoms.
prising that there should be little correlation between pa-
tient-based symptom severity scoring systems such as the
SNOT-22 and the Lund-Mackay score. The absence of
correlation does not suggest that either score is invalid, but
that they measure different aspects of the disease process.
Predictive Value of the Lund-Mackay Score
We found an increase in complication rate with increasing
Lund-Mackay score. This risk is independent of extent of
surgery. Although the majority of reported incidents were
minor, it is important to counsel patients as to the increased
risk associated with more extensive disease and higher
Lund-Mackay scores before surgery.
The predictive value of radiologic stage in treatment
outcome measured in terms of symptomatic improvement is
controversial. Because the primary abnormality identified
by the CT scan is mucosal disease, it may be expected that
patients with greater preoperative disease severity may be
more likely to have significant residual mucosal disease
after treatment. Two recent studies failed to find any corre-
lation between preoperative Lund-Mackay score and symp-
tomatic improvement after ESS.24,25 However, another
study has suggested that CT scores are strong predictors of
symptom levels after treatment.26 Patients with higher dis-
ease severity on CT scan showed significantly larger im-
provement in symptom scores measured with the Chronic
Sinusitis Survey after treatment. This previous study looked
at only 57 patients over a 3-month follow-up period and
noted the need for larger, longer term cohorts to confirm
their findings. We found an association between change in
SNOT-22 scores (or absolute postoperative scores) and the
preoperative Lund-Mackay that suggests those with higher
Lund-Mackay scores have the most to gain from surgery,
although the association is not strong.
We also found a small but significant correlation be-
tween Lund-Mackay score and revision surgery rates at 36
months. The observational design of this study has demon-
strated that the extent of surgery is closely tailored to the
extent of disease demonstrated on the CT scan. If those with
more extensive disease and high Lund-Mackay scores un-
dergo more extensive surgery than patients with less dis-
ease, the effect of this may be to minimize the predictive
value of the Lund-Mackay on its own in terms of revision
rates. However, as symptoms will largely drive patients to
seek further surgical treatment, it is again not surprising that
the correlation between the preoperative Lund-Mackay and
revision rates is small.
CONCLUSIONS
Clinicians often base management decisions on objective
radiologic and endoscopic findings in CRS. Many clinical
guidelines, including those for endoscopic sinus surgery,
use cut-off points for treatment based on clinician-based
scores such as the Lund-Mackay system. One published
study demonstrated that CT scans changed the treatment
decision from medical to surgical management in one third
of CRS patients.27 Validated outcome questionnaires are
often overlooked as they are thought to be too subjective.
However, symptoms drive patients to seek medical treat-
ment, and it is unlikely that asymptomatic patients will
request such treatment regardless of extensive disease on
cross-sectional imaging. Given that biological and physio-
Hopkins et al The Lund-Mackay staging system for chronic . . .
logic measures have an inconsistent relationship to symp-
toms, it is unlikely that treatments directed at objective
measures alone will be fully effective in their relief of
symptoms, and we may be denying treatment to those with
significant potential benefit on the basis of CT findings
alone. We believe that this study gives support to the use of
both the Lund-Mackay and SNOT-22 scores together in the
decision as to whether surgery is likely to give significant
symptomatic relief to patients.
The Lund-Mackay score measures a different aspect of
chronic rhinosinusitis to subjective measures of disease se-
verity with which it is often compared. However, this study
shows it correlates with other markers of disease severity in
CRS, the nature of surgical treatment offered, and the out-
come of such treatment.
AUTHOR INFORMATION
From the Clinical Effectiveness Unit (Drs Hopkins and Browne), Royal
College of Surgeons of England, the Royal United Hospital Bath
(Dr Slack), the Royal National Throat, Nose and Ear Hospital (Dr Lund),
and the Milton Keynes General Hospital NHS Trust (Dr Brown).
Corresponding author: Claire Hopkins, Carmay, Chelsfield Lane, Orping-
ton, BR6 7RR.
E-mail address: clairehopkins@yahoo.com.
AUTHOR CONTRIBUTIONS
Claire Hopkins, project design, data collection and analysis, writer; John
P. Browne, project design, data collection and analysis, editorial com-
ments on manuscript; Rob Slack, project design, data analysis, editorial
comments on manuscript; Valerie Lund, project design, editorial com-
ments on manuscript; Peter Brown, project design, editorial comments on
manuscript.
FINANCIAL DISCLOSURE
Valerie J. Lund is on the advisory board of Schering-Plough.
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3. Oluwole M, Russell N, Tan L, et al. A comparison of CT staging
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