The Impact Of The Addition Of Budesonide To Low-Pressure, High-Volume Saline Sinus Irrigation For Chronic Rhinosinusitis
Phase: PHASE4
Conditions: Rhinosinusitis, Chronic Eosinophilic Rhinosinusitis, Allergic Rhinosinusitis
Sponsor: Washington University School of Medicine

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STUDY PROTOCOL 
 
Project Title: The Impact Of The Addition Of Budesonide To Low-Pressure, High-Volume Saline Sinus 
Irrigation For Chronic Rhinosinusitis 
 
 
NCT02696850 
 
 
Short Title: Neti-Cort Study 
 
Estimated Start Date: December 1, 2015 
 
PI Name: Jay F. Piccirillo, MD 
 
Co-PI: John Schneider, MA, MD 
Stanley Thawley, MD 
Allison Ogden, MD 
Andrew Drescher, MD 
Heidi L’Esperance, MD 
 
 
 
Sponsor: Otolaryngology-Head and Neck Surgery Department, Washington University in St. Louis School 
of Medicine, St. Louis, Missouri 

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Abstract 
 
Chronic rhinosinusitis (CRS) is a condition characterized by inflammation of the paranasal sinuses and 
lining of the nasal cavity for 12 weeks or more.  The characteristic symptoms of rhinosinusitis include 
facial pain-pressure-fullness, and nasal discharge accompanied by nasal obstruction. Rhinosinusitis is 
exceedingly common and estimates suggest that 1 in 8 adults are affected and over 30 million cases are 
diagnosed each year.  Analysis of national ambulatory data demonstrates that rhinosinusitis accounts 
for more outpatient antibiotic prescriptions than any other diagnosis. 
 
CRS is primarily an inflammatory disease, with occasional exacerbations associated with infection. 
Treating the episodic infections alone leaves the underlying condition untreated, likely contributing to 
an increased frequency of exacerbations.  CRS is associated with sinus edema and impaired mucociliary 
clearance. With edema-related obstruction and retained mucus, bacterial infection can more easily 
occur. 
 
Nasal sinus saline irrigation (aka Neti-Pot) is widely recommended and is a common treatment for CRS. 
The use of either isotonic ("normal" saline) or hypertonic saline is recommended and exact 
recommendations for amount of volume vary substantially. There have been over 12 studies (10 RCTs, 1 
systematic review, and 1 meta-analysis) examining the impact of saline irrigation in the management of 
CRS. Both of the reviews concluded that nasal saline irrigation is an effective treatment for CRS with a 
high benefit to risk margin. Nasal saline irrigation is low-cost, has an excellent safety profile, and has 
high patient acceptance, which make it an appealing long-term topical treatment strategy. 
 
Budesonide is an anti-inflammatory glucocorticoid steroid that is used for a variety of common ailments. 
Among conditions related to the respiratory tract, budesonide is used as an inhalational drug for the 
treatment of asthma, COPD, allergic rhinitis, and nasal polyps. Three studies examined the use of topical 
budesonide delivered through low-pressure, high-volume saline irrigation. All three studies reported 
dramatic improvement in symptoms with minimal local or systematic effects. 
 
The goal of this research project is to explore the impact of the addition of budesonide to high-volume, 
low-pressure nasal sinus saline irrigation (aka “Neti-Pot”-type systems) for patients with chronic 
rhinosinusitis with or without nasal polyps. 
 
The specific aims of this study are as follows: 
1. To determine the incremental benefit of the addition of budesonide to nasal irrigation for CRS 
patients. 
2. To describe the adverse effects related to budesonide nasal saline irrigation. 
 
To answer the research question, the study design will be a double-blind placebo-controlled randomized 
clinical trial. Up to 80 adult patients with complaints of purulent (not clear) nasal drainage accompanied 
by nasal obstruction, facial pain-pressure-fullness, or both and reduction or loss of smell for 12 weeks or 
greater will be eligible. The intervention will be 4 weeks of budesonide powder added to saline rinse or 
lactose placebo added to saline rinse alone.  The primary outcome measure will be the average per- 
patient change in the SNOT-22 between the two treatment groups. 

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SYNOPSIS 
 
Study Title 
The Impact Of The Addition Of Budesonide To Low-Pressure, High-Volume 
Saline Sinus Irrigation For Chronic Rhinosinusitis 
Objective 
The objective of this research project is to explore the impact of the addition of 
budesonide to low-pressure, high-volume saline nasal irrigation (“Neti-Pot”) for 
patients with chronic rhinosinusitis with or without nasal polyps. 
Study Period 
Planned enrollment duration for each subject: 1 month 
Planned study duration: I year 
Number of Patients 
Up to 80 adult patients with complaints of purulent (not clear) nasal drainage 
accompanied by nasal obstruction, facial pain-pressure-fullness, or both and 
reduction or loss of smell for 12 weeks or greater. 
Study Drug 
Budesonide and identical appearing placebo containing lactose.  Budesonide is 
an anti-inflammatory glucocorticoid steroid that is used for a variety of common 
ailments. 
Study Design 
Prospective, double-blind, placebo-controlled randomized clinical trial 
Inclusion and 
Exclusion Criteria 
Inclusion Criteria: 
Twelve (12) weeks or longer of two or more of the following signs and symptom 
consistent with chronic rhinosinusitis (CRS)1, 2: 
· mucopurulent drainage (anterior, posterior, or both), nasal obstruction 
(congestion),facial pain-pressure-fullness, and decreased sense of smell 
 
AND inflammation  documented by one or more of the following 
findings: 
 
· purulent (not clear) mucus or edema in the middle meatus or ethmoid 
region, 
· polyps in nasal cavity or the middle meatus, and/or 
· radiographic imaging showing inflammation of the paranasal sinuses 
 
Exclusion criteria: 
· Unable to speak English 
· History  of comorbid ciliary dyskinesia, cystic fibrosis or any other 
mucociliary condition 
· Dependence on prolonged corticosteroid therapy for comorbid 
conditions, such as asthma and chronic obstructive pulmonary disease. 
· History  of oral or systematic antibiotic use in the past 2 weeks 
· History  of nasal or sinus surgery within past 6 weeks 
· History  of cerebrospinal fluid leak 
· History  of allergy to budesonide or other topical steroids 
· Pregnant or breast feeding 
· Current infection  or history of one of the following infections: 
Tuberculosis (TB) lung infection, or Herpes infection of the eye. 
· Baseline SNOT-22 total scores below 9 were excluded due to the 
inability to achieve a minimally clinically improved difference 
· Known history of bleeding disorder, topical or injectable lidocaine 
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Primary Outcome 
The change in the SNOT-22 (©2006, Washington University, St. Louis, MO) 
score between baseline and four-week intervention and calculated as: 
∆SNOT-22 = SNOT-22baseline — SNOT-224-week follow-up. 
Measurements 
1.   SNOT-22 
2.   ACE-27 Comorbidity Index 
3.   Lund Kennedy Endoscopy Grading Scale 
4.   Lund – MacKay CT score (not required) 
5.   Global Clinical Impression Scale 
Statistical 
Methodology 
Within subject change in SNOT-22 between intervention groups. Sub-group 
analyses will be performed for patients with and without polyps and prior 
history of sinus surgery 

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Statement of the Research Problem 
 
 
 
 
Definition and Burden of Rhinosinusitis 
 
Chronic rhinosinusitis (CRS) is a condition characterized by inflammation of the paranasal sinuses and 
lining of the nasal cavity for 12 weeks or more.3 The characteristic symptoms of rhinosinusitis include 
facial pain-pressure-fullness, and nasal discharge accompanied by nasal obstruction. Rhinosinusitis is 
exceedingly common and estimates suggest that 1 in 8 adults are affected and over 30 million cases are 
diagnosed each year.4, 5   Analysis of national ambulatory data demonstrates that rhinosinusitis accounts 
for more outpatient antibiotic prescriptions than any other diagnosis.6 Patients with CRS visit primary 
care clinicians twice as often as those without the disorder and have 5 times as many prescriptions 
filled.7. A survey performed in 2007 found that approximately $8.3 billion is spent annually on CRS, 
primarily on prescription drugs and office-based care.8  Surgery, which costs on average $7,700 per 
patient, is performed nearly 250,000 times per year in the United States9   In September 2005, the 
balloon sinuplasty device received FDA approval as the first catheter-based system for dilation of the 
paranasal sinuses. This minimally invasive procedure has caught the attention of the media and the 
public and its rate of adoption within the otolaryngology community has been rapid, albeit with 
controversy surrounding its indications and outcomes. 
 
CRS is primarily an inflammatory disease, with occasional exacerbations associated with infection. 
Treating the episodic infections alone leaves the underlying condition untreated, likely contributing to 
an increased frequency of exacerbations. In this way, CRS is very similar to chronic bronchitis. CRS is 
associated with sinus edema and impaired mucociliary clearance. With edema-related obstruction and 
retained mucus, bacterial infection can more easily occur.10 
 
Mucus hypersecretion is a hallmark of chronic rhinosinusitis (CRS) and is associated with several common 
symptoms. Mucin 5AC (MUC5AC) is a major respiratory mucin gene that codes for a gel- forming mucin 
glycoprotein found in the gastric and respiratory epithelia.  MUC5AC is overexpressed in CRS patients 
both with and without nasal polyps.[1-6]  Furthermore, CRS is associated with changes in nasal epithelial 
tissue, including epithelial damage and an increase in basement membrane thickness.[7-9] 
 
Medical Management 
 
The medical management of CRS includes antibiotics, topical nasal steroid sprays, saline irrigation. 
Antibiotics are often prescribed for CRS and national surveys suggest a large degree of over utilization 
with development of serious adverse side effects and resistant organisms.11-24 
 
Nasal Sinus Irrigation 
 
Nasal sinus saline irrigation (aka Neti-Pot) is widely recommended and is a common treatment for CRS. 
The use of either isotonic ("normal" saline) or hypertonic saline is recommended and exact 
recommendations for amount of volume vary substantially. There have been over 12 studies (10 RCTs, 1 

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systematic review, and 1 meta-analysis) examining the impact of saline irrigation in the management of 

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CRS. Of these 12 studies one was a systematic review and the other was a meta-analysis18, 25   Both 
studies concluded that nasal saline irrigation is an effective treatment for CRS with a high benefit to risk 
margin. Nasal saline irrigation is low-cost, excellent safety profile, and high patient acceptance make it 
an appealing long-term topical treatment strategy.26 
 
 
 
 
Topical Nasal Steroid Spray 
 
The impact of intranasal corticosteroid sprays (INCS) in patients with CRS without polyps was explored 
with two high quality systematic reviews.  In the first published in 2009, Kalish et al.27 reviewed 424 
potential studies and only nine randomized trials involving 657 patients were eligible. Of these nine 
studies, only 5 were acceptable for further inclusion. The summary estimate for overall response to 
treatment showed no significant benefit and substantial variability among studies (5 trials: RR 0.75, 95% 
CI 0.50-1.10, P = 0.14, chi(2) = 13.78, I(2) = 66.2%). Total symptom score was reported in three trials with 
a standardized mean difference favoring topical steroids. The authors concluded that there is 
insufficient evidence to demonstrate a clear overall benefit for topical steroids in CRS without polyps; 
however, their use appears safe and may show some symptomatic benefit.  Snidvongs et al.28 published 
a Cochrane Review in 2011 that combined 5 trials reporting symptom scores. When compared to 
placebo, topical steroid improved symptom scores (standardised mean difference -0.37; 95% confidence 
interval (CI) -0.60 to -0.13, P = 0.002; five trials, n = 286) and had a greater proportion of responders (risk 
ratio 1.69; 95% CI 1.21 to 2.37, P = 0.002; four trials, n = 263). The authors' concluded that topical 
steroid is a beneficial treatment for CRS without polyps and the adverse effects are minor. The authors 
also concluded that direct topical delivery of steroid to the sinuses may bring more beneficial effect than 
simple nasal delivery and that further studies comparing different topical drug delivery methods to the 
sinuses are warranted. 
 
While the use of INCS is generally recommended in the setting of CRS, there is evidence of the limited 
penetration of the steroid beyond the nasal cavity and into the paranasal sinuses29, 30. Therefore, there 
has been great interest in the use of novel delivery approaches and devices to improve intra-sinus 
corticosteroid deposition.31 
 
 
 
 
Non-Standard Delivery of Topical Steroids 
 
Three studies examined the use of topical steroids delivered through low-pressure, high-volume saline 
irrigation. Snidvongs et al. 32 published a prospective cohort of 111 patients, 49 of whom had a 
diagnosis of CRS without nasal polyps.  Treatment was with once daily nasal irrigations of 1mg 
budesonide/betamethasone in 240 ml of normal saline in the immediate post-operative period. 
Significant improvements were seen in SNOT-20 scores (2.3 +/- 1.1 vs 1.2 +/- 0.9), symptom scores (2.5 
+/- 1.1 vs 1.4 +/- 1.0) and Lund-Kennedy endoscopy scores (4.3 +/- 2.0 vs 1.9 +/- 1.6). No adverse 
outcome analysis was reported. Another study, completed by the PI and colleagues at Washington 

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University33, was an open-label prospective study enrolling 9 subjects.  Subjects received a 30 day course 

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of 250 µg budesonide diluted into 5 mL of isotonic saline and delivered into each nostril QID. Subjects 
also underwent adrenal function assessment with the cosyntropin test before and after budesonide 
therapy. All subjects showed adequate adrenal response to cosyntropin stimulation before and after the 
budesonide trial and the mean change in SNOT-20 scores before and after budesonide therapy was 
statistically and clinically improved. Steinke34 conducted a prospective pilot study in 8 subjects with 
allergy as defined by a positive skin prick test and 4 subjects were classified as having aspirin- 
exacerbated respiratory disease, and all but 1 had physician-diagnosed asthma. The subjects received a 
3-month course of twice daily budesonide irrigations (500 μg into >100 ml saline). The median sinus CT 
score before treatment was 15 (maximum, 30), which improved to 5 (P < .05) after treatment.  Based on 
a visual analog scale, the authors we calculated scores for each of 16 sinus symptoms on a scale of 0 to 
6, with 6 being severe and 0 none (maximum, 96). After budesonide treatment, subjects’ sinus scores 
decreased (mean ± SD) from 43.1 ± 5.4 to 20.1 ±3.0 (P<.02). In addition, subjects reported a significant 
improvement in sense of smell. Of the four patients with nasal polyps, three had complete resolution. 
The authors concluded that their study supports the concept that addition of budesonide inhalation 
suspension to standard nasal saline irrigation produces subjective and objective benefit in eosinophilic 
sinus disease and that a double-blind, placebo-controlled study of budesonide inhalation suspension in 
nasal saline washes for patients with CRS was warranted. 
 
 
 
 
Specific Aims 
 
The goal of this research project is to explore the impact of the addition of budesonide to low-pressure, 
high-volume nasal sinus saline irrigation (aka “Neti-Pot”) for patients with chronic rhinosinusitis with or 
without nasal polyps. 
 
The Specific Aims of this study are as follows: 
 
1. To determine the incremental benefit of the addition of budesonide to nasal irrigation for CRS 
patients. 
 
Hypothesis: Budesonide is a topical corticosteroid with potent anti-inflammatory properties and when 
delivered via nasal saline irrigation will be more effective than normal saline alone in the treatment of 
symptoms associated with chronic rhinosinusitis. To evaluate this hypothesis a double-blind 
randomized clinical trial will be performed among adult subjects presenting to Washington University 
Department of Otolaryngology-Head and Neck Surgery for the treatment of chronic rhinosinusitis. The 
primary outcome measure will be the within subject change in SNOT-22 scores among subjects in the 
two arms of the study after four weeks of daily low-pressure, high volume sinus irrigation containing 
either isotonic saline and budesonide or isotonic saline alone. 
 
2. To describe the adverse effects related to budesonide nasal saline irrigation. 
 
Subjects will be queried regarding adverse events experienced during participation in the study and a 

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determination of the likely association with budesonide will be made. 

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Experimental Plan, Methods, and Data Analysis 
 
Study Design 
 
Double-blind placebo-controlled randomized clinical trial 
 
Subjects 
 
Up to 80 adult patients with complaints of purulent (not clear) nasal drainage accompanied by nasal 
obstruction, facial pain-pressure-fullness, or both and reduction or loss of smell for 12 weeks or greater. 
 
Inclusion Criteria: 
 
Twelve (12) weeks or longer of two or more of the following signs and symptom consistent with chronic 
rhinosinusitis (CRS)1, 2: 
· mucopurulent drainage (anterior, posterior, or both), nasal obstruction (congestion),facial pain- 
pressure-fullness, and decreased sense of smell 
 
AND inflammation  documented by one or more of the following findings: 
 
· purulent (not clear) mucus or edema in the middle meatus or ethmoid region, 
· polyps in nasal cavity or the middle meatus, and/or 
· radiographic imaging showing inflammation of the paranasal sinuses 
 
 
 
 
Exclusion criteria: 
 
· Unable to speak English 
· History  of comorbid ciliary dyskinesia, cystic fibrosis or any other mucociliary condition 
· Dependence on prolonged corticosteroid therapy for comorbid condition, such as asthma and 
chronic obstructive pulmonary disease. 
· History  of oral or systematic antibiotic use in the past 2 weeks 
· History  of nasal or sinus surgery within past 6 weeks 
· History  of cerebrospinal fluid leak 
· History  of allergy to budesonide or other topical steroids 
· Pregnant or breast feeding 
· Current infection  or history of one of the following infections: Tuberculosis (TB) lung infection, 
or Herpes infection of the eye. 
· Baseline SNOT-22 total scores below 9 were excluded due to the inability to achieve a minimally 
clinically improved difference 
 
Variables of Interest 
 
Demographic - age, gender, and race. 
 
Index condition – Duration of CRS symptoms, response to previous treatments 

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Co-morbid conditions - Presence and severity of general comorbid conditions will be assessed with ACE- 
27.35    Presence of rhinosinusitis-specific comorbidities will include: inhalant allergies, asthma, and 
aspirin sensitivity 
 
Previous sinus and/or nasal surgery - Previous sinus and/or nasal surgery, including functional 
endoscopic sinus surgery, turbinate reduction, and septoplasty will be captured and duration since 
surgery to time of enrollment. 
 
 
 
 
Randomization 
 
The study statistician, Dr. Dorina Kallogjeri, will use a randomized block design for study drug 
assignment. 
 
 
 
 
Intervention 
 
The study intervention will be budesonide powder (0.5 mg/capsule) or an identical-appearing placebo 
product containing lactose.  All subjects will be provided with the 8-ounce (240 ml) NeilMed Sinus Rinse 
Regular Bottle Kit and a one-month supply of USP Grade Sodium Chloride & Sodium Bicarbonate 
Mixture (pH balanced, Isotonic & Preservative & Iodine Free) commercially prepared packettes. Subjects 
may substitute the NeilMed Sinus Rinse Regular Bottle Kit for a nasal irrigation system, which in the 
opinion of the Principal Investigator, is similar to the NeilMed system and embodies the low-pressure, 
high-volume concept of nasal irrigation. Examples of such systems include, but are not limited to, 
ceramic or plastic neti pot or nasal douch (Nasendusche). Subjects will need to purchase distilled water 
or boil tap water for five minutes for use with the saline irrigation. Subjects will be required to dissolve 
the contents of two capsules into the 8-ounce (240 ml) NeilMed Sinus Rinse Regular Bottle along with the 
saline rinse. All subjects will be instructed to irrigate both right and left nasal cavity with one-half of the 
contents of the nasal rinse once daily. The subjects will receive written instructions and a video prior to 
initiation of the intervention to ensure proper delivery. 
 
 
 
 
Each study bottle will contain 60 capsules of Budesonide or placebo and will be assigned with a number 
from 1-80. Only Dr. Kallogjeri (biostatistician) will have a list that links the treatment type (Budesonide 
or placebo) with the bottle number. The bottle number will correspond to the randomization schedule 
provided from Dr. Kallogjeri. The subject and the rest of the study team will remain blinded to the 
randomization assignment. The subject and the rest of the study team will only know what bottle 
number is being assigned, not which treatment is contained in each bottle. Dr. Kallogjeri is the 
biostatistician of the study and otherwise is not involved with the participants. 
 
In the event of a Serious Adverse Event determined by the PI to necessitate the breaking of the blind, 

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the intervention assignment will be revealed by Dr. Kallogjeri to the medical staff doctor caring for the 

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patient. In the event Dr. Kallogjeri is unable to be reached in a time needed, to assure the safety of the 
subject, the blind can be broken by Sara Kukuljan, RN, or Drs. Piccirillo or Schneider and information will 
be shared with the medical staff assuming care for the patient. 
 
The active drug and placebo will be prepared by Genesis Pharmacy, St. Louis Missouri and delivered to 
the Clinical Outcomes Office where the products will be stored in a locked cabinet.  The cost of sufficient 
budesonide for the study duration (i.e., 60 budesonide capsules) will be $75 and the cost of sufficient 
quantity of lactose capsules will be $25. 
 
Budesonide 
 
Budesonide is an anti-inflammatory glucocorticoid steroid that is used for a variety of common ailments. 
Among conditions related to the respiratory tract, budesonide is used as an inhalational drug for the 
treatment of asthma, COPD, allergic rhinitis, and nasal polyps. The mechanism of action of budesonide is 
similar to other corticosteroids and includes a wide range of inhibitory activities against multiple cell 
types (e.g., mast cells, eosinophils, neutrophils, macrophages and lymphocytes) and mediators (eg, 
histamine, eicosanoids, leukotrienes, and cytokines) involved in allergic- and non-allergic-mediated 
inflammation.(AstraZeneca 2000 2000) 
 
Subjects randomized to the budesonide intervention arm will be required to mix 1.0 mg (provided as 
two capsules containing 0.5 mg budesonide each) budesonide into the sinus rinse bottle and rinse each 
nasal cavity with one half of the bottle (~ 4 ounces or ~120 ml) daily. The inert ingredients are: 
loxasperse powder, which increases solubility and dispersibility of budesonide and is microbiologically 
safe; mannitol, which is widely used in pharmaceutical products as a capsule diluent; and Xylifos™ 
powder, which is a proprietary powder excipient used safely in pharmaceutical compounding for nasal 
nebulization or nasal irrigation. 
 
 
 
 
Exemption From IND Requirements 
 
The use of budesonide in a nasal saline rinse is a change in the approved route of administration. An 
exemption from IND requirements will be requested as the proposed use of budesonide in this study 
fulfills all of the criteria for exemption. 
1. Budesonide is lawfully marketed in the United States. 
2.  This study is not intended to be reported to the FDA in support of a new indication or 
significant change in labeling. 
3. This study is not intended to support a significant change in the advertising for the drug. 
4. The study does not involve a route of administration, dose, patient population, or other factor 
that significantly increases the risk (or decreases the acceptability of the risk) associated with the use of 
budesonide. 
5. The study will be conducted in compliance with the requirements for review by an IRB (21 CFR 
part 56) and with the requirements for informed consent (21 CFR part 50). 
6. The study is not intended to promote or commercialize budesonide. 

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Placebo 
 
The placebo product will contain lactose monohydrate and will be supplied in clear plastic capsules, 
which are identical to the budesonide capsules.  The lactose capsule will only contain lactose as there 
are no other ingredients. 
 
Concomitant Medications 
 
At the time of enrollment, most subjects will be expected to already be using topical nasal steroid 
medication (ie., fluticasone or Flonase®). Subjects currently using a topical nasal steroid spray will be 
asked to continue this medication.  Subjects not currently using a topical steroid spray will be asked to 
initiate therapy, unless there is a contraindication or personal reason for not wishing to use. Topical 
nasal steroid sprays are indicated therapy for CRS and not considered experimental. 
 
Patient-reported Outcome Measure 
 
The SNOT-22 (©2006, Washington University, St. Louis, MO) will be used to capture the physical, 
functional, and emotional consequences of rhinosinusitis. The SNOT-22 is a validated, patient-reported 
outcome measure applicable to chronic sinonasal conditions.36  The severity of 22 rhinosinusitis-related 
symptoms and physical signs are measured using a Likert scale as follows: 0= “No problem”; 1=”Very 
mild problem”; 2=”Mild or slight problem”; 3=”Moderate problem”; 4=”Severe problem”; and 
5=”Problem as bad as it can be”. Higher total scores on the SNOT-22 suggest worse patient functioning 
or symptom severity (score range: 0-110). A minimally clinically improved difference (MCID) in 
symptoms that is perceptible and pertinent to the individual patient on the SNOT-22 has been 
previously described as an improvement of at least 8.9 points.37, 38 
 
Primary Outcome  Measure 
 
Study participants will be asked to complete the SNOT-22 at baseline, two weeks, and four weeks. The 
change in SNOT-22 scores between baseline and four weeks will serve as the primary outcome measure 
in this study and will be calculated as: 
 
Primary Outcome Measure, ∆SNOT-22 = SNOT-22baseline — SNOT-224-week follow-up. 
 
To assess the trajectory of change within subjects randomized to the two treatment arms the baseline, 
two-week, and four-week SNOT-22 assessment will be compared. 
 
Secondary Outcome Measure. 
 
The overall response to treatment will be measured with a modification of the Clinical Global Impression 
(CGI) scale.39   Upon completion of the study, subjects will be asked to answer the following question: 
"Overall, how would you rate your response to treatment?"  Response options are: 1 = Very Much 
Improved, 2 = Much Improved, 3 = Minimally Improved, 4 = No Change, 5 = Minimally Worse, 6 = Much 
Worse, 7 = Very Much Worse. 

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Physical Examination 
 
A directed physical examination, consisting of examination of the nasal cavity with a 0-degree rigid nasal 
endoscope, will be performed by a board-certified otolaryngologist after application of topical 
decongestant at baseline and after completion of the four week intervention. The findings from the 
endoscopic examination will be collected for research purposes and will be recorded using the grading 
system proposed by Lund and Kennedy.(Lund and Kennedy 1997) 
 
 
 
 
Endoscopic Findings 
 
 
None Present 
Present 
 
1. Crusting 
 
0 
 
1 
 
2. Erythema 
 
0 
 
1 
 
3. Swelling 
 
0 
 
1 
 
4. Scar Band 
 
0 
 
1 
 
5. Purulent Drainage 
 
0 
 
1 
 
6. Thick Mucous 
 
0 
 
1 
 
 
 
 
None Present 
Present in 
Present outside 
 
 
middle meatus 
middle meatus 
7. Polyps 
0 
1 
2 
 
 
 
Radiologic Examination 
 
Radiologic examination, including CT scan of the sinuses, will not be required for enrollment in the 
study.  Enrolled subjects who receive a CT scan of the sinuses for clinical reasons during the period of 
this study will have the results of the radiologic examination collected for research purposes and will be 
recorded according to the Lund MacKay system and possibly included in the data analysis. 40 

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CT evidence of inflammation of the sinuses will be defined as mucosal thickening of at least one 
paranasal sinus and does not have to be severe enough to be classified as “partial opacification” or have 
a Lund and MacKay score of 1 or greater. 
 
 
 
 
Data Collection 
 
Sources of Research Material  All research-related information, including responses to the 
selected patient-reported outcome measures, will be captured electronically via the use of dedicated 
iPADs. Week 2 patient-reported outcome measures will be captured via email link sent to subjects with 
RedCAP capture. All data will be stored in a specially designed database created by staff in the Clinical 
Outcomes Research Office using REDCap™ (Research Electronic Data Capture) software. Patient 
confidentiality will be maintained through the use of unique patient ID. 
 
Assessment of Treatment Efficacy The change in the average SNOT-22 scores between baseline 
and four weeks will serve as the primary outcome measure in this study and will be calculated as: 
 
Primary Outcome Measure, ∆SNOT-22 = SNOT-22baseline — SNOT-224-week follow-up. 
 
To assess the trajectory of change within subjects randomized to the two treatment arms the baseline, 
two-week, and four-week SNOT-22 assessment will be compared. 
 
Assessment  of Treatment Safety - Treatment safety will be assessed by patient interview and 
will include collection of adverse events experienced by the patient during the four week participation. 
 
 
 
 
Risk Assessment 
 
Budesonide has a potent glucocorticoid activity and weak mineralocorticoid activity. As an inhaled 
product, budesonide has an onset of action in 24 hours and peak effect in 1-2 weeks. The drug is well- 
tolerated and the more frequent side effects include: nose irritation, epistaxis, lightheadedness, and 

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upset stomach. 

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At recommended daily doses in pediatric patients, no adverse effects were seen in the function of the 
hypothalamic-pituitary-adrenal (HPA) axis.(Brogden and McTavish 1992) In a study of 9 adult CRS 
patients who received budesonide in a manner similar as proposed in this study, no suppression of 
adrenal function was observed.(Sachanandani et al 2009) 
 
Data and Safety Monitoring 
 
The Clinical Outcomes Research Office (CORO) created a set of Standard Operating Procedures (SOPs) 
for the conduct of clinical research.  These SOPS are developed, in part, from and are compliant with 
Institutional guidelines for the conduct of human research. 
 
The specific monitoring plan for this study is based on the potential risk of participation and size and 
complexity of the planned investigation. Based on these considerations this study will have a monitoring 
board comprised of Drs. Piccirillo, Schneider, and Ms. Kukuljan knowledgeable about the risks of 
topically applied glucocorticosteroid, nasal anatomy, and Dr. Kallogjeri, the study biostatistician. All 
three individuals will not be part of the core study team. All reports of a Serious Adverse Event (SAE) or 
an Unexpected Adverse Event will be investigated by the monitoring team. All SAEs will be reported to 
Washington University HRPO. 
 
Statistical Analysis 
 
Comparison of within subject difference in SNOT22 scores between baseline and four-week follow-up 
between the 2 treatment groups will be the primary outcome measure.  A clinically meaningful change 
is defined as a change of 9 or more on the SNOT22. 
 
The change in SNOT22 is calculated as: ∆SNOT-22 = SNOT-22baseline — SNOT-224-week follow-up 
 
Independent samples t-test will be used to test for statistically significant difference in ∆SNOT-22 
between 2 treatment groups. 
 
The statistical significance of the observed difference in the percentage of subjects who achieve a 
clinically meaningful difference will be assessed with the chi-square statistic. The 95% confidence 
interval around the observed difference in the percentage of subjects who achieve a clinically 
meaningful difference will be calculated. 
 
To assess the time trajectory of change within subjects randomized to the two treatment arms, the 
baseline, two-week, and four-week SNOT-22 assessments will be computed and compared.  Within 
group differences will be compared using a repeated measure ANOVA. A general linear model (GLM) 
approach will be used to explore through the testing of an interaction effect (treatment group x time) 
whether the magnitude and pattern of change in SNOT-22 scores at baseline, 2 weeks, and 4 weeks is 
different between the 2 treatment groups. In addition to allowing for exploration of the interaction 
effect, the GLM model allows for evaluation of estimated means after controlling for potential 
confounders. A robust regression model will be used if the assumption of the GLM model will not be 

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The distribution of responses on the Clinical Global Impression  (CGI) scale will be calculated within each 
intervention arm and the difference in responses between the two intervention arms will be compared 
for statistical significance with the chi-square statistic. All of the above analyses will be repeated within 
subgroups of nasal polyp and previous surgery subjects. 
 
All statistical analyses will be performed with SAS software.  Statistical significance will be defined as a 
two-tailed test of significance p value of 0.05 or less. 
 
An interim analysis will be performed after Subject 32 has completed 4-week treatment. Stopping rules 
based on the work of O'Brien and Fleming 41 for the conduct of clinical trials will be followed. 
 
An Intention-to-Treat analysis will be used for the final data analyses. 
 
Sample Size Calculations 
 
The sample size for this study was estimated using preliminary data from CRS patients undergoing 
steroid irrigations after sinus surgery. In addition our goal is to be able to detect a clinically meaningful 
difference of 0.8 points or greater in the change in SNOT-22 scores (pre-post) (equivalent to change of 9 
or more points in the overall SNOT22 score) between the 2 treatment groups.  Assuming that the 
variability (SD=1.1) in pre-post changes in SNOT-22 scores reported from Snidvong et al. will remain true 
in our data we estimated that we will need 32 subjects per group (total n=64) to be able to detect with 
80% power at the 2 sided alpha level of 0.05 a difference of 0.8 points or greater in the in SNOT-22 score 
changes between the 2 treatment groups. We plan to enroll 80 subjects in total as we assume a 20% 
drop out/non-compliance rate. 
 
Remuneration 
 
Subjects will receive $45 after baseline and $45 at final visit and upon successful completion of trial. 
 
Timeline of the Study 
 
Subjects will be enrolled in the study for a total of four weeks.  Given the volume of patients seen at the 
Adult Otolaryngology service with diagnosis of CRS, we anticipate it will take one year to complete 
enrollment. 
 
 

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Calendar of Events (Patient) 
 
Study Activity 
Baseline 
(Time 0) 
Week 1 
Week 2 
Week 3 
Week 4 
Consent 
X 
 
 
 
 
Randomization 
X 
 
 
 
 
SNOT-22 
X 
 
X 
 
X 
ACE-27 
Comorbidity 
X 
 
 
 
 
Physical 
examination 
X 
 
 
 
X 
Endoscopic 
examination* 
X 
 
 
 
X 
Radiological 
Examiniations 
(ex. CT sinus)* 
X 
X 
X 
X 
X 
Written 
instructions for 
administration 
of intervention 
X 
 
 
 
 
Intervention - 
budesonide or 
placebo 
 
X 
X 
X 
X 
Global Clinical 
Impression 
 
 
 
 
X 
Participant 
Stipend 
X 
 
 
 
X 
* Includes tissue biopsy; Results only from nasal endoscopic examination and radiological examination 
performed for clinical purposes during the study will be collected for research purposes. 

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