2018 Section 5 - Rhinology and Allergic Disorders

ICAR Executive Summary

TABLE III-4. Summary of recommendations for CRSsNP management

Benefit-harm assessment

Intervention

LOE

Benefit

Harm

Cost

Policy level

Saline irrigation

A Improved

Local irritation, nasal

Minimal

Preponderance of

Recommended

symptomatic, radiologic, and endoscopic outcomes

burning, headaches, and ear discomfort

benefit over harm

Topical corticosteroids (standard delivery)

A Improved symptoms and endoscopic appearance B-C Improvement in symptoms and

Epistaxis, headache

Low to moderate

Benefits outweigh harm

Recommended

Topical corticosteroids (nonstandard delivery)

Epistaxis, nasal

Moderate to high,

Varies by method Irrigation, mucosal atomization, and

irritation, possible systemic absorption

depending on method

endoscopic appearance

maxillary sinus tube are options. YAMIK catheter is recommended against Insufficient evidence for a recommendation Insufficient evidence for a recommendation

Oral corticosteroids

N/A

Antibiotics: oral nonmacrolide Antibiotics: oral macrolide

N/A

B Reduction in

Significant potential for medication interactions. Rare adverse events neutropenia, sepsis, deep vein thrombosis, elevated liver enzymes, drug adverse events, rash, bleeding Local irritation, possible systemic absorption Thrombophlebitis,

Low

Benefits appear to outweigh harm

Option

endoscopy scores and some symptoms

Antibiotics: intravenous C Possible symptom improvement

High

Risks outweigh benefits

Recommendation against

Antibiotics: topical

B None demonstrated in randomized trials A None demonstrated in randomized trials

Moderate to high

Harm outweighs benefits Harm outweighs benefits

Recommended against

Antifungals: topical

Local irritation (rare)

Moderate

Recommended against

Surfactants, Manuka honey, xylitol

N/A

Insufficient evidence for a recommendation

Colloidal silver

N/A

Significant safety concerns

Recommended against

CRSsNP = chronic rhinosinusitis without nasal polyps; LOE = level of evidence; N/A = not applicable.

cortisol levels. MAST - Invasive insertion, epistaxis. YAMIK - Patient discomfort, epistaxis. ◦ Cost: Moderate to High (from US$2.50 per day for budesonide respules, MAST tube US$100 for each tube + variable costs associated with insertion). ◦ Benefits-Harm Assessment: Irrigations - Preponder- ance of benefit over harm, with relatively high cost. MAD - Balance of benefit and harm. MAST - Balance of benefit and harm. YAMIK - Lim- ited evidence shows preponderance of harm over benefit.

◦ Value Judgments: Early evidence for irrigations is low level and there is a higher cost compared to sprays. Strongest evidence of improvement is seen in postoperative patients. ◦ Policy Level: Irrigations - Option in postoperative patients. MAD - Option. MAST - Option. YAMIK - Recommendation against. ◦ Intervention: Corticosteroid nasal irrigations are an option in CRSsNP. They may be most beneficial in postoperative patients. The use of MAD or MAST is an option. Use of the YAMIK device is not rec- ommended based on current evidence.

International Forum of Allergy & Rhinology, Vol. 6, No. S1, February 2016

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