2018 Section 5 - Rhinology and Allergic Disorders

ICAR Executive Summary

◦ Harm: Bleeding, postoperative discomfort/pain, sep- tal hematoma, septal perforation, persistent obstruc- tion, intranasal scarring. ◦ Cost: Cost is related to increased operative time when septoplasty is added to ESS. ◦ Benefit-Harm Assessment: Preponderance of benefit over harm. ◦ Value Judgment: Septoplasty may be required during ESS for surgical access. Patients with nasal septal deviation (NSD) and CRS may experience reduced nasal obstruction when septoplasty is performed at the time of ESS. Correcting a NSD has an unknown impact on sinus disease. ◦ Policy Level: Option in patients with NSD undergo- ing ESS. ◦ Intervention: Septoplasty is an option to be per- formed at the time of ESS. Because the impact on sinus inflammation is unknown, the decision to per- form a septoplasty should be determined by antici- pated reduction in nasal obstruction or the need to access the sinuses for ESS. Middle Turbinate Preservation vs Resection : Rigid ad- herence to middle turbinate (MT) preservation or rou- tine MT resection is not supported by the cumulative evidence. Low level evidence supports both positions. As a result, management of the MT requires a thoughtful approach with considerations of all potential risks, ben- efits, and alternatives. ◦ Aggregate Grade of Evidence: C (Level 1b: 2 stud- ies; Level 2b: 6 studies; Level 3b: 1 study; Level 4: 11 studies). ◦ Benefit: Lengthening of time to recurrence of NPs, possible improvement in olfaction, improved en- doscopy scores. ◦ Harm: Loss of landmark for revision surgery, leading to increased risk of intraoperative complications. ◦ Cost: No additional cost beyond those associated with ESS. ◦ Benefits-Harm Assessment: Most of the potential risks and benefits postulated for MT resection are not supported in the literature. ◦ Value Judgments: MT resection may improve access to the ethmoid cavity during ESS. Thoughtful con- sideration must be given alternatives to removing a nondiseased structure to improve access. The vast majority of the literature purported to support both MT resection and MT preservation is low level and most shows no effect. ◦ Policy Level: Option. ◦ Intervention: MT resection may be employed during ESS, especially in cases of CRSwNP. Image Guidance : The use of image guidance in ESS appears common yet has little supportive evidence. One recent meta-analysis has demonstrated efficacy,

whereas the remaining literature on this topic is low level. ◦ Aggregate Grade of Evidence: D (Level 2a: 1 study; Level 3b: 6 studies; Level 4: 33 studies; Table X-11 in ICAR:RS). ◦ Benefit: Potential for reduction of complications and more complete surgery. ◦ Harm: None identified. ◦ Cost: Moderate. Cost is due to additional equipment, time for setup. ◦ Benefits-Harm Assessment: Benefits outweigh risks, potentially outweigh costs. ◦ Value Judgments: Benefit is likely achieved in more difficult cases, with a higher risk of complica- tion. Achievement of high levels of evidence are complicated by the need for very large sample sizes and possible ethical issues involving clinical equipoise. ◦ Policy Level: Option. ◦ Intervention: Image guidance is an option for ESS for CRSsNP and CRSwNP. Use of Packing : Multiple studies support the position that packing is not necessary for hemostasis in the vast majority of ESS cases. However, in some cases it is nec- essary and existing evidence supports its hemostatic ca- pabilities as well as addresses wound healing and patient comfort. ◦ Aggregate Grade of Evidence: Intraoperative Hemostasis: A (Level 1b: 5 stud- ies; Level 3b: 1 study; Level 4: 2 studies). Postoperative Hemostasis: A (Level 1b: 11 stud- ies; Level 3b: 1 study; Level 4: 1 study). Wound Healing: A (Level 1b: 21 studies; Level 3b: 1 study). Patient Comfort: A (Level 1b: 13 studies). ◦ Benefit: Rapid control of intraoperative bleeding. Po- tential reduction in adhesion formation with some materials. Chitosan-dextran appears to improve os- tial sizes postoperatively. ◦ Harm: Potential for increased discomfort while in situ and on removal. Rare risk of toxic shock syn- drome. Potential for an increased rate of clinically significant adhesions with some materials. ◦ Cost: There is a cost associated with all packing ma- terials, with absorbable materials being more costly than nonabsorbable packing. ◦ Benefits-Harm Assessment: Balance of risks and ben- efits. ◦ Value Judgments: For the majority of sinus surgi- cal cases packing is not required for intraoperative hemostasis and will not reduce the risk of postop- erative epistaxis. Although evidence does exist sug- gesting packing may reduce adhesion formation, it

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

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