xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.22741 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

272

International consensus statement on rhinosinusitis

refractory disease. 281–283 However, clear definition of med ical management and ESS is inherently fraught with dif ficulty due to complexity of what constitutes appropri ate medical therapy and what is the appropriate extent of sinus surgery. While ESS has been shown to be cost effective by multiple studies, 281,282 1 recent study has found the cost-effectiveness of adding frontal sinus surgery to ESS may be questionnable. 284 These difficulties are high lighted in cost-effectiveness studies of recently-developed treatment modalities. The cost-effectiveness of steroid eluting implants compared to non-steroid eluting implants following ESS has been reported in relation to prevent ing additional post-operative interventions such as pro vision of oral steroids or lysis of adhesions. 281,285 How ever, cost-effectiveness analyses of these steroid-eluting stents has not yet been performed in comparison to more realistic alternative treatments, such as no implant place ment or a steroid irrigation, or by using QALYs as the outcome measure. Similarly, the cost-effectiveness of bal loon sinus dilation has been studied in pediatric CRS where upfront adenoidectomy with balloon sinus dila tion was found to be 0.03% more effective but with an incremental cost of USD$81,431, compared to a grad uated approach starting with adenoidectomy alone. 286 These studies show that while new CRS treatments may be clinically effective, their cost-effectiveness may be affected by the clinical scenario and outcome measure considered. Separate consideration should be given to patients with recalcitrant disease despite appropriate medical and sur gical treatment, who may need further treatment such as revision surgery, in-office procedures or additional med ical treatment. 1 Cost-effectiveness study of these CRS patients is nascent. The need for revision ESS is estimated to occur in 15% to 20% in all types of CRS 189,287 and is asso ciated with increased health care expenditure. 288 Another treatment option for recalcitrant disease includes in-office placement of drug eluting implants. 289 Most recently, bio logics have shown promising results for the treatment of recalcitrant CRS, although long term follow-up studies are ongoing. 290,291 The cost-effectiveness studies for revision surgery, implants, and biologics for these CRS patients with recalcitrant disease is needed. 292 This is particularly true for biologics which have annual costs in the tens of thousands of US dollars and studies showing an indefinite need for their use in responders. In asthma, a recent study of the cost effectiveness of biolog ics found that the price of these medications exceeds cost effectiveness thresholds for willingness to pay and that the pricing would need to decrease by 60% to meet these measures. 293 It has therefore been proposed in both asthma and CRS, that to make biologics most cost-effective at their current prices, disease subtypes (eg, endotypes) must be

identified which predict good response to biologic therapy and then patients must be monitored once on biologics to ensure adequate response to continue to justify the cost of treatment. 279,280,293 In this way, the need to establish cost effectiveness for biologics may also help to drive discov ery and innovation in the field of CRS to better implement personalized treatment based on the apriori knowledge of increased likelihood of response to biologics. As new research, device innovation and therapies arise, physicians have a responsibility to assess the improved out comes relative to the current standard of care and also eval uate the associated costs. The balance of these factors is needed to decide what is ultimately best for patient care while being respectful of growing health care costs. Con sideration for this need is especially important now with the rapid proliferation of new treatments for CRS. Acute Rhinosinusitis (ARS) VII.A Incidence and Prevalence of ARS ARS is one of the most commonly diagnosed diseases in the primary care setting, accounting for 2% to 10% of primary care and otolaryngology visits. 5,6 The estimated incidence of ARS ranges from 1.39% to 9% annually depending on the study methodology and population being studied. 7–9 However, ARS symptoms can overlap considerably with other URI symptoms, making an accurate diagnosis challenging. 294,295 It is estimated that adults will experi ence between 1-3 episodes of viral ARS per year. 9,294,295 Fur thermore, the diagnostic criteria for ARS may vary depend ing on country, affecting the calculated prevalence and incidence of ARS between countries. 296 While both viral and bacterial pathogens can cause ARS, the majority of cases probably begin with a viral URI. The incidence of ABRS is unknown, but it is estimated at 0.5% to 2.0% of all viral infections. 10 Classification of ARS into a bacterial vs nonbacterial source is clinically important in determining whether to prescribe antibiotics for treatment. 88 In patients with clinically suspected ARS, the prevalence of bacterial growth on antral puncture or endoscopically-guided cultures ranged from 31% to 61.1% based on recently published meta-analyses. 297,298 How ever, the cohorts in these studies only included patients who sought and received medical attention, thus not cap turing episodes of ARS for which patients did not seek care. VII.B Diagnosis of ARS The diagnosis of ARS is clinical and based on multiple symptoms including nasal congestion or VII