xRead - Nasal Obstruction (September 2024) Full Articles

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International consensus statement on rhinosinusitis

dose, and duration will provide insight to optimize INCS treatment in ARS Table VII-11.

Oral Corticosteroids for ARS Aggregate Grade of Evidence: D (Level 1: 1 study; level 2: 3 studies; conflicting evidence; Table VII-12). Benefit: Systemic steroids may have minimal short-term benefit, no clear benefit as monother apy. Harm: Minimal harm with rare mild adverse event (see Table II-1). Cost: Low. Benefits-Harm Assessment: Benefit of systemic steroids over placebo small when used as adjuvant therapy, minimal risk of harm. Value Judgments: Systemic steroids may improve patient symptoms with low risk for adverse event. Policy Level: No recommendation. Intervention: Systemic corticosteroids may be use ful with severe facial pain or headaches secondary to ARS, otherwise no tangible benefit. No role as monotherapy for ARS. VII.D.3 ARS Management: Topical Saline Spray and Irrigation There were 7 RCTs and 1 meta-analysis assessing the effects of saline in adult patients with ARS. 417,437–441 Of the 7, 2 trials studied patients with presumed ABRS 417,437 The reason for exclusion were: acute viral rhinosinusi tis (AVRS), 440 mixed population of ABRS with AVRS, 438 mixed population of ARS and CRS 441,442 and suspected RS by symptoms without confirmatory examination. 439 Results from a meta-analysis were not included because data were pooled from RCTs studying common colds and AVRS (Table VII-13). 443 Inanli et al. 417 assessed patients with presumed ABRS. Diagnostic criteria were worsening of RS symptoms for longer than 1 to 3 weeks and an abnormal nasal examina tion. Nasal saline treatment using a syringe (10 mL) was given as an adjunct with oral amoxicillin/clavulanic acid. Mucociliary clearance (MCC) time was compared among study groups, including the saline groups: 0.9% saline (n = 13) and 3% saline (n = 12) and the group without topical treatment (n = 12). At 3 weeks, the changes in MCC time among 3 groups were not different. Safety was not assessed.

Intranasal Corticosteroids for ARS Aggregate Grade of Evidence: A (Level 1: 6 studies; level 2: 8 studies; Table VII-11). Benefit: INCS improved patient symptoms as monotherapy in mild or moderate cases and as adjuvant to antibiotics in severe cases and may shorten recovery. Harm: Minimal harm with rare mild adverse event (see Table II-1). Cost: Low. Benefits-Harm Assessment: Benefit of treatment over placebo small, but tangible; minimal harm with INCS. Value Judgments: INCS improved patient symp toms with low risk for adverse event. Policy Level: Use of INCS: Strong recommenda tion. Intervention: INCS should be used as monother apy in mild to moderate ARS or as adjuvant to antibiotic therapy in severe cases of ARS. VII.D.2.b. ARS Management: Systemic Corticosteroids The majority of trials have focused on the role of INCS in CRS, however, 5 trials (2 unavailable in English 425,426 ) have evaluated the role of systemic corticosteroids in treat ment of ARS. Each study used different corticosteroid for mulations in varying doses and duration, thus limiting direct comparison of results. 427,428 Studies by Gehanno et al. 427 and Ratau et al. 429 offered early support for the use of systemic corticosteroids for management of ARS associated symptoms, particularly facial pain. However, Venekamp et al. report the only study performed with out confounding antibiotics. It failed to find significant symptomatic improvement in patients taking corticos teroid monotherapy. 428 A Cochrane review meta-analysis failed to find significant evidence to support systemic corti costeroids in ARS, despite reviewing trial results from 1193 participants. 430 It is possible there may be a role for oral steroid treatment as an adjunct in severe RS, but evidence is currently lacking (Table VII-12). Given the conflicting evidence, there is no recommenda tion for systemic corticosteroids in cases of uncomplicated ARS, with a grade D aggregate quality of evidence.