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

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Orlandi et al.

Gelardi et al. 437 treated presumed ABRS patients (n = 20) with levofloxacin and compared the effects of 2 types of devices for delivering saline irrigation. They showed the benefit of large volume (250 mL) irrigation over the syringe (10 mL) in improvement for rhinorrhea and post nasal drip. When compared to baseline, nasal resistance was decreased in the large-volume irrigation group but not in the syringe group. Safety was not assessed. Nasal saline treatment as an adjunct therapy along with antibiotics may have a role in symptom reduction in ABRS. 88 The sole effects of saline spray/irrigation in the ABRS population cannot be concluded. Beneficial effects of saline irrigation using a 10 mL syringe over no saline treatment were not shown. However, large-volume irri gation (250 mL) showed superior effects over a low vol ume syringe (10 mL). Safety of saline spray/irrigation for treating ABRS cannot be concluded due to limited stud ies. In general, saline treatment is considered safe without reported major adverse effects. 444 Minor adverse effects, including ear fullness, or irritation, are more common in patients receiving hypertonic vs isotonic saline solution. 445 Topical Saline Spray and Irrigation for ARS Aggregate Grade of Evidence: B (Level 3: 2 studies; Table VII-13). Benefit: Not shown when using a low volume syringe (10 mL) but possible improvement in nasal patency, rhinorrhea and post-nasal drip when using a larger volume device (250 mL). Harm: Unclear but possible ear fullness, or irrita tion (see Table II-1). Cost: Minimal. Benefits-Harm Assessment: Balance of benefit and harm. Value Judgments: Saline treatment may improve symptoms when using a large-volume device despite possible minor adverse effects and its min imal cost. Policy Level: Option. Intervention: Saline irrigation may be used in adjunct with antibiotics for ABRS. VII.D.4 ARS Management: Decongestants and Other Adjunctive Treatments VII.D.4.a. Decongestants Decongestants are used in ARS with the presumed benefit of reducing nasal congestion and hence improving patient symptoms. Topical and oral decongestants have shown

to increase ostial patency in healthy individuals and in patients with acute rhinitis and CRS 446–448 There is min imal evidence regarding the use of topical or oral decon gestants in adult ARS. Inanli performed an RCT of ABRS addressing this topic. 417 The primary outcome measure was MCC (MCC) measured by saccharin transit time. MCC was slower initially in patients with ARS and faster 20 min utes following use of oxymetazoline or hypertonic saline. The study utilized MCC as a measure of a defense mech anism against pathogens and noxious stimuli in patients with respiratory infections although this may not be a very relevant clinical outcome in practice. Ultimately however, no significant difference between active treatment groups and controls was observed at the conclusion of the study with respect to improvement in MCC. Wiklund et al., per formed a double-blind RCT on patients with acute maxil lary sinusitis. 449 They compared oxymetazoline vs placebo delivered either as a conventional nasal spray or with a bel lows device. The outcome measures were patient reported symptoms and radiographic improvement. Neither form of oxymetazoline delivery was shown to have significant ben efit over placebo at the study conclusion (Table VII-14). Several international guidelines on this topic have been published. 26,32,88,450,451 None have found sufficient data for an evidenced-based recommendation to be made. Decongestants for ARS Aggregate Grade of Evidence: C (Level 2: 1 study; level 3: 1 study; level 5: 4 studies; Table VII-14). Benefit: Theoretical relief of nasal congestion and restoration of patency of blocked sinus ostia. Harm: Risk of rhinitis medicamentosa (topical) with prolonged use or hypertension (oral), irri tability, palpitations, and insomnia (see Table II-1). Cost: Low direct cost. Benefits-Harm Assessment: Preponderance of benefit over harm has not been demonstrated. Value Judgments: Patient’s comorbidities and age need to be considered due to risk of adverse effects. Policy Level: Option. Intervention: Decongestants are an option in ABRS. Decongestants can reduce congestion in patients with ABRS however side effects should be considered.

VII.D.4.b. Antihistamines Antihistamines are prescribed in ARS on the basis that they reduce nasal secretions. There is a theoretical con cern that the increased viscosity could decrease MCC and