xRead - Nasal Obstruction (September 2024) Full Articles

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ARS recurrences during follow-up (7 in treatment group vs 13 in placebo group; p = 0.06), but this difference was not significant. 421

inflammatory effects of macrolides contributing to the results, along with the difficulty in assessing the risk of long-term macrolides on bacterial resistance. After careful examination of the available literature, it is not possible to provide additional recommendations for the use of antibi otics in RARS different from recommendations for treating ABRS. VIII.D.3 RARS Management: Endoscopic Sinus Surgery A total of 7 studies were identified examining patient outcomes after ESS in RARS patients (Table VIII-6). Six studies looked at quality-of-life (QoL) scores and objec tive measures, while 2 studies reported antibiotic utiliza tion. All studies used standardized inclusion criteria and disease definitions for RARS as defined by AAO-HNS guidelines. 88 Bhattacharyya et al. reported significant improvement in Rhinosinusitis Symptom Inventory (RSI) domains, antihistamine use, workdays missed, and acute episodes among 19 RARS patients undergoing ESS with a mean follow-up of 19 months, although reductions in antibi otic use after ESS were not significant. 506 Poetker et al. showed significant improvement in the RSDI and CSS total and symptom domains, along with significantly fewer sinus medications used postoperatively, among 14 RARS patients with a mean follow-up of 30 weeks. 501 Bhandarkar et al. reported a 61.2% reduction in the average time on antibiotics postoperatively among RARS patients (n = 21), similar to patients with CRS, with a mean follow-up of 17 months. 507 Costa et al. showed that among 142 RARS patients undergoing ESS vs medical management, the ESS cohort experienced greater reduction of SNOT-22 scores at 3, 6, and 12 months follow-up. 208 A crossover cohort (n = 45) who initially underwent medical management con verted to ESS at an average period of 4.8 months, and these patients also showed significant symptom reduction after ESS. Steele et al. showed that RARS patients (n = 20)expe rienced significant improvement in health utility values to near normative values postoperatively, similar to patients with CRSsNP, with a mean follow-up of 14 months. 508 Steele et al. also demonstrated significant improvements in SNOT-22 and RSDI scores, as well as decreased antibiotic use and decongestant use following ESS for RARS patients (n = 20). 248 RARS patients reported fewer lost productivity days postoperatively, similar to CRSsNP patients, though the difference in pre- and post-operative scores was not sta tistically significant. Sohn et al. reported a RARS cohort (n = 43) experienced significant improvement in SNOT 20 scores after ESS at 6 months follow-up. 509 Limitations with these studies include a lack of randomized control

Intranasal Corticosteroids for RARS Aggregate Grade of Evidence: B (Level 2: 3 studies; Table VIII-5). Benefit: Generally well tolerated. May decrease time to symptom relief. May decrease overall symptom severity, as well as specific symptoms of headache, congestion, facial pain, and sensitivity. Harm: Mild irritation (see Table II-1). Cost: Moderate depending on preparation. Benefits-Harm Assessment: Balance of benefit and harm. Value Judgments: Patient populations studied did not adhere to the AAO-HNS clinical practice guidelines definition of RARS, and therefore con clusions may not be directly applicable to this pop ulation. No studies examined the efficacy of INCS in preventing ARS recurrences, so no conclusions can be made in this regard either. Policy Level: Option. Intervention: Option for use of INCS spray for sinonasal symptoms during acute exacerbations of RARS. VIII.D.2 RARS Management: Antibiotics RARS patients average 4 courses of antibiotics yearly. 232,486 Current AAO-HNS guidelines do not provide recommen dations regarding antibiotic use in RARS. 88 A recent, exhaustive systematic review investigated the effective ness of short-course antibiotics on the severity and dura tion of symptoms and recurrences in RARS patients, and failed to identify any placebo-controlled studies. 486 Based on this lack of evidence, the authors of the systematic review concluded that uncomplicated ARS in patients with RARS should be prescribed antibiotics based on the same criteria used to manage primary or sporadic episodes of ARS. More recently, a randomized, double-blinded, placebo-controlled trial among children with RARS (n = 40) showed azithromycin prophylaxis 3 times a week for 12 months significantly reduced RS episodes from 5 to 0.5 per year, 505 although it is difficult to extrapolate find ings among a pediatric population (of which, 83% demon strated IgG subclass deficiencies) to an adult population with RARS. Other limitations included the possible anti