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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International consensus statement on rhinosinusitis

trial data and the inherent difficulties in studying RARS related to accurate diagnosis. While all above studies met AAO-HNS criteria for RARS, additional inclusion criteria differed. Rudmik et al. developed an expert panel to develop appropriateness cri teria for ESS candidacy. 206 Minimum criteria included 4 or more annual episodes of ABRS, confirmation of at least 1 episode using endoscopy or CT imaging, shared deci sion making between patient and physician, and either a failed trial of INCS or significant reduction in RARS related productivity. Leung et al. performed a cost-benefit analysis suggesting that ESS becomes economically ben eficial when patients experience a total of 5 or more episodes over a 12-month period. 202 This study consid ered lost work time and productivity, along with medica tion side effects and costs with recurrent infections, com pared to the time, costs, and surgical risks of ESS and recovery. Two studies involving balloon sinus dilation (BSD) in RARS patients were identified. Current guidelines delin eate a role for BSD in RARS, although CT imaging is required showing evidence of ostial occlusion and mucosal thickening. 510 The first randomized, placebo-controlled, unblinded trial showed that patients who received in office BSD and medical management for RARS (n = 29), compared to patients receiving in-office sham procedure and medical management (n = 30), reported significant improvements in CSS and RSDI scores at 8 and 24 weeks follow-up. 511 BSD also significantly reduced mean num ber of sinus infections at 24 weeks follow-up. Limitations of the trial included a lack of double blinding and vari ability in the surgeons’ discretion regarding which sinuses to dilate, noting a high number of frontal sinuses per formed. Levine et al. reported significant improvement in the SNOT-20 and RSI scores at 1 year among 17 RARS patients with in-office BSD of the maxillary sinus ostia and ethmoid infundibula. 512 Mean number of antibiotic courses, sinus-related physician visits, and acute infec tions were significantly decreased. However, use of INCS or antihistamines and workdays missed were not changed significantly. There were no studies identified comparing ESS to BSD among RARS patients. Therefore, it is not possible to pro vide a recommendation for 1 option over the other, and both options should be discussed with the patient as part of the shared decision making process.

Benefit: Postoperative improvement in patient symptoms. Reduction in postoperative antibiotic utilization, acute episodes, and missed workdays. Results appear comparable to CRS cohorts. Harm: Surgery is associated with potential compli cations (see Table II-1). Cost: Significant costs are associated with ESS. Benefits-Harm Assessment: Preponderance of benefit over harm. Value Judgments: Patients with RARS may bene fit both symptomatically and medically from ESS or BSD. For BSD, pre-operative CT imaging of sinus/ostiomeatal complex involvement during an acute exacerbation is required. Policy Level: Recommendation. Intervention: ESS or BSD is recommended for patients with RARS. IX Chronic Rhinosinusitis without Nasal Polyps (CRSsNP) IX.A Incidence and Prevalence of CRSsNP CRSsNP is a common disease but the true prevalence is dif ficult to measure as the diagnosis involves a combination of both subjective symptoms and objective confirmation. Most epidemiological studies of CRS do not distinguish between CRSsNP and CRSwNP but rather CRS combined. Historically, studies which investigated the prevalence of CRS via questionnaires varied widely in reported esti mates. National surveys in the U.S. assessing CRS symp toms have estimated the prevalence ranging from 2.1% to 13.8%. 9,11–13 In Europe, the prevalence for CRS symptoms has been reported to range from 6.9% to 27.1% depend ing on the country. 14 In China, a survey of 10,636 partici pants in 7 cities reported a prevalence ranging from 4.8% to 9.7% depending on the city. 15 Recently, 2 CRS epidemio logic studies included objective confirmation of CRS with radiologic imaging. In those studies, the prevalence of CRS ranged from 1.7% to 8.8%. 18,19 Billing codes for CRS have been analyzed to estimate the incidence of CRS. In a Canadian population-based analysis of ICD-9 codes, the incidence of CRS was found to be 2.3-2.7 per 1000 people over 1 year. 16 A similar analysis of ICD-9 codes in Pennsylvania found the aver age incidence of CRSsNP to be 1048 ± 48 per 100,000 person-years. 17

Endoscopic Sinus Surgery for RARS Aggregate Grade of Evidence: B (Level 2: 1 study; level 3: 7 studies; level 4: 1 study; Table VIII-6).