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.

2 studies reflects the effect of medical visit, diagnostic procedural and pharmaceutical costs in influencing the most cost efficient diagnostic algorithm. In specialty care, patients with appropriate CRS symp toms who have a negative endoscopy in whom an extended course of symptom-based empiric antibiotic therapy is being considered, an upfront CT would result cost sav ings of $320 per patient (range USD$138-USD$671) com pared to treating the symptoms without confirming the CRS diagnosis. 558 Based on CMS costs and published drug cost information in the United States, the cost of an extended course of antibiotic therapy is almost sim ilar to that of obtaining a CT, and adopting an upfront CT results in substantially reduced antibiotic utilization in symptomatic patients with alternate diagnoses like rhini tis or atypical facial pain. 560,561 It should be noted that these prior cost studies were carried out using 2010 CT and nasal endoscopy costs and the average reimbursement for both has fallen relative to pharmaceutical and medi cal visit costs, likely further favoring confirmation via nasal endoscopy and CT prior to treatment. Other benefits that are not measured in these cost based studies are the societal benefits of reducing antibi otic overuse that results in antibiotic resistance. These ben efits are traditionally weighed against additional imaging related concerns like radiation exposure and access. The availability of alternative CT imaging modalities like cone beam technologies mitigates some of these concerns by facilitating CT availability at the point of care and lowering radiation exposure while maintaining the quality of diag nostic information necessary for CRS. In a recent study, patients demonstrated a poor understanding of radiation exposure involved in imaging, but the majority of patients expressed a preference for accurate treatment for CRS symptoms even if this care entailed additional costs asso ciated with imaging. 562 Therefore, with cost-effectiveness of CT imaging in mind, practitioners should strongly con sider CT imaging to confirm CRS diagnosis in the appro priately symptomatic patient prior to initiation of antibi otic or procedural management of RS. The utility of MRI for diagnosis of CRS is furthermore limited; MRI is gen erally useful only in specific instances such as delineation of mucoceles, AFRS, concern over skullbase integrity, or tumor-associated sinonasal inflammation.

diagnostic algorithm reduces antibiotic utiliza tion. Harm: Concerns regarding radiation exposure. Cost: For 2019, the CMS-based national average payment for CT imaging without contrast material of the maxillofacial area (Current Procedural Ter minology 70486) was USD$141.47. This reimburse ment fee for CT imaging accounts for costs for cap ital equipment, technical execution of the scan and the professional fee associated with interpretation of the CT scan. 557 Benefits-Harm Assessment: Variable, dependent on the pre-test likelihood of disease, access to CT scan, and findings of physical exam and endoscopy. Value Judgments: A patient’s history of radiation exposure and preferences should be taken into account when deciding to confirm CRS with CT. Nasal endoscopy is another method of confirm ing CRS but is less sensitive and cannot delineate anatomy vital for surgical planning. Policy Level: Recommendation. Intervention: CT scanning is recommended for all patients meeting symptom-based criteria for CRS with a lack of objective clinical findings on ante rior rhinoscopy or nasal endoscopy, or for pre operative planning. It is an option for confirming CRS instead of nasal endoscopy. Allergy Chronic rhinosinusitis is characterized by persistent inflammation of the paranasal sinuses. The pathophysiol ogy of CRS involves both the innate and adaptive immune responses. The immune polarization is based on cytokines produced by different types of T cells and innate lym phoid cells (ILCs). Type 1 immune response is associ ated with IFN- γ production from Th1 and ILC1s, type 2 response is mediated by ILC2s and Th2 cells (associ ated with production of IL-4, IL-5, and IL-13 cytokines), and type 3 is characterized by ILC3s and Th17 cells with production of IL-17 and IL-22. Type 2 inflammation is characteristic of CRSwNP, especially in western countries, while accumulating evidence suggests that the inflamma tory pathogenesis of CRSsNP is heterogeneous and type 1, 2, and 3 pathways are implicated. 61,565 Recent evidence IX.C Pathophysiology of CRSsNP IX.C.1 Contributing Factors for CRSsNP:

Using Imaging to Diagnose CRS Aggregate Grade of Evidence: B (Level 2: 1 study; level 4: 2 studies; Table IX-2). Benefit: CT imaging is more sensitive than nasal endoscopy and obtaining imaging earlier in the