xRead - Nasal Obstruction (September 2024) Full Articles

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Orlandi et al.

TABLE IX-23 Aggregate grades of evidence for occupational and environmental factors Item Explanation Smoking

Level C, multiple case-control and cross-sectional studies identify smoking as a contributing factor for CRS. This is also supported by animal studies. Level C, observational studies identify associations between pollutants and CRS severity and need for treatment. Limitations in prior studies regarding diagnosis and design have been improved in recent studies.

Pollutants

allowing for subgroup analyses. Ideally, accomplishing this will lead to an investment into well-designed and ran domized studies that can then be employed to explore the potential underlying pathogenesis between exposure and disease. IX.D Chronic Rhinosinusitis without Polyps: Management IX.D.1 Management of CRSsNP: Saline (Spray and Irrigation) In an updated search since the ICAR-RS-2016, 14 RCTs, 3 systematic reviews and 1 cohort study were identified. Three RCTs were excluded due to the inclusion of mixed ARS/CRS patients. 439,442,1046 One RCT was excluded due to unusable data. 1047 A Cochrane review 1048 was discussed in the section of CRSwNP as it extracted data from partic ipants with mixed ARS/CRS 442 and CRSwNP. 1049 Finally, the data from 10 RCTs, 2 systematic reviews and 1 cohort were extracted for assessment. To address the duration of saline treatment, 4 studies were evaluated. A study by Heatley et al. 1050 and a sys tematic review by Harvey et al. 1051 assessed disease-specific QoL at 2 weeks and did not show difference between the saline treatment and the control. A cohort study by Perkasa et al. 1052 assessed the outcomes at 6 weeks and showed no difference in QoL between the saline irrigation group and the control. Finally, a randomized trial by Taccariello et al. 1053 evaluated outcomes at 8 weeks, and demon strated significantly greater improvement in the QoL and endoscopy in 2 study groups: nasal saline irrigation and seawater nasal spray, compared to the non-saline group. To address the differential benefits, if any, of isotonic vs hypertonic saline, a systematic review by Kanjanawasee et al. 445 was identified. Pooling the data, a greater bene fit of hypertonic over isotonic saline was revealed (mean difference in total nasal symptoms scores − 0.37; 95% CI, − 0.58, − 0.15). Ural et al. 1054 demonstrated improvement in MCC after 10 days in the group receiving hypertonic saline irrigation, but the improvement was not shown by isotonic saline irrigation treatment. Two RCTs by Berjis et al. 1055 and Culig et al. 1056 evaluated the effects

of tonicity on symptoms score and hypertonic showed better improvement in congestion over isotonic saline solution. An RCT by Nimsakul et al. 1057 studied the effects of tem perature on saline treatment and concluded that warming up saline was not necessary. At 1 hour after the interven tion, MCC improved in both room temperature and heated saline irrigation (40 ◦ C) without a difference between the 2 temperatures. In addition, there were no differences in peak nasal inspiratory flow, nasal volume change, nasal resistance, and symptoms score. There was no adverse event reported. Different devices give different volume and pressure of saline delivery which may impact the penetration of the saline solution into the posterior part of the nasal cavity and postoperative cavity. Pynnonen et al. 441 demonstrated greater improvement on disease-specific QoL and symp tom scores in patients using large volume (240 mL) iso tonic saline irrigation, compared to saline spray. When a large volume (240 mL) of a pot was compared to a medium volume of a bulb syringe (around 60-90 mL), Heatley et al. 1050 demonstrated that both devices improved symptom scores without a difference in patient preference, satisfac tion and bacterial colonization. Taccariello et al. 1053 com pared a medium volume (60 mL) of nasal saline irrigation by cupped hand and seawater nasal spray and found that 60 mL of nasal saline irrigation did not bring greater benefit over seawater spray for QoL score, symptom scores, MCC and rhinomanometry test results. Adverse effects of saline irrigations are minor and quite rare. These include local irritation, nasal burning, nau sea, itching, pain, otalgia, and epistaxis. 445,1051 A higher risk ratio (2.38; 95% CI, 1.05, 5.40) for adverse effects was reported in hypertonic saline use, especially for nasal burn ing and irritation. 445 However, these adverse events sub sided spontaneously and did not affect their high satisfac tion among patients. 442

Nasal Saline for CRSsNP Aggregate Grade of Evidence:

∙ Saline irrigatons ( ≥ 60 mL): B (Level 1: 2 studies, level 2: 1 study; level 3: 4 studies; Table IX-25).