xRead - Nasal Obstruction (September 2024) Full Articles

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International consensus statement on rhinosinusitis

∙ Saline irrigatons ( < 60 mL): B (Level 1: 2 studies; level 2: 1 study; level 3: 1 study, level 4: 1 study). ∙ Saline sprays: B (Level 2: 2 studies; level 3: 2 studies). ∙ Saline drops: N/A (Level 3: 1 study). Benefit: Improvement in QoL, endoscopic appear ance for CRSsNP, and role in maintenance therapy. Benefit over the control were shown with saline irrigiatons ( ≥ 60 mL) and at 8 weeks duration. Harm: Minor and rare adverse effects. Nasal burn ing and irritation are more reported with hyper tonic irrigation (see Table II-1). Cost: Minimal. Benefits-Harm Assessment: Preponderance of benefit over harm. Value Judgments: Topical management is essen tial for treating a chronic inflammatory disease of the nose and paranasal sinuses. Regimen and delivery method impact the penetration of saline and its ability for mechanical removal of thick mucus. The use of saline irrigation ( ≥ 60 mL) is rec ommended as an adjunct to standard treatment. Saline irrigiatons ( < 60 mL), saline spray and drop show less benefit but could be an alternative. Policy Level: Recommendation. Intervention: Saline nasal irrigation improves symptoms, QoL and nasal endoscopy for patients with CRSsNP. Duration of treatment should be greater than 8 weeks. Hypertonic saline is more effective but may be more irritating than isotonic saline. There is no advantage of heated saline (40 ◦ c) over room temperature saline. Devices with volume greater than 60 mL bring greater benefits. IX.D.2 Management of CRSsNP: Topical Corticosteroids Topical corticosteroids may be delivered using standard sprays or using irrigations and other nonstandard meth ods. These 2 broad delivery methods will be discussed sep arately. IX.D.2.a. Topical Corticosteroids: Standard Delivery (Sprays) INCS have been used extensively in the treatment of CRSsNP, however clinical evidence supporting their use in this patient cohort has been variable both in quality, delivery mechanism and type of corticosteroid. The major ity of studies included mixed populations such as chronic

rhinitis, CRSsNP, and CRSwNP limiting the ability to make strong recommendations for or against the intervention. Variability in clinical and radiographic diagnosis for this diagnostically heterogeneous population is an additional challenge, particularly in trials recruiting from primary care. Finally, newer trials have found more pronounced results comparing novel devices and high-volume irriga tions with both placebo and traditional nasal sprays. Three high quality systematic reviews with meta analyses address INCS in CRSsNP. Kalish et al. 1061 in 2009 combined 5 trials reporting overall response to treatment. 504,1062–1065 When evaluated as a single group, there was no benefit found, with significant variabil ity among studies noted (aggregate data: RR = 0.75; 95% CI, 0.50-1.10, p = 0.14). It is worth noting that 3 trials 1062,1063,1066 reported change in symptom scores, and showed a standardized mean difference favoring INCS use (RR, 0.63; 95% CI, 0.16-1.09, p = 0.009). In a second high quality review, Snidvongs et al. 1067 published a Cochrane review in 2011 that combined 5 trials 1062,1063,1066,1068,1069 reporting symptom scores in patients treated with INCS compared to placebo. A significant improvement in stan dardized mean difference of symptom scores was found in the treatment arm (SMD = − 0.37; 95% CI, − 0.60 to − 0.13, p = 0.002), with no evidence of significant hetero geneity. Two of the studies administered steroids following sinus surgery, 1066,1068 1 study included only surgically naïve patients, 1069 1 included a mixed population of surgical and non surgical patients 1062 and the remaining study did not specify surgical status of the included patients. 1063 Four trials 1062,1063,1070,1071 in patients with CRSsNP were identi fied and concluded there was little effect of INCS on HRQL and disease severity with a small improvement seen in a general health subscale indicating a limited role for INCS. Since the Kalish and Snidvongs systemic reviews, 2 addi tional randomized trials were published showing mixed results. Mosges et al. 1070 randomized 60 CRSsNP patients in a double-blinded study to receive either mometasone furoate spray 200 μ g BID or placebo for 16 weeks. Less than 10% of included patients had a history of sinus surgery, and none had surgery within 6 months leading up to the start of the study. Total symptom scores improved in both groups during treatment, with no significant difference seen ( − 7.27vs − 5.35, p = 0.51). A significant improvement was seen in endoscopy scores in the treatment arm ( p = 0.002). The authors noted their small sample size may limit the ability to detect a significant difference, and no power calculation was reported. Zeng et al. 1072 randomized 43 patients with no history of sinus surgery in a single-blinded treatment comparison study to receive either mometasone furoate 200 μ g daily or clarithromycin 250 mg daily for 12 weeks. Significant improvements in both symptom and