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.

endoscopy scores were seen in both treatment groups, with no significant difference noted between the groups. The lack of a placebo control, and small sample size weakened the quality of this study. The literature examining the efficacy of INCS for CRSsNP is less robust than that of CRSwNP which does limit generalizability of results. Minimal, though consis tent improvements are seen in both surgical and non surgical patients. All included studies utilized spray as a delivery method for INCS. No studies meeting inclusion criteria were iden tified utilizing drops. Intranasal Corticosteroid (Standard Deliv ery) for CRSsNP Aggregate Grade of Evidence: A (Level 1: 3 studies, Level 1: 9 studies; Table IX-26). Benefit: Improved symptom scores, improved endoscopy scores. Harm: Epistaxis, headache (see Table II-1). Cost: Low to moderate (USD$0.61-USD$4.80 per day depending on medication). Benefits-Harm Assessment: Possible mild benefit overharm. Value Judgments: Direct sinus delivery methods showed greater effects on symptom scores, there fore should be considered in more complex cases of CRS or following failure of treatment with sim ple sprays. Policy Level: Option. Intervention: Standard metered dose INCS could be used in treatment of CRSsNP, particularly if pri mary symptoms are that of rhinitis. IX.D.2.b. Topical Corticosteroids: Nonstandard Delivery Penetration of nasal sprays beyond the nasal cavities into the paranasal sinuses has been shown to be limited, par ticularly in patients who have not previously undergone ESS. 1075,1076 This has led to an increased use of novel deliv ery devices to improve corticosteroid deposition, and clin ical outcomes. Five articles addressing the use of corticosteroid sinus irrigations met inclusion criteria, 3 prospective cohort studies and 2 high quality RCTs. In a 12 month follow up study, Harvey et al. compared high dose mometasone spray (2 mg) with a similar dose of large volume mometa sone irrigation in post-operative ESS patients. 1077 Steroid irrigations improved patient reported symptoms, radio

graphic scores and endoscopy appearance as compared to the steroid spray. The study included both CRSwNP (77%) and CRSsNP (33%), limiting generalizability regarding CRSsNP. Tait et al. compared budesonide irrigations with saline alone in patients with primarily CRSsNP adminis tered over 30 days and concluded improved subjective and objective outcomes in the budesonide group with an aver age difference of 7 points on the SNOT-22 and improved endoscopic scores, however the results did not reach sta tistical significance. 1078 Snidvongs et al. 1079 published a prospective cohort of 111 patients, 49 who had a diagnosis of CRSsNP (analyzed separately). Treatment was once daily irrigations of 1 mg budesonide/betamethasone in 240 mL of normal saline in the immediate post-operative period. Significant improvements were seen in SNOT-20 (2.3 + / − 1.1vs1.2 + / − 0.9), symptom (2.5 + / − 1.1vs1.4 + / − 1.0),and Lund-Kennedy endoscopy scores (4.3 + / − 2.0 vs 1.9 + / − 1.6). Two smaller studies were published by Sachanandani et al. 1080 and Steinke et al., 1081 of 9 and 8 patients respec tively. Improvements in disease specific QoL (SNOT-20), symptom and endoscopy scores were shown, but the small patient numbers limits conclusions. There have been con cerns about the potential for increased systemic absorp tion with subsequent adrenal suppression with corticos teroid irrigation use, yet 2 studies have shown no evidence todate. 1082,1083 A novel exhalational delivery device developed using fluticasone has shown promise in case series, 1071,1084,1085 although no comparisons with steroid sprays or topi cal steroid irrigations have been performed. Two single arm, prospective studies included CRSsNP patients. Sher et al. enrolled 603 CRSsNP patients and noted an average improvement in SNOT-22 scores of 23.2. 1084 EXHANCE 12, a 12 month prospective single arm design included 189 CRSsNP patients and noted SNOT-22 scores decreased by an average of 21.1 with improved Lund-Kennedy endoscopy scores. 1085 Using a similar device, Hansen et al. 1071 published a double-blinded RCT of 20 patients using a bi-directional spray device. Patients received a 12 week course of either fluticasone propionate 400 μ g or placebo twice daily. Significant improvements in subjec tive patient symptom scores were seen in the corticosteroid group. Overall RSOM-31 and endoscopy scores showed no statistically significant changes. The main weakness of this study was the small sample size. One article investigated mucosal atomization devices (MAD). Thamboo et al. 1086 randomized 20 patients in an unblinded comparison study to a 12-week course of either 1 mg budesonide via MAD or budesonide irrigations. Clin ically significant improvements in SNOT-22 scores were seen in both arms, although only in the MAD group did this reach statistical significance. Importantly a statisti cally significant difference in stimulated cortisol was seen