xRead - Nasal Obstruction (September 2024) Full Articles

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International consensus statement on rhinosinusitis

in the MAD group at 60 days, although this did not reach threshold for diagnosis of adrenal suppression. A long term safety follow up in 2017 1087 raised some concerns about elevated intraocular pressure and adrenal suppres sion with this device and recommended screening with long-term use. Finally, 3 studies have examined the role of sinonasal catheters for steroid delivery. 1066,1069,1088 All studies were small with 20, 13, and 25 patients, respectively. Furukido et al. 1069 reported a single-blinded RCT utilizing the YAMIK sinus catheter. Twenty-five patients were treated with a one-month course of weekly irrigations of betamethasone (0.4 mg/mL) or saline. No difference was seen between treatment groups in symptoms or sinus x-ray scores. Lavi gne et al. 1066 randomized 20 patients to receive either 256 μ g budesonide or placebo via a unilaterally placed max illary sinus antrostomy tubes (MAST) for 3 weeks. The budesonide treatment group had a significant improve ment in clinical scores, as well as significant reductions in tissue biopsy eosinophil counts and IL-4 and IL-5 lev els compared with placebo. Moshaver et al. 1088 reported a case series of 13 patients who had bilateral MAST tube placement and daily irrigations of tobramycin (10 mL of 0.8 mg/mL) and 0.4 mL of a mixture containing ciprofloxacin (2 mg/mL) and hydrocortisone (10 mg/mL). Significant improvements in both SNOT-16 and endoscopy scores were seen and maintained at 16-week follow-up. Given the invasive nature of catheter placement with epistaxis as a common side effect and the limited clinical uptake of these methods, the authors would not recommend their use in clinical practice. Intranasal Corticosteroids (Nonstandard Delivery) for CRSsNP Aggregate Grade of Evidence: Irrigations – A (Level 1: 1 study, Level 2: 5 studies; level 3: 1 study; level 4: 3 studies), Atomizer/exhalational device – C (Level 2: 2 studies; level 3: 2 studies), Irrigation tubes – C (Level 2: 2 studies, Level 4: 1 study; Table IX-27). Benefit: Irrigations – Improvement in HR-QoL, subjective symptom scores and endoscopic appearance in postoperative patients. Atom izer/exhalational device – Improved subjective symptom scores and endoscopy scores. Harm: Irrigations – minor (epistaxis, nasal irrita tion). No evidence of adrenal suppression using irrigation delivery. Atomizer devices – possible adrenal suppression; MAST – invasive insertion, epistaxis. See Table II-1.

Cost: Moderate to high (from USD$2.50 per day for budesonide respules, unknown costs of atom ization/exhalational devices. MAST tube USD$100 for each tube + variable costs associated with insertion). Benefits-Harm Assessment: Irrigations – Prepon derance of benefit over harm, with increased cost compared to nasal sprays. Atomizer/exhalational device – Possible benefit, possible long-term harm. MAST – Limited evidence balancing harm and benefit. Value Judgments: Evidence for irrigations good with best evidence in post-operative patients. Policy Level: Irrigations – Recommended in postoperative patients, option for use in non surgical/medical therapy patients. Atomiz ers/exhalational devices - Option. MAST – No recommendation. Intervention: Corticosteroid nasal irrigations are recommended in CRSsNP in postop erative patients and an option in nonsur gical/medical therapy patients. The use of atomizers/exhalational devices is an option. No recommendation for MAST. IX.D.3 Management of CRSsNP: Oral Corticosteroids There are 6, level 4 studies and 2, level 2 studies that evaluate the benefit of oral corticosteroids in patients with CRSsNP. All include oral corticosteroids with other interventions including oral antibiotics, topical INCS, and saline irrigations. Four of the 6 include both CRSwNP and CRSsNP patients. The 2 groups are separated as much as possible in the following summaries. Liu 2018 1090 described 100 patients diagnosed with CRSsNP, treated either with oral antibiotics, oral corti costeroids or both. The corticosteroid agents used were either methylprednisolone for 6 days or prednisone for 20 days. All 3 groups showed significant post-treatment improvements of their Lund-Mackay scores ( p ≤ 0.002). All 3 groups showed improvement in symptoms to varying degrees but this was not analyzed statistically. The num ber of patients ultimately requiring surgery was not signif icantly different among the 3 groups. Poetker 2013 1091 performed an iterative systematic review of corticosteroid use in CRS and evaluated 4 level 4 studies. They report data showing both subjective and objective improvements in CRSsNP patients treated with oral corticosteroids. The risks of corticosteroids are