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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acknowledged but the authors felt there is a balance of benefit to harm and recommend oral corticosteroids as an option. Young 2012 1092 reported on 80 patients with CRS, 28 of whom also had nasal polyps, treated with 3 weeks of oral antibiotics, a prednisone taper, topical budesonide spray (200 μ g to each nostril BID) and saline washes. Patient symptoms were assessed via visual analog scale before and 3 months after starting therapy. Results did not specify response in patients with or without polyps, how ever 30 patients reported sufficient improvement such that surgery was not offered. The presence of polyps was not found to be a predictive factor for the need for surgery. Lal and Hwang 2011 1093 performed a systematic review of corticosteroid use in CRSsNP patients. They included 30 studies in their review, most of which were level 4 or 5 evi dence. They identified no RCTs and no studies evaluating corticosteroids as a single therapeutic agent for CRSsNP. The single level 3 study included addressed the use in children. Lal and Hwang emphasized the widespread use despite the paucity of data on corticosteroid and encour aged more research be done. Lal 2009 1094 reported on 145 patients, 82 of which were CRSsNP. All patients received 4 weeks of antibiotics, a 12 day corticosteroid taper, intranasal corticosteroid sprays, topical intranasal decongestant spray, and saline irriga tions. Post-treatment, patients were followed for a mini mum of 8 weeks. Of the CRSsNP cohort, 55% of patients were “successfully” treated, defined as complete reso lution of symptoms. Forty-five percent “failed” medical therapy, defined as persistent symptoms, and 22 (31%) remained symptomatic enough to elect to pursue surgery. Combined therapy with oral corticosteroids, antibiotics and intranasal corticosteroid spray together did not allow assessment of benefit due to oral corticosteroids alone. Hessler 2007 1095 prospectively followed CRS patients using the SNOT-20 + 1 (Sino-Nasal Outcomes Test-20 plus olfaction). Fifty of the patients that completed the study were CRSsNP. Patients were treated by a combination of medical therapy (antibiotics, oral cor ticosteroids, intranasal steroids, anti-histamines, anti leukotrienes, herbal medications, saline) without a univer sal treatment algorithm. A non-significant improvement in the SNOT-20 + 1 scores was found in patients using pred nisone for ≥ 11 days ( p = 0.29). Subramanian 2002 1096 reported on 40 patients (23 CRSsNP) treated with a 10-day prednisone taper, 4-8 weeks of antibiotics, saline irrigations, and topical intranasal cor ticosteroid sprays. They reported significant improvements in symptom scores and Lund-Mackay CT scores post treatment ( p = 0.0005); however no specifics were pro vided as to the timing of the post-treatment CT or symp toms scoring in these patients. Additionally, there was no

way to determine the benefit from each component of the therapy. Ikeda1995 1097 evaluated the effect of oral corticosteroids alone on CRS symptoms. Twelve patients with CRSsNP based on nasal endoscopy and imaging, who had failed top ical intranasal steroids, underwent olfactory testing before and after treatment with a 10-14 day taper of prednisone. The authors found significant improvements in both detec tion and recognition thresholds following the prednisone course ( p < 0.05, < 0.01, respectively). More recent data confirms what has been assumed in that corticosteroid use is associated with increased dis ease severity in CRSsNP. Yamasaki and colleagues evalu ated CRSsNP patients and noted that when evaluated over a 12 months period, increased corticosteroid use reflected worseQoL. 28 Despite the common use of oral corticosteroids for CRSsNP, high level evidence to support their use is lack ing, even as part of a multi-drug regimen. Higher doses are associated with more side effects and though the cost of oral corticosteroids is low, potential costs due to adverse effects must be considered. 1098,1099 Given the potential risks of systemic corticosteroids, higher quality evidence supporting the use of steroids in CRSsNP patients is cru cial to balance these risks. There are no current studies evaluating the benefit of oral corticosteroids in the peri-operative period, represent ing a large gap in evidence and a potential area for future study. Oral Corticosteroids for CRSsNP Aggregate Quality of Evidence: C (Level 2: 2 stud ies; level 4: 6 studies; Table IX-28). Benefit: Subjective improvement in patient symp toms associated with CRS, objective improvement in imaging. May avoid need for surgery in some patients. Harm: Risks of corticosteroids are well known (see Table II-1). Optimal duration and dosage have not yet been studied. Cost: Low. Benefits-Harm Assessment: Perceived balance of benefit to harm, but not objectively assessed ade quately. Value Judgments: Improvement in patient symp toms is important. Recommendation Level: Option. Intervention: The use of oral corticosteroid in CRSsNP is an option and should be individualized based on patient preference and co-morbidities.