xRead - Nasal Obstruction (September 2024) Full Articles

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International consensus statement on rhinosinusitis

hyperplasia. 1201 Chronic rhinorrhea or post nasal drip are some of the most troubling and difficult to treat symptoms of this condition. There are few clinical studies of mucolytic agents. Dornase-alfa, which degrades the DNA in mucus that is largely derived from neutrophils, and thiol-derivatives such as N-acetyl cysteine, which target the di-sulphide bridges between mucopolysaccharides, are the most thor oughly investigated mucolytics. 1202,1203 Guaifenesin is readily available and frequently taken by patients trou bled by thick respiratory tract mucus. It is believed to act by stimulating the volume of mucus secretion and reduc ing its viscosity, 1204 so it is not strictly a mucolytic. There are however no clinical studies supporting its efficacy for the treatment of CRS. Agents that remove nasal mucus by sheer force (such as saline lavage) or by acting as a surfac tant are addressed in separate sections of this document. A recent systematic review concluded there is moderate quality evidence to show the benefit of inhaled Dornase alfa, determined by improvements in functional expira tory volume within 1 second (FEV1) and a decrease in pul monary exacerbations, in trials lasting up to 2 years. 1205 A review of the efficacy of Dornase-alpha for non-CF respi ratory disease found no improvement in lung function or QoL in patients with bronchiectasis, but some benefit was seen in patients with severe asthma. 1206,1207 A Cochrane review found no evidence supporting the clinical efficacy of thiol-derivatives such as N acetylcysteine for patients with CF. 1208 Nonetheless, more recent studies have shown that thiol-based agents have not only mucolytic effects but also have anti-inflammatory and anti-bacterial properties, and further research is warranted. 1209 There is a surprising dearth of studies investigating the efficacy of mucolytics for the treatment of CRS. Most of the recent literature describes their use in the treatment of CRS in patients with CF in which topical Dornase-alfa led to some improvement in nasal symptom scores. 1210,1211 Due to insufficient evidence, no recommendation can be given regarding the use of mucolytic agents in either CRSwNP or CRSsNP. The 1 subgroup that may derive some benefit from nebulized Dornase-alpha are patients with CRS secondary to CF. However, the cost-benefit ratio requires further study. Medications Because of limited data, CRSsNP and CRSwNP are com bined in this analysis and recommendations. Phytotherapy, as defined in EPOS 2012, 31 is “the use of plants or herbs to treat diseases.” In spite of the huge IX.D.11 Management of CRS: Herbal

recommendation for the use of probiotics in CRSsNP and CRSwNP is possible at this time.

Probiotics for CRS Aggregate Grade of Evidence: not applicable (Table IX-37).

IX.D.9 Management of CRS: Decongestants Because of limited data, CRSsNP and CRSwNP are com bined in this analysis and recommendations. For CRSsNP, no evidence exists to support the use of topoical or oral decongestants. Surveys report that less than half of otolaryngologists recommend the use of decongestants 1197,1198 Duration of use and development of rebound nasal congestion (rhinitis medicamentosa) is unclear though reported. Given the possible harm of rebound nasal congestion and lack of known benefit, we recommend against the use of decongestants in CRSsNP. For CRSwNP 1 RCT has shown benefit of topical nasal decongestants when used in combination with INCS. 1199 They did not find any patients who developed rhinitis medicamentosa. While there appears to be a balance of benefit and harm, because of the limited amount of evi dence, decongestants are an option when used as an adjunct to INCS in CRSwNP. No recommendation is given for its use as monotherapy.

Decongestants for CRS Aggregate Grade of Evidence: not applicable (Table IX-38).

IX.D.10 Management of CRS: Mucolytics Because of limited data, CRSsNP and CRSwNP are com bined in this analysis and recommendations. CRS is frequently associated with an increase in the volume and viscosity of sinonasal mucus. 1200 The clini cal manifestations of some phenotypes (such as CRS sec ondary to cystic fibrosis) are a direct result of changes in the physical characteristics of the mucus produced. One of the histopathological hallmarks of CRS is mucus gland