xRead - Nasal Obstruction (September 2024) Full Articles

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Orlandi et al.

long term through improved access of topicals. 1141 ESS improves delivery of saline irrigations to address hyper secretory mucin, compensates for impaired ciliary func tion, and facilitates delivery of pharmaceutical agents, all of which are goals of topical management of CRSsNP. The Influence of Sinus Surgery. Numerous studies have examined the effect of sinus surgery on the distribu tion of topical therapies in the nose and sinuses in both CRSwNP and CRSsNP. 1259 Surgical interventions ranged from sinus ostium dilation to procedures that completely remodel the paranasal anatomy. 1263 Unoperated sinuses appear to receive little topical therapy, with more exten sive procedures resulting in increasing distribution in general. 1134,1264–1266 Specifically, a minimum of 4-5 mm ostial size is required to allow sinus penetration with high volume irrigators. 1134 Standard sinus surgery increases dis tribution of topical therapies to all sinuses, but has no impact upon nasal cavity delivery. 1265,1266 The removal of partitions in sinus surgery also improves the penetration of second generation topical spray treatments. 1267–1269 While there are both direct and indirect costs surrounding surgi cal intervention, there is a preponderance of benefit over harm to improve delivery of local topical therapies and avoid systemic therapies. 1259 The largest benefit with ESS in CRSsNP is that penetration of topical therapy is greatly enhanced post-ESS. Delivery Device. Delivery appears to be best achieved with large volume devices. 1134 Previous studies have shown that low-volume devices do not reliably penetrate the sinuses, although delivery into the nasal cavity has been demonstrated. High-volume devices ( > 60 mL, but gener ally > 100 mL) have been found to improve delivery into the sinuses. 1258,1270 The definition of “high-volume” is some what arbitrary but clinical evidence suggests it may assist with both mechanical cleaning or lavage and drug delivery. High-volume devices can unfortunately carry unwanted side effects with eustachian tube dysfunction and local irri tation being reported in up to one fourth of patients. How ever, these are often mild and compliance is high. 1271 First generation, low-volume devices such as drops, sprays, and nebulizers are an acceptable alternative if nasal cavity or limited sinus delivery is needed, but should not play a sig nificant role in the management of CRSsNP as they do not reliably reach within the sinuses and provide no mech anism for lavage. However, second generation systems using pulsating aerosols or exhalation delivery systems do appear to provide significant deposition of drug to oper ated sinuses, but do not provide the additional benefit of lavage. 1267–1269,1272–1278 Head Positioning. Head position improves delivery in the previously operated patient, especially for low vol ume devices. 1260,1261 Very limited sinus delivery occurs in the unoperated patient regardless of head position.

There were no studies found on the efficacy of capsaicin in CRSsNP, nor has any comparison been made between the efficacy of topical capsaicin and other medical man agement for CRS, such as topical steroids. Given that it has shown some benefit in limited studies and is well tolerated with no long term side effects shown, 1247 itmay be an option as an adjunct in CRS treatment. Capsaicin for CRS Aggregate Grade of Evidence: C (Level 2: 1 study, Level 3: 1 study, Level 4: 1 study; Table IX-43). Benefit: Improvement in subjective symptoms and objective findings in CRSwNP. No literature eval uating CRSsNP. Harm: Well-tolerated with no long term side effects shown. Cost: Minimal. Benefits-Harm Assessment: Balance of benefits andharm. Value Judgments: Limited studies evaluating cap saicin treatment in CRSwNP and no studies com paring capsaicin to standard CRS treatments. Cap sacin should not replace these treatments, but may be considered as an adjunct. Policy Level: Option. Intervention: Use of topical capsaicin as an adjunct treatment for CRS. IX.D.13 Management of CRSsNP: Influence of Head Position, Device, Surgery, and Nasal Anatomy on Distribution of Topical Medications A previous review by Orlandi et al. 1258 synthesized the find ings of multiple EBRRs regarding CRS which is included in the recommendations of this statement. These EBRRs have evaluated sinus distribution of topical therapies from intranasal delivery as influenced by; surgery, delivery device utilized, head position during delivery, influence of nasal anatomy. The findings of the cumulative stud ies show that surgery followed by high volume delivery devices are critical for effective delivery of topical thera pies within the paranasal sinuses. 1259 t 1077,1085 Head posi tion appears to affect distribution 1260,1261 but neither posi tion nor volume seems to overcome the influence of surgi cal state. 1262 ESS is an important component in the management of medically refractory CRS, both primarily and for the