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.

IX.D.14 Management of CRSsNP: Immune Workup and Treatment Because of limited data, CRSsNP and CRSwNP are com bined in this analysis and recommendations. Tas et al. performed a randomized controlled study using thymic hormone preparation thymostimulin (TP-1) and placebo in a cross-over trial. TP-1 was proven to be effec tive in patients with recurrent CRS who were immunolog ically deficient in cell-mediated immunity. 1280 However, TP-1 was taken off the market and a related therapeutic target, thymosin 1 α (a 28 amino acid peptide isolated from thymosin fraction 5), is under study. 1281 Thymic hormone preparation thymostimulin was shown to be effective and safe in 1 study but it is now not available in the market. Thus, thymostimulin cannot be recommended. There is debate on the role of Ig replacement. Roifman and Gelfand evaluated sinopulmonary disease frequency after high and low dose therapy with IVIG. High dose Ig achieved minimal trough serum IgG levels and decreased symptoms and frequency of major and minor infections. 951 However, after a long-term follow-up of a large cohort of patients with CVID, Quinti et al. found routine Ig admin istration, at a monthly dosage of 400 mg/kg weight of IVIG at intervals ranging between 2 and 3 weeks, was associated with increased prevalence of CRS and bronchiectasis. 951 This was supported by a study from Rose et al. in which the inflammatory cytokines were markedly elevated in nasal lavage which had a discrepancy with serum IgG level. 1282 In a systematic review of 243 patients with activated phosphoinositide 3-kinase delta syndrome, the majority were placed on long-term Ig replacement therapy, with 12.8% ultimately receiving stem cell transplantation. 1283 High dose IVIG was used to treat autoimmune hemolytic anemia and immune thrombocytopenic purpura in 38 (84.4%) patients. 1283 Another review noted that in patients with primary immunodeficiency and CRS, Ig replacement therapy, appears to be most effective when administered at high doses early in the disease course. 1284 Lucuab Fegurgur et al. show that in a subset of patients with CRS with selective IgM deficiency (n = 8), all but 1 patient had resolution of symptoms on high dose IVIG. 1285 Simi larly, Khokar et al. describe 78 adult patients with IgG sub class deficiency who had reduction in infection frequency and antibiotic requirement after treatment with IG, with a mean dose of 436 mg/kg/4 weeks. 947 IG replacement therapy, at various dosing, was found to have a positive impact on the frequency of RS in 31 patients with CVID

However, in the postoperative cavity, sinus delivery is improved with the head down and forward position, although the influence of head position is overcome with high-volume devices, especially to the frontal sinus. 1258,1270 The head down and forward position appears to be opti mal for topical delivery but may be impractical or difficult for those with limited mobility. For high volume devices, proper head position is less critical for solutions to reach the sinuses in the post-operative state, but to reach the sphenoid sinus consistently, patients will often need to irri gate in the nose-to-ceiling position. 1278,1279 Local Nasal Anatomy. While it may seem axiomatic that correcting local septal and turbinate deformities would enhance local drug delivery, there is little evidence to sup port this assumption, although in second generation spray devices, it is most likely important. 1277 In evaluation of the potential benefits and harms of altering nasal anatomy and/or using longstanding decongestants to improve topi cal medication delivery, the evidence-based review did not find significant data supporting this practice. 1259 Despite this, level C evidence supports that high-volume irrigations are able to overcome minor anatomic variations in the nasal cavity and still achieve sinus delivery for those with prior sinus surgery. Nasal cavity delivery with low-volume devices can be overcome with pharmacologic deconges tion or head position but this is of little benefit to patients with CRSsNP in whom mechanical clearance of mucus is a primary goal of the intervention. Nasal surgery or a chronic topical vasoconstrictor use, without documented airflow obstruction, is unproven and increases the risk for harm andcost. Conclusion . The goal of topical therapy in CRSsNP is directed at clearance of mucus and correcting the mucostasis that characterizes this condition. Enabling sinus distribution of topical therapies, primarily corticos teroids, antibiotics and mucolytics, allows effective local pharmacologic management, and is best achieved through use of high-volume irrigations or second-generation spray devices. The mechanical shear force that is provided by high volume irrigations in the post-operative state may be a major factor to manage the mucostasis. Advantages of direct topical medical therapy include the potential for delivering higher local drug concentrations and minimiz ing systemic absorption. Current evidence suggests that optimal topical sinus delivery occurs after surgery and with high volume irrigation and second-generation spray devices.