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

438

International consensus statement on rhinosinusitis

and SAD 931 An open-label, prospective multi-center sin gle arm study which was conducted to assess the safety of a highly purified 10% polyvalent immunoglobulin prepa ration dosed from 0.22 to 0.97 gm/kg every 3 to 4 weeks for 12 months, and was well tolerated by patients with primary immunodeficiency. 1286 The benefits of Ig replace ment were discussed in several review articles as well, including decreasing the rate of sinopulmonary infections and acute hospitalizations in patients with CVID. 1287–1289 The effect of IG replacement is controversial and this is a challenging issue on which to provide guidelines, because IVIG carries the risk of significant side effects (petechial bleeding, fatigue, headache, nausea, dyspnea, tachycardia, abdominal pain, and even anaphylactoid reaction) and can be expensive. The long-term benefit of IG replacement in controlling CRS is less encouraging. Still, Ig replacement is an approved treatment for CVID as it can prevent pul monary disease and complications from CRS, such as sub periosteal and intracranial abscesses, meningitis, and sep sis. The use of IG replacement in other immune disorders including SAD or IgG subclass deficiencies remains con troversial. Patients on immunosuppressive therapy are another important sub-group of patients with immune dysregu lation. Papagiannopoulos et al. describe 15 patients with CRS on immunotherapy and compare their histopathol ogy variables and treatment outcomes with other patients with CRSwNP and CRSsNP. 1290 CRS on immunotherapy patients exhibit histopathology and disease severity similar to CRSsNP. The authors note that, in the appropriate clini cal context, discontinuing or changing a patient’s immuno suppressive regimen may be a valid treatment option. 1290 Wang et al. present 28 patients on a TNF- α inhibitor diag nosed with RS. These patients had mainly CRSsNP and the authors suggest modification of anti-TNF- α therapy should be considered as an option in the medical management of these patients. 1291 ESS results were compared in CRS with immune dys function or autoimmune disease vs controls. The results were similar in both groups, which suggests that patients with immune dysfunction may experience similar benefit from ESS. 954 In a review of 21 patients with immunod eficiency undergoing ESS, the revision rate was 14%. 1292 Mazza et al. report in their systematic review that patients with immunodeficiency experience similar benefit after ESS when compared to immunocompetent patients in relation to symptoms and QoL. 1284 ESS may have a similar role as in patients with normal immune function, but a strong indication for surgery is not clear. Larger future studies will be required to confirm the safety and clinical benefit of these studies. Prophylactic antibiotics and early culture-directed antibiotics were also recommended by expert

groups. 947,1281,1289,1293–1296 Yet there are no consensus guidelines on the use of antibiotics in refractory CRS with immunodeficiency. Pimenta et al. report a cross-sectional study of 8 patients with hypogammaglobulinemia in which most received prophylactic antibiotic therapy, however, no therapeutic outcomes were discussed. 930 Prophylactic antibiotics may reduce infections in immun odeficient patients, but, there is an increased concern on antimicrobial resistance and alterations to the sinus microbiome. Early culture-directed antibiotics are theoret ically advisable, but there is a lack of definitive evidence to support this. Overall, since the current studies were small in scale and not based on controlled trials, the balance of risk to benefit is unclear (Table IX-44). Complications from CRSsNP can be considered accord ing to anatomic location, pathophysiology, clinical course, or disease severity. Although these conditions can be indolent, acute exacerbations can be life-threatening and may require surgery, particularly in immunocompromised patients or those with altered sinus anatomy. The true inci dence of these complications is not well described. Herein, major and minor complications of CRSsNP are reviewed. Major complications of CRSsNP typically occur as a result of worsening infection that extends into the eye, brain and/or lungs. The microbiology of these complica tions differs from that of ARS. 1299 Direct extension of RS into the orbit or chronic inflammatory changes near the orbit may begin with minor signs (eg, preseptal cellulitis) but can rapidly lead to orbital cellulitis/abscess causing enophthalmos, 1300 epiphora, 1301 diplopia, 1302 proptosis, 1303 optic neuropathy 1304,1305 and vision loss. 1306–1308 A recent study reported increased risk of orbital complications in adults, specifically in patients with previous sinus surgery or dehiscence of the lamina papyracea. 464 This study found that older age was the only major risk factor when look ing at both CRSwNP and CRSsNP combined. Invasive fun gal (most often seen in immunocompromised individuals) or bacterial infection along the skull base can lead to an epidural abscess or cavernous sinus thrombosis. 1309 These conditions require prompt diagnosis and often multidisci plinary intervention. The chronic inflammatory response observed in CRSsNP can worsen existing airway hyperre activity, but can also lead to adult-onset asthma. 164 While the paranasal sinuses may act as a reservoir for chronic pulmonary infections, this association has not been well documented. When CRS is present concomitantly with recurrent pneumonia, immunodeficiency should be suspected. IX.E Chronic Rhinosinusitis without Nasal Polyps: Complications