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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International consensus statement on rhinosinusitis

Only 1 study compared corticosteroid irrigations to standard delivery techniques in a double-blind placebo controlled trial involving 44 patients which evaluated the use of 240 mL corticosteroid irrigations vs simple nasal cor ticosteroid spray. 1077 All patients underwent similar ESS and post-operatively received 2 mg of mometasone daily via nasal spray or large volume irrigation (240 mL) for 12 months. Every participant in the trial was given both a nasal spray device as well as an irrigation device and were instructed to use the irrigation followed by the spray but were blinded to which device contained the corticosteroid. Patients received post-operative antibiotics and systemic corticosteroids but none of these were given longer than 3 weeks. They were evaluated at 12 months and while both groups improved greatly from either intervention, it was the corticosteroid irrigation group that had larger improve ment in nasal blockage (-69.91 ± 29.37 vs − 36.12 ± 42.94; p = 0.029), Lund-Mackay scores (LMS) (-12.07 ± 4.43 vs − 7.39 ± 6.94; p = 0.031), and modified Lund-Kennedy scores (mLK) (7.33 ± 11.55 vs 21.78 ± 23.37; p = 0.018). Importantly, at the 12-month endpoint, there were several patients that had begun to deteriorate in the nasal spray steroid group and the overall 12-month symptom VAS was better in the nasal irrigation steroid group. One other study compared corticosteroid irrigations in addition to routine care in the management of polypoid AFRS and demon strated clinically meaningful benefits in symptoms, endo scopic scores and recurrence rate 1587 but was not blinded nor placebo controlled. In the remaining 3 RCTs, corticosteroid irrigations were compared to saline alone. 1078,1586,1588 Huang et al. 1586 per formed their study over a 3-month period post complete ESS where patients received 1 mg budesonide or saline. The benefit seen in each group was significant but similar between groups. Tait et al. 1078 also performed a double blind placebo controlled trial comparing budesonide irri gations vs saline irrigations in 61 patients. All patients used 240 mL irrigation once daily and were evaluated after 30 days with SNOT-22, LK grading, and a modification of the Clinical Global Impressions scale. The budesonide group had improved scores, but these measures did not reach clinical significance over saline. Rawal et al. performed a single blind randomized controlled trial with 50 polyp patients comparing normal saline irrigations (60 mL) to normal saline plus budesonide (0.06 mg/60 mL twice daily for a total daily dose of 0.12 mg/d). All patients underwent ESS and last follow-up was variable between 3 to 6 months after surgery. However, the specifics of the surgical proce dures performed were not reported. All patients were given a 12-day corticosteroid taper following surgery. Patient results were evaluated with QoL (SNOT22, RSOM31 [Rhinosinusitis Outcomes Measurement Test], RSDI [Rhinosinusitis Disability Index]) and olfaction (UPSIT

Intranasal Corticosteroids (Standard Deliv ery) for CRSwNP Aggregate Grade of Evidence: A (Level 1: 2 studies, Level 2: 5 studies; Table X-18). Benefit: Improved symptoms, endoscopic appear ances, polyp size, and QoL, objective tests of olfac tion, airway analysis (NPIF) and polyp recurrence but the magnitude of the clinical effect is small. Harm: Epistaxis, nasal irritation, headache (see Table II-1). Cost: Moderate depending on preparation. Benefits-Harm Assessment: Benefit outweighs harm. Value Judgments: Twice daily dosing should be considered if the magnitude of observed clinical benefit is limited. Policy Level: INCS: Strong Recommendation. Twice Daily Dosing: Option. High concentration/dose: No recommendation due to mixed and insufficient evidence. Intervention: Topical nasal corticosteroids (sprays or drops) are recommended for CRSwNP before or after sinus surgery. Consideration for twice daily dosing or additional short-term corticos teroid drop if initial treatment effect is small. X.D.2.b. Topical Corticosteroids: Nonstandard Delivery There has been a significant shift in the evidence base for topical corticosteroid delivery via techniques other than standard sprays and drops in the management of CRSwNP. In this summary, interventions that focused on the peri operative management of ESS were not included. Inter ventions such as implants, stents, mometasone soaked cellulose foam, triamcinolone soaked sponge and other therapies designed to be placed at the time of surgery are reviewed elsewhere in this consensus statement (Sec tion XII.D.7). Corticosteroid Irrigations. There were 5 randomized con trolled studies 1077,1078,1586–1588 that assessed the use of corti costeroid irrigations since 2014 and a meta-analysis, which due to publication timing did not include most of these studies 1589 . Previously identified confounding factors such the delivery technique, volume, and surgical state of the patients in these trials were addressed since 2014 but con tinue to produce heterogeneity. There are published com prehensive narrative reviews of corticosteroid irrigations in both the otolaryngology 1089 and allergy literature. 1590