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.

X.D.13 Management of CRSwNP: Topical Alternative Therapies X.D.13.a. Topical Alternative Therapies for CRSwNP: Surfactants Because of limited data, CRSsNP and CRSwNP are com bined in Section IX.D.12.a . X.D.13.b. Topical Alternative Therapies for CRSwNP: Manuka Honey Because of limited data, CRSsNP and CRSwNP are com bined in Section IX.D.12.b . X.D.13.c. Topical Alternative Therapies for CRSwNP: Xylitol Because of limited data, CRSsNP and CRSwNP are com bined in Section IX.D.12.c . X.D.13.d. Topical Alternative Therapies for CRSwNP: Colloidal Silver Because of limited data, CRSsNP and CRSwNP are com bined in Section IX.D.12.d . X.D.13.e. Topical Alternative Therapies for CRSwNP Furosemide The recurrence of edematous nasal polyps after ESS is difficult to control. Investigators have hypothesized that using a topical diuretic, such as furosemide, could reduce recrudescence of this disease by improving edematous infiltrate. To this end, topical furosemide delivered nasally was able to prevent experimentally induced rhinitis within a patient cohort in Italy compared to controls. 1661 Passali et al ., supplemented these findings in 2 sub sequent randomized, non-placebo controlled trials. The authors explored the efficacy of intranasal furosemide in preventing relapse of nasal polyposis for up to 6 years. 1566,1662–1664 In these studies, the experimental group was comprised of patents having undergone recent ESS that were provided furosemide post-operatively for 1 month. Each patient received 2 sprays in each nostril every day for 30 days; the dose consisted of 50 ug per puff of furosemide diluted in physiological solution. The con trol group consisted of no treatment while a third group was treated with the intranasal corticosteroid, mometa sone. Only 17.5% of patients treated with furosemide had relapses, compared with 24.2% in the mometasone group and 30.0% in the untreated group. 1566,1663 Thus, Passali et al. demonstrated that topical nasal furosemide started post-ESS significantly reduced the recurrence of nasal polyps over INCS (mometasone) or no treatment. Over 13 years later a placebo-controlled clinical trial was carried out in Iran by Hashemian et al. The investiga

tors performed a triple blind, randomized-controlled study comparing topical furosemide to a placebo nasal spray in the setting of INCS (fluticasone) use. 1664 Prior to surgery, all patients were treated with 30 mg of prednisolone, 400 mg cefixime, and flucticasone 2 puffs twice a day for 10 days. After surgery, both groups received 400 mg of oral cefixime for 10 days and resumed their INCS. Addition ally, the intervention group received 2 puffs twice daily (ie, 300 μ g per day) of topical furosemide for 2 months, while the control group received a placebo spray. The pri mary endpoint was nasal polyposis as measured by the Meltzer endoscopic grading scale, 1665 CT, SNOT-22 and VAS pain scale. These outcomes were measured 6 months after the intervention, demonstrating a reduction in poly posis across both groups. This reduction, however, was substantially greater in the furosemide group compared to the placebo group. The grade of polyps was 0 in 79% of the patients in the furosemide group (n = 33) compared with 38% in the placebo group (n = 16). Furthermore, the effects of topical furosemide vs placebo on the severity of polypo sis were significantly lower in the furosemide group based on SNOT-22 scoring (difference, 8.05; 95% CI, 3.24-12.85) and VAS (difference, 0.81; 95% CI, 0.22-1.39), but not sig nificantly different based on CT scan scoring (difference, 2.52; 95% CI, − 0.35 to 5.39). Finally, adverse events were nearly non-existent in both groups. There was 1 minor complaint of nasal irritation, 2 reports of constipation, and 1 reported headache in the furosemide group, while the placebo group similarly demonstrated 1 complaint of nasal irritation and 2 reported headaches. The authors suggested that furosemide is a safe and effective topical therapeu tic agent in reducing severity of nasal polyposis following ESS. 1666 There are several important limitations to these stud ies. Neither Hashemian et al. nor Passali et al. 1566 reported on the prevalence of asthma or aspirin intolerance in their cohort of patients with CRSwNP. Hashemian et al. did not document the type or extent of “sinus surgery,” 1664 whereas Passali et al. divided procedure type into endoscopic polypectomy plus anterior ethmoidectomy (n = 95), endoscopic polypectomy plus anteroposterior eth moidectomy (49) 1566,1663 and endoscopic polypectomy (n = 26). 1566 Hashemian et al. demonstrated no significant difference in the grade of polyposis prior to intervention, whereas Passali et al. 1566 stated that “the severity of dis ease before surgery was similar” in the control and inter vention groups. 1566,1663 Nevertheless, post surgical severity of recurrence of polyposis by Passali et al. was divided by staging constructed by the authors and compared across groups; interestingly the placebo group, which had the greatest recurrence, had significantly greater amount of stage 3 polyposis. 1566 Hashemian et al. reported that after intervention, 79% of the patients in the furosemide group