xRead - Nasal Obstruction (September 2024) Full Articles

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International consensus statement on rhinosinusitis

X.D.14 Management of CRSwNP: Influence of Head Position, Device, Surgery, and Nasal Anatomy on Distribution of Topical Medications Much of the evidence on this topic is evaluated in Sec tion IX.D.13. Topical medication distribution in CRSwNP shares many of the same goals as it does in CRSsNP. Treat ment of CRS is primarily focused on reducing mucosal inflammation, removing bacterial infection or pathologic biofilm, and improving sinonasal function. 490 As such, topical therapies play a large role in both CRSwNP and CRSsNP. However, it is in CRSwNP that the advantages of topical drug delivery, with the potential for higher local drug concentration and reduced exposure to systemic med ications, has the potential to modify the disease condition. ESS is an important component in managing CRSwNP as it provides anatomical modifications to facilitate topi cal access, both initially and long term. 1141 Corticosteroids, either topical or oral, are a proven intervention for the primary management of CRSwNP, which is characterized by continual production of inflammatory mediators and polyp formation. Ensuring effective topical delivery within the paranasal sinus cavity is fundamental to the long-term management of CRSwNP. 1077,1667 Endoscopic sinus surgery plays a significant role in CRSwNP both through direct effects on the mucosa and by facilitating delivery of topical steroids. Indeed, perhaps the greatest benefit of ESS in CRSwNP is improved pene tration of topical therapy in post-ESS patients. Penetration is best accomplished with large volume devices. 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 significant role in the management of CRSwNP as they do not reliably reach within the sinuses and provide no mechanism for lavage. However, second generation systems using pulsating aerosols or exhala tion delivery systems to appear to provide significant deposition of drug to operated sinuses, but do not provide the additional benefit of lavage. 1085,1267–1269,1272–1279,1667 Enabling effective local pharmacologic management in CRSwNP relies on true sinus distribution of topical thera pies. Shifting patients away from reliance on systemic med ications and toward consistent local treatment underlies the success of contemporary CRSwNP therapy. Advantages of topical medical therapy include direct drug delivery to diseased tissue, potential for delivery of higher local drug concentrations, and reduced systemic effects. Current evi dence suggests that optimal topical sinus delivery occurs after surgery and with high volume irrigation and second generation spray devices.

had a polyposis score of 0 compared with 38% in the control group. Finally, Kroflic et al. examined the use of topical furosemide treatment preoperatively to determine sur gical outcomes in patients with CRSwNP. 1666 Topical furosemide was given by inhalation (6.6 mmol/L solu tion) 7 days prior to surgery to 20 patients; this was com pared to a separate cohort of 20 patients who received 7 days of oral steroids. Although polyposis grade was not reported, both groups demonstrated significant improve ment in nasal symptoms and polyposis on endoscopy. Furosemide did not significantly decrease edema across the entire group. However, on subgroup analysis of pre viously un-operated patients, the authors found a signif icant reduction in mucosal edema, which was measured on histopathology as distance from the surface submucous gland. 1666 There was no difference in estimated intraoper ative bleeding between the 2 groups. 1666 Furosemide for CRSwNP Aggregate Grade of Evidence: B (Level 2: 3 studies, Level 3: 1 study; Table X-28). Benefit: Reduced recurrence of nasal polyps fol lowing ESS over placebo nasal spray. Harm: Topical furosemide appears safe. However, no pharmokinetic or pharmodynamic studies have been performed to assess systemic safety with nasal delivery. Systemic absorption is unknown and limited clinical experience and long-term use limits applicability. Cost: Low. Benefits-Harm Assessment: Benefits likely bal ances with harm when used on a rotating basis as studied. Value Judgments: After ESS in the presence of ineffective polyp control with INCS spray, the addition of topical furosemide to reduce polyp recurrence appears to outweigh the potential risks. Policy Level: Option. Intervention: Topical furosemide started after ESS and in combination with an INCS may reduce the recurrence of nasal polyps in patients with CRSwNP.

X.D.13.f. Topical Alternative Therapies for CRSwNP: Capsaicin Because of limited data, CRSsNP and CRSwNP are com bined in Section IX.D.12.f.