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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medications in AERD patients. 1687 Parikh et al. have reported on the use of daily topical nasal lysine-aspirin in aspirin-sensitive patients. Interestingly, with only 75 mg applied intranasally, this study provided high level evi dence for alterations of cysLT receptors and weaker evi dence levels for improved clinical outcomes using this regimen. 1671,1688 Additional systematic reviews have been performed with aggregate evidence to assess the safety and efficacy of desensitization. A systematic review and meta-analysis by Chu et al. in 2019 included evidence from 5 randomized controlled trials and 233 patients showed moderate certainty evidence that desensitization and daily aspirin therapy improves symptom scores and QoL. However, the evidence from this study also suggested with high certainty that adverse event rates including gastritis were increased with desensitization. 1689 Another very large systematic review of 24 studies reported that 23/24 of these studies recommended desensitization based on improvements in multiple parameters including nasal symptoms, corticosteroid use, revision surgery rate, and polyp scores, although no assessment of adverse events was performed. 1690 In future trials, potential differences in the clinical bene fits of low-dose vs high-dose daily aspirin should be evalu ated by randomized double-blind prospective dose-finding trials as the interpretation of the previously reported data in the literature are limited by their open study design. Such trials are needed in an effort to find agreement on the lowest effective and safe dosing. Aspirin Desensitization for AERD Aggregate Grade of Evidence: A (Level 1: 2 stud ies; level 2: 10 studies; level 3: 3 studies; level 4: 12 studies; Table X-29). Benefit: Reduced polyp re-formation after surgery, increased QoL and reduced CRS-symptoms in AERD. Reduced need for systemic corticosteroids. Reduced number of surgical revisions. Harm: Gastrointestinal bleeding, increased mor bidity in renal disease and blood clotting issues at high maintenance doses. Less than 3% gastroin testinal side effects with low-dose protocols. Cost: 1) Initial cost of desensitization. 2) Mini mal direct costs for daily aspirin doses. 3) Costs potentially reduced if future surgical interventions reduced, less medication use, fewer physician vis its for asthma. Benefits-Harm Assessment: Clear benefit over harm.

Value Judgments: Aspirin desensitization fol lowed by daily aspirin therapy is 1 of the very few disease-modifying medical treatment options

available for patients with AERD. Policy Level: Recommendation.

Intervention: Aspirin desensitization should be considered in AERD patients after surgical removal of NPs to prevent recurrence.

X.E Allergic Fungal Rhinosinusitis X.E.1 AFRS Pathophysiology AFRS is a noninvasive, eosinophilic subtype of CRSwNP defined by specific characteristics. 1691–1693 The most widely accepted diagnostic criteria for AFRS was proposed by Bent and Kuhn and includes: (1) type I hypersensitiv ity, (2) nasal polyposis, (3) characteristic CT findings, (4) eosinophilic mucus without fungal invasion, and (5) pos itive fungal stain. 1694 These criteria help to differentiate AFRS from other subtypes of CRSwNP. The differences in the clinical presentation of AFRS from other CRSwNP subtypes support likely unique molecular pathways contributing to its pathophysiology. AFRS patients are younger, atopic, and can present with unilateral disease. 1692,1693,1695,1696 Associations with lower socioeconomic status and African American ethnicity have been identified with a male predominance of 1.5 2.6:1. 1697–1700 In addition, AFRS almost exclusively presents in geographic regions characterized by warm temperatures and high humidity conducive to fungal growth. 1701 Clini cally, AFRS tends to present with severe CT findings and significant polyp burden, yet patients can report mini mal sinus symptoms. 1693,1702 Characteristic CT scan find ings include expanded paranasal sinus filled with high density material and often bony erosion of sinus walls. 1703 Although uncommon in other CRSwNP subtypes, greater than 30% of AFRS patients have skull base or orbital expansion/erosion, 1703–1707 potentially causing visual dis turbance or facial deformity. 1691,1693 Vitamin D3 levels are also decreased in CRSwNP and AFRS, with levels inversely correlating with bone erosion. 18 Finally, the prevalence of asthma in AFRS patients has been reported by many groups to be lower than other CRSwNP subtypes (23% vs 48-80%). 166,167,1697,1708 Within the expanded sinuses in AFRS is eosinophilic mucin characterized as thick and tenacious, and con sists of necrotic and degranulating eosinophils in a background of mucin, Charcot-Leyden crystals, and