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.

Benefits-Harm Assessment: At this time benefit outweighs harm. Value Judgments: Anti-IgE therapy will reduce the circulating levels and improve subjective symp toms in the short term. Policy Level: Option. Intervention: Consider use in difficult to treat AFRS patients with persistent thick mucoid and inflammatory discharge despite topical steroid therapy. X.F Chronic Rhinosinusitis with Nasal Polyps: Complications Complications from CRSwNP can be broadly classified into: (1) erosion and compression of the orbit and skull base, and (2) outflow obstruction with mucocele for mation. Alternatively, these can also be categorized in anatomic terms: (1) orbital complications resulting in loss of vision, proptosis, diplopia, and epiphora and (2) intracranial complications such as meningitis, altered mental status, and other neurologic deficits, including olfactory loss. Although erosion of the lamina papyracea and skull base can occur with longstanding polyp growth, direct compres sion of the orbit and brain is rare. In a series of 82 patients with AERD, 2 patients developed encroachment and sub sequent infections of the lacrimal apparatus, and 2 patients had erosion of the medial orbital wall, leading to orbital cellulitis in one and proptosis in the other. 1743 Reports of intracranial invasion or involvement in the setting of NPs are rare. Typically, orbital and skull base involvement is characterized by smooth expansion without dural or peri orbital invasion. In AFRS substantial involvement of the skull base and lamina papyracea occurs in up to 50% of cases. 1704,1744 The role of gender and ethnicity is unclear, but African American males have been reported to have a higher inci dence of erosion. 1745 Compressive non-infective optic neu ropathy with visual loss is less common (about 4%) but can also occur. 1746 NPs can also cause sinus outflow obstruction, leading to mucocele formation. In 1 study of NP patients, the incidence of mucocele in unoperated CRSwNP cases was 0.6%, while the incidence in surgically treated patients was 2.5/100 patients per year. 1747 The frontoethmoid region was the most commonly affected. Furthermore, patients with AERD were at increased risk. In the aforementioned series of 82 patients with AERD, 3 of the 7 orbital complications

Immunotherapy for AFRS Aggregate Grade of Evidence: N/A (Level 3: 1 study; Table X-32). Benefit: May reduce inflammation and reduce other allergic symptoms. Harm: Risk of local and systemic reactions, includ ing anaphylaxis (rare). Cost: Moderate. Benefits-Harm Assessment: Equal. Value Judgments: Immunotherapy may be an option for patients with AFRS if they also have other allergic symptoms. Policy Level: Option. Intervention: immunotherapy remains a reason able treatment option. X.E.3 AFRS Management: Anti-IgE Given the Type I fungal hypersensitivity and typical extremely elevated serum IgE levels, anti-IgE may repre sent a treatment option for AFRS patients. ICAR-RS-2016 found minimal evidence in this area and made no recom mendations. Since then, 2 studies have been published. Gan et al. 1742 performed a retrospective review on AFRS patients receiving omalizumab. They reported decrease in the use of corticosteroids and antifungals as well as good SNOT22 and endoscopic scores. However, they did not have a comparison arm and results compared to the pre surgical state. Therefore, it is difficult to make any treat ment conclusions. Mostafa et al. 1643 performed a prospec tive single-blind RCT examining 20 patients with AFRS. Patients received 1 dose of omalizumab 150 mg 2 weeks postoperatively or twice daily topical nasal steroids for 6 months. The study revealed significantly lower IgE lev els at 12 weeks in the omalizumab arm. Moreover, there was a decrease in SNOT and TNSS score favoring the oma lizumab arm at 24 weeks. However, as this study only included a 6-month treatment period, it is difficult to deter mine the long-term benefit of using anti-IgE therapy. Anti-IgE for AFRS Aggregate Grade of Evidence: B (Level 2: 1 study; level 4: 1 study; Table X-33). Benefit: Reduce the level of circulating IgE. Harm: Unknown risks of prolonged use of biolog ics. Cost: High.