xRead - Nasal Obstruction (September 2024) Full Articles

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International consensus statement on rhinosinusitis

which investigated immunological changes in nasal secre tion of CRSwNP patients during clinical worsening of their CRS symptoms. IL-6, major basic protein, myeloper oxidase, eosinophil-derived neurotoxin (EDN) and uric acid were significantly elevated during AECRS. 1751 In the subset of AERD CRS, salicylates are known to trigger respiratory exacerbations. Philpott et al. suggested that there is an association between symptom exacerbation in response to food products with higher potential sal icylate content, specifically wine, in both CRSsNP and CRSwNP patients. 1755 It has also been described that MCC is impaired in a subgroup of patients with chronic inflammatory mucosal changes. This appears not a result of impaired beat frequency of the cilia themselves, but rather to a lack of coordination of the motor arrays as well as altered viscosity of the mucus blanket caused by the elevated levels of mediators and cellular proteins within. 1756 The prolonged contact time of microorganisms to mucosal surfaces and antigen presenting cells appears to be another factor in the individual susceptibility to acute exacerbations of CRS. Similarly, some of the changes seen in atrophic rhinitis in combination with CRS has been hypothesized to be another predisposing factor for AECRS. 1757 The seasonal variation observed in AECRS has also been investigated. Rank et al. performed a retrospective cohort study of 800 patients, finding that AECRS is more likely to occur during winter months, suggesting a pattern sim ilar to ARS. The authors discussed different hypotheses, including a potential relationship between CRS disease activity and viral infection, air quality, air temperature, air humidity, or indoor allergen/irritant exposure as potential contributing factors. However, Talat et al. argued that sea sonal variations in CRS symptoms may be explained by changes in mood, in the winter, which is associated with increased depressed mood, potentially causing people to feel that CRS has worsened. 1758 XI.C Management of AECRS No evidence-based treatment recommendations for AECRS currently exist. Following the initial ICAR-RS publication, 1 advances have been made toward under standing the etiology, immunological features, and possible risk factors of AECRS. 29,212,1010,1751,1759 Consensus guidelines and expert opinion recommend short-term antibiotics for AECRS, in the setting of a positive culture to provide symptomatic relief. 1,31 The treatment for ARS with the implementation of antibiotics has been extrapolated and applied to AECRS, despite AECRS being recognized as a distinct entity from ARS 210,1760 Antibiotics and treatment of the preexisting CRS are often implemented.

There is only 1 RCT to date that investigated patients with AECRS. Patients were randomized to amoxicillin clavulanic acid for 14 days compared to placebo. The patients were evaluated using the Visual Analogue Scale Severity Scoring Assessment (SSA), and the absolute score difference between day 0 and 14 was calculated. Next, the Lund-Kennedy nasal endoscopy scores were obtained on day 0 and 14, and endoscopy directed middle meatus swabs were collected on day 0 and 14. The SNOT-22 was used to evaluate the QoL after treatment at 12 weeks. The results showed that antibiotics did not change the short-term evo lution of symptoms or nasal endoscopy findings. Despite the amoxicillin-clavulanate providing high coverage (82% of the bacteria cultured), only 29% demonstrated eradica tion of the original organism on day 14. The QoL scores in the antibiotic group when compared to the placebo cohort were similar at 12 weeks. The addition of an antibi otic to intranasal steroid spray did not provide additional benefit. A fundamental limitation of this study was the small sample size. 211 Several non-randomized studies have been reported in the literature. However, it is difficult to draw meaningful conclusions due to the heterogeneous nature of the studies, the adoption of varying criteria for an AECRS diagnosis, diverse clinical endpoints documented, and small sample sizes. Recently, a retrospective chart review of patients with AECRS compared outcomes of culture-directed and non-culture directed (empiric) antibi otic use. Culture-directed therapy for AECRS showed an improvement in Lund-Kennedy endoscopy scores long term, but not in the short term. Furthermore, culture directed antibiotics does not improve short or long-term QoL in CRS. 1761 This is in contrast to an earlier study that showed a decreased short-term QoL improvement in the post ESS patients treated with culture inappropriate antibiotics, which is defined as at least 1 cultured organ ism resistant to or not covered by the prescribed post operative antibiotics. In these cases, the antibiotics were not adjusted after culture results were available. However, the decreased QoL was no longer apparent at 6 months in this study. 1762 Overall, it is difficult to draw any com parisons, as this cohort represented patients treated with antibiotics post ESS, who may not meet ICAR-RS defini tion of AECRS. 1 In summary, clinical studies for the management AECRS are still lacking and further high-quality studies are needed in this area (Table XI-1). Because of the paucity of evidence, no recommendation is currently possible. XI.D Complications of AECRS Data on orbital, osseous, and intracranial complications related to AECRS are scarce, but are usually related to