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International consensus statement on rhinosinusitis

ICAR-RS-2021 document, a few key points should be remembered. First, addition of surgery into the benefit harm assessment, with its own potential benefits, harms, and costs, alters this balance. Second, AMT is typically given as a combination of therapies, and traditional rec ommendations for therapy in CRS address them as single modalities. Third, as a result of the lack of trials of opti mal therapy combinations, the best we can provide at this point are consensus recommendations extrapolated from available evidence. Current recommendations here do not differ from those provided in ICAR-RS-2016. Intranasal Corticosteroid Sprays. Given the favorable balance of benefit to harm for INCS use, there is little debate to include this treatment in AMT protocols. Saline Irrigations. The same is true of saline irrigations. They should be included in AMT protocols. Oral Corticosteroids. The inclusion of a short course of oral corticosteroids should be considered separately for CRSwNP and CRSsNP, based on differing amounts of evi dence and recommendations for each condition. For CRSwNP, the best available evidence and balance of benefits and harm appear to favor a single short course of oral corticosteroids. Section X.D.3 summarizes this evi dence and recommends their use. It should be noted however, that repeated or prolonged trials may not be beneficial. Leung et al.’s economic analysis of poten tial complications demonstrated that a breakeven thresh old favors surgery over medical therapy when CRSwNP patients required oral corticosteroids more than once every 2years. 1615 For CRSsNP, given the generalized lack of evidence and risk of significant adverse events, it is challenging to pro vide a recommendation to include oral corticosteroids in an AMT protocol. The efficacy of oral corticosteroids in CRSsNP is unknown (see Section IX.D.3). Oral Antibiotics. As in the case of oral corticosteroids, it is helpful to differentiate recommendations for CRSwNP and CRSsNP. Antibiotic use in CRSsNP is reviewed in Section IX.D.4, where insufficient evidence is found to recommend for or against their use in the case of nonmacrolide antibiotics. Macrolide antibiotics are found to be an option in CRSsNP. As part of possible AMT, the benefit-harm assessment for antibiotics changes once surgery is in the balance. Antibi otics are therefore recommended for AMT in CRSsNP. Section X.D.4 reviews antibiotic use in CRSwNP and recommends against courses < 3 weeks for non-AECRS. No evidence was found regarding nonmacrolide courses longer than 3 weeks and, as in CRSsNP, macrolides are considered to be an option in CRSwNP. In balancing these potential harms and benefits against those of surgery, antibiotics should be considered an option for AMT in CRSwNP.

There is divergence regarding the choice of antibi otics. North American guidelines advocate the use of culture-directed antibiotics, or in the absence of culture data, a broad-spectrum antibiotic such as amoxicillin clavulanate. In contrast, EPOS bases their recommenda tions on antibiotic-associated anti-inflammatory effects; thus, long-term macrolides are considered optional for patients with CRSsNP. The prior 2012 edition of EPOS included doxycycline as a management option for CRSwNP, however the updated 2020 version no longer recommends this as an option. The ICAR-RS-2016 state ment found insufficient evidence to recommend 1 class of antibiotics over another in an AMT protocol. Surveys of otolaryngologists from around the world (Table XII-6) reveal broad adherence to combination treat ment recommendations. This does not confirm the effec tiveness of such regimens, but does suggest acceptance of published guidelines. Newer surveys are needed that inves tigate “appropriate” medical therapy specifically, and com bination therapies. In summary, the evidence for what should constitute AMT prior to surgical intervention is lacking. Recom mendations are given based on available evidence, but the grade of evidence is D, leading to weak strength of recommendation. Appropriate Medical Therapy Prior to Surgery Aggregate Grade of Evidence: D (Tables XII-5 and XII-6). Benefit: Symptomatic improvement; avoidance of risks and costs of surgical intervention. Harm: Risk of medication adverse events, poten tial for increasing antibiotic resistance (see Table II-1). Cost: Direct cost of medications and management of adverse events. Benefits-Harm Assessment: Differ for particular therapy and clinical scenario. Value Judgments: Perceived lower risk of antibi otic treatment vs risks of surgery, although evi dence has shown a low breakeven threshold for surgery vs oral corticosteroids. Additional evi dence is needed in assessing antibiotic vs surgery benefit-harm balance. Clearly, patient preference plays a large role in the decision to continue med ical therapy or to proceed with surgery. Policy level: Recommendation, though weak based on strength of evidence.