xRead - Nasal Obstruction (September 2024) Full Articles

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Orlandi et al.

XII.B.1.c. When should AMT be deemed to have failed? Failure of AMT has been broadly defined as insufficient symptomatic response to AMT in the presence of con tinued radiological or endoscopic evidence of CRS. How ever, the question of what exactly constitutes certain met ric thresholds in this setting of failure have not been studied specifically. Instead, clinicians have investigated “appropriateness criteria” for surgery, using RAND/UCLA methodology as an attempt to define the transition from AMT to surgical candidacy. 283 This group deemed that in patients with CRSwNP, surgery can be appropriately offered when the Lund-Mackay score is ≥ 1 and a SNOT-22 of ≥ 20 following treatment with INCS (8 weeks duration or greater) and a short course of oral corticosteroids (1-3 weeks duration). The recommendation for CRSsNP is sim ilar, but instead of oral corticosteroids, the panel decided upon a short-course of broad spectrum/culture-directed antibiotics (2-3 weeks duration), or a prolonged course of a low dose anti-inflammatory antibiotic (12 weeks duration or greater). XII.B.1.d. What is the response rate and long-term control rate following MMT/AMT? The response rate to previous trials of MMT varies between 30.4% and 90% (Table XII-9). 1092,1094,1096,1925,1926 Fewer studies are available regarding AMT specifically. A recent study by Speth et al. demonstrated a reduction in sys temic corticosteroid and antibiotic use for patients on AMT (INCS and nasal saline rinses). 1927 It is accepted the CRS has a chronic relapsing course, but the long-term fate following a successful trial of med ical therapy is not well reported. However, the success of continued medical therapy can be used as a proxy for this outcome. A 2017 meta-analysis comparing continued med ical therapy to sinus surgery demonstrated significantly improved QoL and endoscopic scores for patients under going surgery. 1928 XII.B.2 Timing of Sinus Surgery Capacity issues in the UK’s National Health Service, a pub licly funded healthcare system, and pathway restrictions result in many patients having sinus surgery after many years of persistent symptoms; more than 50% of patients have an interval of more than 5 years since the onset of CRS symptoms before their first surgery. In this context, Hopkins et al., studied the impact of timing of surgery on outcomes. Data from both the UK prospective audit of surgery for CRS and UK primary care electronic datasets were analyzed. 95,1917 Patients were classified according to the duration of their CRS until their first surgical

Intervention: For CRSsNP: Appropriate medi cal therapy prior to surgical intervention should include INCS, saline irrigations, and antibiotics. Oral corticosteroids are an option. For CRSwNP : Appropriate medical therapy prior to surgical intervention should include a trial of INCS, saline irrigations, and a single short course of oral corti costeroids. Oral antibiotics are an option. XII.B.1.b. How long should appropriate medical management last? There are no published RCTs addressing the optimal dura tion of AMT, or its individual components when specifi cally used in this setting. A recent meta-analysis demon strated benefit with half-dose macrolide therapy when used for a duration of 24 weeks in patients with CRSsNP, although this effect was seen in a diverse population (presurgical, concurrent ESS, and postsurgical). 1121 Recommendations diverge with respect to guidelines, with European groups allowing for a prolonged course of low-dose macrolides in CRSsNP, while North American groups recommend a longer course than would be pre scribed in ABRS, but up to a maximum of 4 weeks (Table XII-7). This is reflected in clinical practice with 1 in 4 specialists using a course of 6 weeks or more in the UK, compared with less than 1 in 30 amongst US rhinologists (Table XII-8). Duration of Medical Therapy Prior to Surgery Aggregate Grade of Evidence: D (Tables XII-7 and XII-8). Benefit: Symptomatic improvement; avoidance of risks and costs of surgical intervention. Harm: Risks of medication adverse events, poten tial of increasing antibiotic resistance. Cost: Direct cost of medications and management of adverse events. Value Judgments: Low risk of treatment and delay of surgery vs risks of surgery considered in recom mending a 3-4 week trial. Policy Level: Recommendation, though weak based on strength of evidence. Intervention: A trial of 3-4 weeks of AMT should be considered as the minimum.