xRead - Nasal Obstruction (September 2024) Full Articles

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International consensus statement on rhinosinusitis

success of ESS; 1952 particularly because a bloody field can impair surgical dissection, prolong the length of the proce dure and increase the rate of complications. 1952,1953 There are studies that suggest that the extent of preoperative dis ease may be a predictor for bleeding during ESS. 1954,1955 In order to create an unobscured surgical field, cor ticosteroid and antibiotic treatment are both commonly prescribed as preoperative treatment measures because of their potential to decrease inflammation and vascularity of the sinus mucosa. However, to date there is no uniform consensus on dosage or duration of antibiotics or corticos teroids used preoperatively for CRS. Preoperative Management in CRSsNP XII.C.1.a. Effect of Preoperative Corticosteroids in CRSsNP There are no clinical trials investigating the role of pre operative corticosteroid use in only CRSsNP patients, as most studies are cohorts comprising both CRSsNP and CRSwNP patients (Table XII-1). Albu and colleagues 1953 demonstrated in an RCT that preoperative INCS treat ment for 4 weeks resulted in significantly less intraoper ative blood loss, better surgical field, and shorter oper ation time. Subgroup analysis demonstrated that these effects were also significant in CRSsNP patients. Although a recent meta-analysis also showed similar blood loss reduction, 1956 Tirelli and colleagues 1957 have shown that chronic topical corticosteroid for at least 3 months prior to ESS caused more intraoperative bleeding in both CRSsNP and CRSwNP patients on the Boezaart score. 1958 Collectively, non-chronic topical corticosteroid use as preoperative treatment may lead to a better surgical field. However, there are no studies to evaluate the role of preop erative oral corticosteroid before ESS in CRSsNP, and there are significant known risks with their use. 1959,1960 XII.C.1

Patient Selection and Achieving a Minimally Clinically Important Difference in Sinus Surgery Aggregate Grade of Evidence: B (Level 1: 2 studies; level 2: 1 study; level 3: 11 studies; level 4 studies: 2 studies; Table XII-11). Benefit: Use of baseline disease-specific QoL met rics (eg, SNOT-22 score ≥ 20) as criteria for surgical intervention in CRS patients can help standardize patient selection and improve outcomes by choos ing patients who have a high likelihood of achiev ing an MCID post-op. Harm: Exclusion of patients based on SNOT-22 scores alone who may otherwise benefit from surgery (eg, high symptom-specific burden such as smell loss, loss of productivity, co-morbidities such as asthma, odontogenic sinusitis). Cost: Ignorance of individual specific symptoms or loss of productivity at work if criteria for surgery notmet. Benefits-Harm Assessment: The majority of stud ies suggest a pre-operative SNOT-22 score may be used to predict likelihood of achieving a minimal clinically important difference after ESS with a recommended SNOT22 score ≥ 20, but acknowl edge certain patients with low pre-op SNOT22 may benefit from surgery. Value Judgments: Standardizing patient selection and surgical indications may help improve CRS patient outcomes post-operatively. Policy Level: Option. Intervention: Patient selection for surgical inter vention for CRS with and without NP should take into consideration baseline patient reported symp tom burden. Those with greater symptom burdens have a higher likelihood of achieving an MCID and may benefit from surgery. However, each patient should be considered individually with a shared decision making process between surgeon and patient.

Preoperative Corticosteroids in CRSsNP Aggregate Grade of Evidence: C (Level 1: 1 study, Level 2: 1 study, Level 4: 1 study; Table XII-12). Benefit: Objective decrease in intraoperative bleeding, and potential objective improvement in surgical field and less operation time seen with INCS. Subjective reduction in surgical difficulty. Harm: Possible side effects (see Table II-1). Cost: Low.

XII.C Preoperative Management for Sinus Surgery The primary objective of preoperative management is to create optimal surgical conditions to ensure the best patient outcomes. An unobscured endoscopic view dur ing surgery is one of the most important factors for the