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.

Benefit-Harm Assessment: Preponderance of ben efit over harm in INCS. Unknown for oral corticos teroids. Value Judgment: Improvement in surgical field (less bleeding) is important. Policy level: Recommendation for INCS. No rec ommendation for oral corticosteroids. Intervention: INCS are recommended prior to ESS inCRSsNP. XII.C.1.b. Effect of Preoperative Oral Antibiotics in CRSsNP Similar to INCS, no studies have been identified address ing the preoperative use of systemic antibiotics in only CRSsNP. One study found preoperative antibiotic use led to significantly better SNOT scores but not endoscopic scores, especially in the rhinologic subset. However, the high antibiotic dose group (more than 29 days out of 90 days prior to ESS) was relatively less improved. 1961 Inaddi tion, macrolide therapy was reported effective. 1105,1121,1962 Moreover, several studies in CRSsNP patients have found that short term (9-14 days) use of antibiotics improved clinical symptoms with no significant difference in sev eral types of antibiotics. 1102–1104 Although there has been no trial to directly investigate the effect of preoperative antibiotics on intraoperative ESS conditions, patients with impaired nasal patency, impaired sense of smell and more than 2 nasal symptoms have experienced more intraop erative bleeding and longer surgery time. 1963 Collectively, short term, culture directed oral antibiotic treatment for CRSsNP may be beneficial before surgery, and the disad vantages need to further investigated. 1964 No recommenda tions are given in this regard because of no direct studies. XII.C.2 Preoperative Management in CRSwNP XII.C.2.a. Effect of Preoperative Corticosteroids in CRSwNP Three articles and 1 meta-analysis have investigated the effect of oral corticosteroids on CRSwNP and CRSsNP before ESS. 255,1953,1957,1965 Both Pundir 1965 and Hwang’s 1966 studies found that preoperative corticosteroids signifi cantly decreased intraoperative blood loss, surgery time and improved surgical field during ESS, compared to controls. Furthermore, Hwang and colleagues’ meta analysis 1966 found the effects on intraoperative bleed ing were similar for topical or systemic corticosteroids. Wright and Agrawal 255 found that preoperative oral cor ticosteroid treatment led to significantly greater improve

ment in inflammation of the nasal mucosa and decreased surgical difficulty, compared to preoperative placebo treatment. Similarly, Atighechi and colleagues 1967 have reported CRSwNP treated with a 5-day course or single dose of systemic corticosteroid could improve the surgi cal field. Ecevit and colleagues 1616 performed a prospec tive double blind randomized trial to investigate the effect of preoperative steroids (60 mg prednisolone once daily for 7 days and tapered to 10 mg every other day then stopped on day 17) for nasal polyps. The authors showed that in addition to improvement of blood loss, surgical field and surgery time, preoperative steroid also decreased the time for hospitalization. In conclusion, preoperative treat ment with topical or oral corticosteroids is recommended to ensure better intraoperative conditions in CRSwNP patients in the absence of co-morbidities, which could be aggravated with systemic corticosteroids. Preoperative Corticosteroids in CRSwNP Aggregate Grade of Evidence: B (Level 1: 2 studies; level 2: 4 studies; level 3: 3 studies; level 4: 1 stud ies); 3 studies show contradicting results (Table XII-13). Benefit: Objective improvement in surgical field, decrease in surgery blood loss, and operation time. Subjective reduction in surgical difficulty. Harm: The possible risks of steroids are well known (see Table II-1) but there were no specific reports about side effect in CRSwNP without co morbidities. Cost: Low. Benefit-Harm Assessment: Preponderance of ben efit over harm. Value Judgment: Improvement in surgical field is important. There is no evidence-based agreement on dosage and duration. For oral corticosteroids, 30-60 mg within 7 days with or without tapering is a commonly prescribed regimen. Policy Level: Recommended. Intervention: Recommendation for the use of oral and topical corticosteroids in the preoperative management of CRSwNP.

XII.C.2.b. Effect of Preoperative Oral Antibiotics in CRSwNP There are no studies on preoperative antibiotic therapy for CRSwNP. Perica and colleagues 1969 found macrolides can decrease polyp size, but the role of preoperative antibiotic