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

569

Orlandi et al.

therapy for CRSwNP needs further investigation. Thus no recommendation is therefore given in this regard.

XII.D Surgical Principles/Techniques XII.D.1: Extent of Surgery XII.D.1.a. Ostium Size Since the introduction of endoscopic techniques for the surgical treatment of CRS in the 1980s, the goals of ESS have been to reestablish ventilation and drainage of the paranasal sinuses and improve delivery of topical medi cations and irrigations through enlargement of the natu ral ostia. 1970 Modifications to conventional ESS techniques have been described to match the extent and location of a patient’s sinus disease. Modifications that reduce the extent of conventional sinus surgery include minimally invasive sinus technique (MIST) and balloon dilation of the sinuses. MIST is based on the premise that transition spaces, not the natural ostia, serve as bottlenecks for obstruction in the setting of CRS. MIST therefore addresses the clear ance of these transition spaces, rather than the enlarge ment of sinus ostia. For example, MIST involves removal of the uncinate, but does not include direct enlargement of the natural ostium itself. 1971–1973 In comparison to MIST, ESS provides direct enlargement of the natural sinus ostia, which may be beneficial in cases of more severe inflam matory disease or to address anatomic variants, such as an infraorbital ethmoid (Haller) cell. Ostial enlargement may also be advantageous for clearing disease within the sinuses, such as polyps or fungal debris. Large ostial open ings can also allow for monitoring and office management of the disease process. Cohort studies of CRS patients undergoing MIST have demonstrated improvements in sinonasal symptoms maintained up to 2 years after surgery. 1974,1975 However, improvements were found to be greater in patients who underwent concomitant nasal polypectomy at time of MIST, 1975 calling into question the extent to which the MIST-specific technique contributed to clinical improve ment. Two RCTs have been reported with patients under going a MIST procedure on 1 randomly-chosen side and traditional ESS, including maxillary antrostomy, per formed on the other. 1976,1977 Although no significant dif ferences in objective evidence of disease were detected between sides, maxillary sinuses with smaller post operative ostia were associated with maxillary sinus opaci fication or OMC obstruction. 1976 In another prospective trial, patients with chronic maxillary RS were randomized to receive either a small maxillary antrostomy, with mean diameter of 6 mm, or a large maxillary antrostomy, with

TABLE XII-12 Evidence for preoperative corticosteroid administration in CRSsNP Study Year LOE Study Design Study Groups Clinical Endpoint Conclusions Pundir 1956 2016 1 Systematic review of randomized trials CRSsNP and CRSwNP treated with 4-week course of mometasone furoate Intraoperative blood loss Statistically significant reduction in blood loss on Boezaart score. Albu 1953 2010 2 Individual RCT CRSsNP and CRSwNP treated with 4-week course of mometasone furoate Intraoperative blood loss and operation time Statistically significant reduction in blood loss and operation time. Tirelli 1957 2019 4 Prospective cohort CRSsNP and CRSwNP treated with at least 3 months INCS Intraoperative blood loss Statistically significant increase in blood loss with no difference between CRSsNP and CRSwNP.