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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compared to traditional large-hole technique in patients with minimal sinus disease. Policy Level: Option. Intervention: Less extensive sinus interventions are likely reasonable options in patients with min imal OMC or maxillary sinus disease.

study by Alsharif et al., 50 patients with CRSwNP were sur gically treated in 1 of 3 groups: traditional, non-stripping ESS; partial reboot; and full reboot with Draf III. They noted that full reboot with Draf III resulted in significantly less polyp recurrence over 2 years. However, the approach to the frontal sinus was not standardized between groups. Recently, some authors have found that a more aggres sive approach to the maxillary sinus may be effective for treating recalcitrant CRSwNP. These techniques, tradition ally used for access for removal of maxillary sinus neo plasms, include the Caldwell-Luc procedure and a modi fied endoscopic medial maxillectomy. The latter approach includes near total removal of the inferior turbinate, widening the maxillary sinus opening to its anatomic boundaries with the option of extending the window ante riorly into the anterior wall of the maxillary sinus facilitat ing increased access for topical therapies. 1985,1987,1989,2000 Mucosal Preservation vs Mucosal Removal in ESS Aggregate Grade of Evidence: C (Level 2: 3 studies; level 4: 4 studies; Table XII-15). Benefit: In patients with CRSwNP mucosal removal is associated with improvement in QoL scores, sustained improvements in smell, and decreased polyp recurrence. Harm: Potential for direct damage to olfactory mucosa or CSF leak at middle turbinate attach ment. Risk of chronic crusting. Cost: Direct and indirect costs related to ESS. Benefits-Harm Aassessment: For patients with CRSwNP, the evidence suggests mucosal removal is associated with sustained improvement in QoL scores, sustained improvements in smell and decreased rates of polyp recurrence. However, sub stantially more research is required with direct comparison to mucosal preserving ESS. Further, rates of complications such as CSF leak, scarring, or crusting should be considered. Value Judgments: Evidence is based on very few studies in the literature, virtually all from the same research group. The data available at this time is limited and its broad applicability to additional patient cohorts unclear. Policy Level: Option. Intervention: Mucosal stripping is an option in patients with CRSwNP.

XII.D.1.b. Mucosal Preservation vs Mucosal Removal In recent years, there has been increased discussion about the potential effectiveness of removing paranasal sinus mucosa during ESS for the treatment of CRS. While there is minimal data regarding this technique for patients with CRSsNP, this has been a more widely studied approach for CRSwNP and has been dubbed “nasalization.” In this more radical approach, a complete ethmoidec tomy is performed along with removal of lateral, non olfactory ethmoid mucosa. The middle turbinate is also typically removed during the procedure. Studies, though limited in number, have shown positive results for the nasalization procedure. 1780,1996 In a retrospective 5-year study, patients with CRSwNP who underwent nasalization ethmoidectomy demon strated better symptom relief by VAS at 8.41 + / − 0.40com pared to 5.69 + / − 0.83 after ethmoidectomy ( p = 0.002). 1780 Further, total recurrence rate was 22.7% in the nasaliza tion group, and 58.3% in the ethmoidectomy group ( p < 0.01). 1780 In a second study looking at patients with CRSwNP failing medical management, a group receiving nasalization was compared to a group receiving a single course of oral steroids. The nasalization group showed bet ter sustained long term results. 1997 Despite these encourag ing results, the data on direct comparison between nasal ization to routine, mucosal preserving, ethmoidectomy is quite limited, thus limiting broader applicability of the technique for CRS. Additional studies have evaluated olfactory improve ment after nasalization. 1996 The initial study by Jankowski et al. in 2003 noted improvement in olfaction with pre operative steroids and nasalization. 1996 Two more recent studies have also assessed nasalization and olfaction, show promising results when applied to patients with severe hyposmia using the Sniffin stick smell test. 1997,1998 Despite the sustained olfactory improvement after nasalization, the effectiveness of this approach compared to mucosal preserving ethmoidectomy was not studied. Additional studies have taken a modified approach to removal of inflamed mucosa, called the “reboot” proce dure. In this technique, authors have proposed stripping of all polypoid mucosa thereby giving the mucosa the oppor tunity to regrow in a more functional manner. 55,1999 In a