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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International consensus statement on rhinosinusitis

in the polyethylene terephthalate group. Patients in the polyurethane/nitinol group also experienced significantly better QoL outcomes. 2220 The unbalanced nature of this study demands further investigation. The frontal sinus, with its narrow diameter, has been stented with inert material post-operatively for over 100 years, beginning with a gold tube in 1905. 2221 There are currently no randomized studies evaluating post-operative inert stents in the frontal sinus. Some authors proposed that stenting should be considered when the neo-ostium is < 5 mm or has been significantly demucosalized ( > 50%), and that stents should be maintained for at least 6 weeks. 2211,2222 Numerous case series 2223–2231 have evalu ated soft silicone stents, either fashioned or proprietary, in the postoperative frontal sinus. These uncontrolled studies and have found that inert frontal sinus stents reduce steno sis and reoperation rates. The longest duration of stent ing described is 6 years. 2228 Despite the conclusion that these frontal sinus stents are well-tolerated and may reduce stenosis, evidence exists that biofilm formation may com plicate their use long-term. 2232 Middle Meatus/Ethmoid Stenting Aggregate Grade of Evidence: B (Level 2: 4 studies; level 4: 5 studies; Table XII-22). Benefit: Well-tolerated; reduction in synechiae; improved sinus patency. Harm: Biofilm formation, pain upon removal, potential restenosis, may not change symptoms or endoscopic score. Cost: Minimal to moderate. Benefit-Harm Assessment: Preponderance of ben efit over harm. Policy Level: Recommendation. Intervention: Use of inert stents after eth moid/middle meatus sinus surgery.

Benefit-Harm Assessment: Balance of risks and benfits. Policy Level: Option. Intervention: Use of inert stents after frontal sinus surgery.

XII.D.7 Drug Eluting Packing, Stents, and Spacers in Sinus Surgery While ESS is quite successful in treating medically resis tant CRS, postoperative inflammation may hamper the ultimate recovery of patients. Postoperative failures may be caused by synechiae formation, ostial stenosis, neo osteogenesis, middle turbinate lateralization and recurrent polyposis. 2205,2233–2236 These complications are currently mitigated by saline irrigations to reduce crusting, postop erative debridement, adhesion lysis, as well as topical and systemic corticosteroids. Postoperative debridement can be painful and the use of systemic corticosteroids carries potential side effects. Topical corticosteroids can be useful in improving healing but efficacy is limited by patient com pliance as well as the inability to deliver sufficient drug to the ethmoid bed in the setting of post-operative edema. 2237 In order to improve postoperative healing, a wide vari ety of techniques have been developed including the use of packing, stents and spacers. Nasal packing is principally designed for postoperative hemostasis and in animal mod els some packing materials demonstrate improved wound healing. Stents and spacers on the other hand are designed to maintain middle meatal patency and allow irrigation without obstruction. If the stents also elute drug, they can potentially provide local medical therapy to the sinus mucosa, independent of patient compliance with minimal systemic side effects. 2238 Non drug-eluting stents can act as spacers to prevent adhesion formation and provide a scaffold for mucosal regrowth, however there is conflicting evidence on their effectiveness. 2227,2236 Controversy also exists in regard to duration of placement and the type of stent employed. 2238 Silastic stents have been associated with biofilm formation postoperatively which may be counter-productive in the treatment of CRS. 2232 The off-label addition of steroid to dissolvable packing has shown improved outcomes for wound healing post ESS. In a DBRCT, Grzeskowiak 2018 showed that the addi tion of a steroid to Nasopore R demonstrated significant improvement in wound healing and secretions, when com pared to Nasopore R alone. In a 3 armed study, Ha et al. showed that the addition of Budesonide to CD gel

Frontal Sinus Stenting Aggregate Grade of Evidence: D (Level 4: 10 stud ies; Table XII-23). Benefit: Well-tolerated; reduction in synechiae; improved sinus patency. Harm: Biofilm formation, infection related to stent, pain upon removal, potential restenosis,

may not change symptoms. Cost: Minimal to moderate.