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

similar to those included in the underlying clini cal trials. Intervention: Corticosteroid-eluting stents can be considered in the postoperative ethmoidectomy cavity.

Outcome measures included the SNOT-22, visual analogue symptom score, endoscopic score, CT score, eosinophil count, and adverse events. They identified 824 potential tri als, but only 5 trials (n = 331) met all inclusion criteria, and only 3 could be included in the meta-analysis and those 3 trials used 4 different irrigants: Ringer’s lactate, hyper tonic saline, electrolyzed acid water, and Amphotericin B. The authors found no significant difference in symptom scores or endoscopic scores between the groups treated with saline and other solutions. They concluded that addi tional solutions were no better than saline alone, although the treatments were quite heterogeneous. The overall evidence supporting the use of saline irriga tions remains grade B, and we make a recommendation for normal saline irrigations. Sinus cavity debridements. There were no new RCTs reported in the review period however there was a Cochrane review 2256 on this topic, which included the studies reviewed in ICAR-RS-2016. The primary outcomes were health related quality of life (HRQoL) scores, dis ease severity, and adverse effects. Secondary outcomes included endoscopic appearance, use of post-operative medical treatment, and revision surgery rate. Four stud ies (n = 152) were included in the review. One reported SNOT-22 data, with a non-significant difference between the 2 groups at 6 months follow up. Two RCTs (n = 118) reported Lund-Kennedy score data; mean scores were bet ter in the debridement group but the difference was not statistically significant (effect size =− -0.31; 95% CI, − 1.35to 0.72). Four RCTs (n = 152) reported on adhesion rate and the debridement group had a lower adhesion rate which was statistically significant (relative risk = 0.44; 95% CI, 0.28-0.68). Revision surgery rates were not reported in any study. The authors concluded that the evidence was rel atively low quality, however the available evidence sug gested that postoperative debridement was associated with a significantly lower risk of adhesions at 3 months follow up. The evidence for this treatment remains grade B, and we make a recommendation for postoperative outpatient debridement. Topical corticosteroids. There were 3 new articles iden tified – one RCT and 2 SR/MAs. Rawal et al. 1588 reported on 42 patients with CRS with polyps, who were random ized to topical irrigations with budesonide vs saline; out comes were validated HRQoL questionnaires and olfaction scores at 3-6 months. The authors found no statistically sig nificant differences in HRQol or olfaction between groups, although they noted that both groups did show improve ment in HRQOL over time, demonstrating the benefit of saline irrigation. One SR/MA was reported in 2015. 1956 There were 18 RCTs (n = 1309) identified comparing topical steroids

XII.E Postoperative Management following Sinus Surgery In studies of postoperative management, 1 problematic issue is the continued heterogeneity of reported postop erative health metrics which is likely related to the need for clinicians to optimize for both short-term and long term patient outcomes. For example, short-term patient centered outcomes (eg, pain and return to work) need to be considered within a context that aims to reduce the risk of needing long-term revision surgery (eg, reduced synechia formation and endoscopic control of inflam mation). For example, some articles report on reduction in pain, and while that may be a legitimate short-term outcome, many surgeons are using treatments to reduce synechia, or reduce endoscopic mucosal inflammation, to reduce the risk of requiring long-term revision surgery. So even though some evidence might assess a certain out come, it might not address the entire clinical spectrum. Postoperative care was thoroughly reviewed in ICAR RS-2016 1 and the following discussion highlights additions to the evidence since then. Recommendations are based on the totality of the evidence (Tables XII-25 and XII-26). Saline irrigations. There have been no new studies com paring normal saline irrigation with no irrigation. There was 1 new study comparing hypertonic saline with nor mal saline irrigation, and 1 systematic review with meta analysis (SR/MA) on the effects of nasal irrigation with dif ferent solutions. Peric et al. 2254 performed a single-center RCT in 30 patients with AERD; 15 subjects per group. They compared postoperative irrigation with seawater solution containing 2.3% NaCl with normal saline (0.9% NaCl). Pri mary outcome was a non-standardized symptom score and secondary outcome was a non-standardized endoscopic score, both at 1 month. They found that the hypertonic group achieved improved symptom and endoscopic scores, with statistical significance ( p < 0.001). However, the abso lute differences were quite small (eg, symptom score preop to postop: 38 to 6 hypertonic, 40 to 9 saline), and it is likely that these differences were not clinically meaningful. Chen et al. 2255 performed a SR/MA with a broad ques tion. They evaluated the efficacy of nasal irrigation after ESS with various solutions, compared to normal saline.