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

627

Orlandi et al.

with placebo, including several different delivery mecha nisms for the steroid – topical spray, steroid-impregnated spacer, and steroid irrigation. Twelve studies addressed symptom score and 8 addressed endoscopic score. Their meta-analysis found no significant difference in postoper ative symptom scores between the steroid and no steroid groups, however they found significant improvement in endoscopic score in the steroid group at 6 and 12 months in pooled patients with CRSwNP and CRSsNP, and lower polyp recurrence rate in the subgroup of patients with CRSwNP. Also, 4 studies found no significant increase in postoperative infection rate with use of topical corticos teroids.. Another SR/MA was reported in 2018, 2257 which specif ically focused on steroid high-volume irrigations. They found that the pooled data on the effect of steroid irrigation showed large differences in QoL scores (mean difference = 21.9, minimal clinically important difference (MCID) = ∼ 9) and endoscopic scores (mean difference = 4.23,MCID = ∼ 4), which were both statistically and clinically signif icant. The comparative data however showed no benefit when compared to saline irrigations in QoL scores (mean difference = 3.0) and endoscopy scores (mean difference = 0.33). They did not identify any adverse effects from steroid irrigation, such as increased intraocular pressure or adrenal suppression. The evidence remains grade A, and supports a strong recommendation for the use of topical nasal steroids. Oral antibiotics. We identified 2 new RCTs on the postoperative use of oral antibiotics. Amali et al. 1115 reported a placebo-controlled RCT of 60 patients after ESS, where 40 patients received oral placebo, and 20 received azithromycin 250 mg daily, both for 12 weeks. Primary out come was SNOT-22 score at 12 weeks. The azithromycin group showed a statistically significantly larger score reduction than the placebo group: azithromycin 34.05 preop to 5.85 postop; placebo 36.20 preop to 10.07 postop ( p < 0.001). However, the absolute difference between the 2 groups is 4.22, and the minimal clinically important dif ference on the SNOT-22 is approximately 9. So the small difference noted was likely not clinically meaningful. Haxel et al. 1116 reported a single-center, prospective, double-blinded RCT of 58 patients on the use of low-dose erythromycin after ESS. Group 1 (n = 29) received ery thromycin 250 mg daily and group 2 (n = 29) received placebo, both for 3 months. The primary outcome mea sures were eosinophilic cationic protein and myeloperoxi dase levels in nasal mucus, and a number of secondary out comes, assessed at 3 and 6 months. The authors reported no significant differences between groups in primary outcome measures. They only noted a single statistically significant difference in endoscopy scores favoring the erythromycin group at 3 months, however at 6 months the differences

were not statistically significant, and there were no signif icant differences between groups in any other secondary outcomes. The evidence remains level B, and we make a recom mendation of option for use of antibiotics, citing both ben efits and potential side effects. Topical decongestants. No new studies were identified in the review period which addressed topical deconges tants. ICAR-RS-2016 review found insufficient evidence to support their use, and made a recommendation against topical decongestants, because of potential side effects and no clear benefit. Packing/spacers without medication impregnation. There were no new studies addressing packing or spacers without medication impregnation. The prior review identified indi vidual RCTs and a systematic review with meta-analysis. There was heterogeneity in the outcome measures, and in the packing materials used, however there were improve ments (fewer synechia, better cavity appearance) demon strated with packing compared to no packing, and there was a trend toward less pain with dissolvable packing vs removable packing. The overall evidence was grade B, but because of the data heterogeneity, the recommendation was option for the use of packing or spacer. Drug-eluting spacers/stents. There were 3 new studies identified in the review period: a Cochrane review, an RCT and an economic analysis. In the Cochrane review by Huang et al. (9), their primary outcome measure was symptom improvement. They reviewed 159 possible abstracts, and found 21 trials which potentially answered their question, however none met all inclusion criteria. So, their conclusion was that they were “unable to provide evidence to establish whether steroid-eluting sinus stents have potential advantages and disadvantages for patients with CRS undergoing ESS.” Gyawali et al. 2258 reported an RCT of 58 patients compar ing triamcinolone-impregnated polyvinyl alcohol packs placed as a spacer, with saline-impregnated packs, which were removed on day 2. The side for the triamcinolone pack was chosen randomly and the opposite side served as the saline control; observers were blinded to side. Pri mary outcomes were the Lund-Kennedy endoscopic score and the Peri-Operative Sinus Endoscopy score (POSE), at 3 weeks. The authors found statistically significant differences favoring the steroid-receiving side on both endoscopy scores: Lund-Kennedy, steroid 0.53 vs saline 1.31 ( p < 0.0001); POSE, steroid 1.21 vs saline 1.95 ( p = 0.004). While there is no established MCID for these tools, given the overall range of the scales, certainly the Lund-Kennedy difference seems clinically meaningful, and perhaps also the POSE. The follow-up assessment was only at 3 weeks however, so it is not clear whether the improvements were sustained.