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

groups achieved statistically significant improvement of these outcome metrics after 3 weeks of treatment, which did not improve further after 6 weeks of treatment. Pedi atric compliance with NSI may be initially considered with skepticism, though with parental assistance, compliance is greater than 90%. 1158 Reports on the efficacy of INCS such as fluticasone or mometasone are conflicting due a lack of proper clinical trials. 26 However, given the low systemic absorption, the low risk profile, and the favorable efficacy in adults with CRS, use of INCS is recommended as first line therapy. INCS is recommended both as a component of medical management and in post-operative treatment regimens, particularly in patients suspected to have IgE-mediated pathophysiologic processes. 26 Scientific evidence supporting the use of systemic antibi otics in PCRS is limited. An empiric broad-spectrum treatment with culture-directed antibiotics for 21 days could however be recommended based on clinical prac tice observations and extrapolation from studies in pedi atric ARS. 2349 Initial empiric treatment with amoxi cillin/clavulanate, and second (cefuroxime) or third (cef dinir and cefixime) generation cephalosporins could be used as first-line antibiotics. In case of allergy to peni cillin, cephalosporins and macrolides, or clindamycin, could alternatively be prescribed as second- or third-line antibiotics, respectively. Systemic corticosteroids have demonstrated clinical effi cacy in the management of PCRS as an adjunct to systemic antibiotics. Ozturk et al. performed a double-blinded, ran domized prospective trial of 48 children (age 6-17 years) who were treated with either amoxicillin/clavulanate and methylprednisolone or amoxicillin/clavulanate and placebo twice daily for 30 days. Both groups demonstrated significant improvement in symptom and CT scores. How ever, children who received corticosteroids had signifi cantly greater improvement in symptom scores, CT scores, and duration of benefit. There were no treatment-related adverse events in either group. 2350 However, the poten tial for serious side effects with systemic corticosteroid use should reserve consideration of such therapy for dis ease recalcitrant to more conservative measures and as a possible adjuvant to surgical therapy. There is limited knowledge of the risks of using systemic corticosteroids in pediatric CRS. However, based on studies on pedi atric asthma, 2351 a single short-term systemic corticos teroids course could be considered in pediatric patients suffering from CRS not responding to more conservative measures. 2351 Randomized prospective studies examining antihistamines, decongestants or bacterial lysates in the management of PCRS are lacking. Contributing comorbid conditions, such as GERD, immunodeficiencies, PCD, and CF, may increase the com

plexity of PCRS management. Randomized prospective data and clinical consensus examining the efficacy of anti-reflux medication in the management of PCRS are lacking. 26,2341 Surgical intervention should be considered after appro priate medical therapy has failed. While there is no precise definition of appropriate medical therapy, it should generally include a course of antibiotic therapy, INCS, nasal saline irrigation, and consideration of oral corticosteroids. 26 Surgical treatment options may vary based on the patient’s age, anatomy, extent of disease, and comorbid conditions. In younger children, adenoid disease may play a larger role in the development of CRS, both as an obstruc tive process and as a reservoir for bacterial growth. 2352 There is evidence that adenoidectomy alone is an effective treatment for PCRS in children up to age 6 years, and may have similar efficacy in some children up to age 12, though evidence is lacking beyond this age group. 2341 A 2008 meta analysis of 9 studies (moderate evidence: level 2 in 5 stud ies and level 4 in 4 studies) found a clinical improvement, as judged by caregivers, in 70% of children aged 4-7 years with CRS after adenoidectomy. 2353 A 1999 prospective, non-randomized cohort study analyzed the success of ade noidectomy and ESS in children aged 2 to 14 years, where failure was defined as persistence of symptoms and need for additional procedure at 6 months postoperatively. Ade noidectomy had a 47% success rate, while ESS had a 77% success rate. 2354 A 2017 prospective interventional study in 66 children aged 4-12 years with refractory CRS showed improvement in QoL scores after adenoidectomy when compared to baseline in 88% of children using the SN-5 instrument. 2355 Because there is a significant overlap of symptoms between CRS and chronic adenoiditis, the diag nosis before surgery must rely on objective measures such as nasal endoscopy or CT scan. In children with CRS symp toms, a Lund-Mackay score of 5 or greater may be consid ered diagnostically “positive” for CRS with a high positive predictive value, whereas CRS symptoms and a CT score below that probably indicates isolated adenoiditis. 2345 Sup porting this concept, a retrospective study found that in pediatric patients with Lund-Mackay scores greater than 6, the addition of maxillary sinus irrigation at the time of ade noidectomy improved clinical symptoms 1 year after the procedure. 2356 Most data supporting ESS for PCRS are retrospective, and study subjects and design are heterogeneous. In a 2013 systematic review, Makary et al. reported success rates over 82% with a minor complication rate of 1.4%. 2357 Another systematic review and meta-analysis performed by Vlas tarakos et al., also in 2013, reported a surgical success from 71 to 100% for improvement of PCRS symptoms and QoL with a low incidence (0.6%) of major complications. 2358