xRead - Nasal Obstruction (September 2024) Full Articles

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Orlandi et al.

In the last decade, balloon sinus dilation (BSD) has been introduced as a surgical option. A recent multicenter prospective study reported a favorable safety profile of BSD in children. Sinus dilations were performed in 50 children and adolescents aged 2-21 years. No complications were reported. 2359 Most studies report cases that combined BSD with other surgical interventions such as adenoidectomy and/or ethmoidectomy, 2360–2362 and prospective random ized trials have not been performed. Hence, it is uncertain how much benefit is due to BSD alone. 2346 Finally, con sensus exists that the use of CT imaging is recommended prior to ESS, and image guided navigation has a role in revi sion ESS or if distorting polyposis is present. 311,2341 Though a potential for therapeutic improvement is acknowledged, there is limited pediatric data regarding turbinoplasty or excision of obstructive concha bullosa. With respect to postoperative debridement, 1 study failed to show signif icant postoperative benefit. 2341 XIII.B.5 Pediatric CRS: Complications Literature for complications related to pediatric CRS is sparse with no identified systematic reviews related specif ically to this topic. One systematic review of intracra nial complications in combined pediatric RS (PARS and PCRS) identified risk factors for male gender and adoles cent age without discerning between PARS and PCRS. 2318 Case reports and small case series of pediatric CRS highlight extra-cranial and intra-cranial complications which are similar to those of PARS, including orbital abscess, frontal bone chronic osteomyelitis (Pott’s puffy tumor), mucocele, intracranial abscess, and cavernous sinus thrombosis. 39,2363–2365

have been shown to be the leading causes of both morbid ity and mortality in CF, control of sinonasal disease has become a focus for improving pulmonary outcomes. 2372 In addition, as life expectancy for individuals with CF increases, factors such as QoL are taking on increasing importance. 2373 Medical intervention, normally comprising long-term combinations of oral and topical treatment, remains the first step in managing CRS in CF patients. Consensus rec ommendations for medical treatment are lacking, as a 2019 Cochrane Review failed to identify any studies that met the inclusion criteria of randomized trials of medical interven tions compared to each other or to placebo. 2374 Given the improving life expectancy for patients with CF, there is a growing need for sound clinical research that can guide our decisions for medical treatment of CRS in this population. Nasal saline irrigation Despite robust evidence for saline irrigations in the medi cal treatment of CRS in general, 1 there remains no conclu sive evidence supporting their use for CRS related to CF. Hypertonic saline theoretically creates an osmotic gradi ent to improve MCC and is occasionally considered as a nasal irrigation due to reports of positive pulmonary out comes in CF with nebulized inhalation. 2375 In addition, a 2016 Cochrane review showed improvement in disease specific QoL with 2% nasal saline irrigation vs placebo in non-CF patients with CRS. 1048 However, a more recent double-blind crossover RCT compared nebulized hyper tonic 6.0% saline to isotonic 0.9% saline in CF patients with CRS and failed to show any comparative benefit in SNOT 20 score at 1 month, while also resulting in increased nasal irritation. 2376 Oral and topical antibiotics While inhaled antibiotics have gained significant traction in the treatment of lower airway infections in CF, the treat ment of sinonasal colonization of Pseudomonas aerugi nosa has not been well studied, with only a single RCT showing QoL improvement with daily intranasal nebu lized tobramycin in a cohort of 6 patients vs placebo. 1150 However, more robust data exists for the use of antibi otic therapy during the postoperative period in an effort to eradicate chronic sinonasal bacterial colonization. 2377,2378 While macrolides have shown promise in treating lower airway disease due to antibacterial and anti-inflammatory effects, 2379 further studies are needed to reveal the utility of systemic antibiotics in treating CRS in CF patients.

XIV Special Considerations in Rhinosinusitis XIV.A Cystic Fibrosis (CF)

CF is a genetic disorder caused by autosomal recessive inheritance of mutations in the CFTR protein, leading to exocrine gland dysfunction. 2366 The resulting disruption in ion and water transport results in impairment of MCC and propensity for bacterial colonization. 2367 The incidence of CRSwNP and CRSsNP in CF patients has been reported at 90% to 100% and 36% to 58%, respectively. 2368–2370 The concept of the unified airway model, when applied to this population, suggests that the sinuses may act as a bacterial reservoir for transmitting disease to the lower airways. 2371 As pulmonary infection and inflammation