xRead - Olfactory Disorders (September 2023)

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PATEL et al.

TABLE IX.14 Evidence for CRSsNP-related olfactory loss management with topical antifungal therapy Study Year LOE Study design Study groups

Clinical end point Conclusions

VAS (0–100)

Compared with

Ebbens

2006

2

RCT

Nasal amphotericin B 10 mg (n = 59) Yellow-colored placebo (n = 57)

et al 1437

placebo, there was no significant benefit in the topical antifungal group placebo, there was no significant benefit of the topical antifungal

Wechta

2004

2

RCT

Nasal amphotericin B 4 mg (n = 40) Placebo (n = 40)

VAS (0–10)

Compared with

et al 1438

Jiang

UPSIT R

2018

2

RCT

Nasal amphotericin B 20 mg (n = 37) Placebo (n = 36)

Compared with

et al 1439 placebo, there was no significant benefit of the topical antifungal CRSsNP = chronic rhinosinusitis without nasal polyps; LOE = level of evidence; RCT = randomized controlled trial; UPSIT R = University of Pennsylvania Smell Identification Test; VAS = visual analog scale.

OF. 1447 Evidence for surgical management of OD related to AR is extremely limited and further investigation is war ranted (Table IX-19). ESS for OD in patients with CRS. Aggregate grade of evidence : C (Level 2: five studies; Level 3: 30 studies; Level 4: five studies). Benefit : ESS appears to improve subjective and objec tive measures of olfaction in patients with CRS. This bene fit is most notable in patients with CRSwNP and those with severe baseline OD. Harm : Risks of ESS are considered low but include bleeding, orbital injury, CSF leak, and risks of general anes thesia. Cost : Direct: Moderate to high upfront monetary costs associ ated with sinus surgery and postoperative care. Indirect: Time required for procedure and recovery. Benefits-harm assessment : Benefit over harm, par ticularly in patients with CRSwNP. Benefit to harm ratio less clear in patients with CRSsNP and those with minimal baseline OD. Value judgments : Candidates with worse baseline OD and those with CRSwNP are more likely to benefit from ESS. Policy level : Recommendation. Intervention : As part of a shared decision-making pro cess with the patient, it is reasonable to recommend ESS in those with OD related to CRS in whom medical manage ment has failed. Turbinate surgery for OD in patients with AR Aggregate grade of evidence : C (Level 3: four studies; Level 4: one study).

Benefit : Five small studies that note improvement in subjective measures of olfaction in patients with AR. Two studies with objective data with mixed results. Overall, data are very limited. Harm : Relatively low risks, which include bleeding, infection, injury to adjacent structures, and risks of anes thesia. Cost : Direct: Moderate monetary cost that varies based on site of care. Indirect: Low because of short recovery time after pro cedure. Benefits-harm assessment : Unclear given lack of data. Value judgments :None. Policy level : No recommendation. Intervention : Turbinate reduction is typically per formed in patients with AR who complain of nasal con gestion despite medical therapy. No recommendation can be made for patients with AR whose chief complaint isOD. D Treatment of intracranial, neurotransmitter, neurodegenerative diseases Structural lesions, neurochemical imbalances, and accel erated neuronal death and neuroinflammation in olfactory processing regions can perturb odor-evoked processing, emotional response, and functional behavioral response. Medical treatment of OD related to intracranial disease, neurochemistry/neurotransmitter imbalances, and neu rodegenerative disease is primarily designed to improve