Impact of Perioperative Systemic Steroids on Surgical Outcomes in Patients With Chronic Rhinosinusitis With Polyposis: Evaluation With the Novel Perioperative Sinus Endoscopy (POSE) Scoring System

Postoperative Oral Corticosteroid Use Following Endoscopic Sinus Surgery for Chronic Rhinosinusitis: A Systematic Review and Meta-Analysis

BackgroundPatients with chronic rhinosinusitis (CRS) refractory to medical management often require endoscopic sinus surgery (ESS). Oral corticosteroids (OCSs) are frequently prescribed postoperatively, but the evidence of their efficacy is limited.ObjectiveThe purpose of this study is to evaluate the efficacy of OCS use in patients with CRS following ESS.MethodsA systematic search was performed to identify studies examining the use of OCSs in patients undergoing ESS for CRS. The primary outcomes were sinonasal outcome test (SNOT) and Lund-Kennedy (LK) endoscopic scores. Secondary outcomes were visual analog scale (VAS) scores. Meta-analysis was conducted using a fixed effects model with a heterogeneity test via the I2 statistic.ResultsThe search yielded 1899 articles, and 22 were included in the qualitative analysis, 14 of which were randomized controlled trials with 793 total patients. OCS use differed based on type, dosage, and duration. Studies included in meta-analysis did not show a significant difference in SNOT (Standardized Mean Difference [SMD] -0.03, Confidence Interval [CI] -0.47-0.40, I2 0%), LK (SMD -0.20 CI -0.57-0.17 I2 58%), or VAS (SMD 0.19 CI -0.25-0.63 I2 54%) scores between steroid and non-steroid groups. Two studies that assessed OCSs in the allergic fungal rhinosinusitis (AFRS) subtype of CRS showed significant improvement in outcomes. Two additional studies examined OCS versus itraconazole in AFRS, with both groups showing improvement but neither one with greater significance.ConclusionThis study showed no significant difference in SNOT, LK, or VAS scores in patients with CRS who received OCSs following ESS. Given the limited number of studies in the analysis, further investigations are warranted before making recommendations.

Perioperative Use of Systemic Steroids Within Otolaryngology-Head and Neck Surgery: Evidence-Based Guidance for Clinicians

OBJECTIVE

To review and synthesize the available evidence for use of perioperative systemic steroids for otolaryngologic surgical procedures.

DATA SOURCES

A comprehensive literature review with evidence-informed recommendations.

REVIEW METHODS

Databases were queried for medical subject heading terms and keywords related to perioperative systemic corticosteroids use for comprehensive otolaryngology and subspecialty procedures including otologic, sinonasal, sleep, laryngeal, head and neck, facial plastics, and pediatric surgery. Perioperative period included preoperative (up to 7 days prior to surgery), intraoperative (on the day of surgery), and postoperative (initiated within 24 hours after surgery) timeframes.

CONCLUSIONS

Evidence from clinical practice guidelines, systematic reviews, and original research studies supports perioperative systemic corticosteroid use for specific otolaryngologic indications. Numerous studies support perioperative steroid use for nausea, vomiting, or edema in tonsillectomy, rhinoplasty, and thyroidectomy, although formal guideline recommendations are limited. Strong evidence supports perioperative steroid use before and after endoscopic sinus surgery for chronic rhinosinusitis with polyposis and fungal sinusitis. Evidence of benefit is sparse or absent on systemic perioperative steroid use for the middle and inner ear, laryngeal, salivary gland surgery, and reconstructive facial plastic surgery.

IMPLICATIONS FOR PRACTICE

Although perioperative administration of systemic steroids is routinely performed for many otolaryngologic surgeries, high-level evidence is limited to specific contexts. Evidence supports the benefit for reducing nausea, vomiting, or edema for several otolaryngologic procedures, as well as for either chronic rhinosinusitis with polyposis or fungal sinusitis. However, these benefits need to be weighed against risks, and further investigations are needed to define the role for perioperative steroids in otolaryngology.

The Association of TSLP and IL-4 with Patient-Reported Outcome Measures in Chronic Rhinosinusitis with Nasal Polyps

BACKGROUND

Thymic stromal lymphopoietin (TSLP) plays an important role in mediating the type-2-inflammatory response. This study examined how TSLP and interleukin (IL)-4 levels in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) correlated with clinical and postoperative outcomes.

METHODS

Solid-phase sandwich ELISA was used to analyze TSLP and IL-4 levels in mucus (n = 47), plasma (n = 17), polyp (n = 30), inferior (n = 25), and middle (n = 26) turbinate tissue collected during functional endoscopic sinus surgery (FESS) in CRSwNP patients (n = 76) and controls (n = 11). Inclusion criteria includes patients with medical treatment refractory CRSwNP confirmed by endoscopy or maxillofacial CT. Exclusion criteria include history of immunodeficiency, coagulation disorders, fungal sinusitis, or cystic fibrosis. Levels of TSLP and IL-4 were correlated with SNOT-22, UPSIT, and fractional exhaled nitric oxide (FeNO) using MannWhitney U two-tailed test and linear regression with Spearman correlation coefficient test.

RESULTS

TSLP is elevated in the inferior turbinates (effect size = 2.695, p = 0.0007) of CRSwNP patients compared to controls. IL-4 is expressed at elevated levels in the inferior (effect size = 3.092, p < 0.0001) and middle turbinates (effect size = 2.041, p = 0.019) compared to controls. Mucus TSLP (r = 0.4013, p = 0.0153) and IL-4 (r = 0.6138, p < 0.0001) positively correlate with preoperative FeNO levels. Lower TSLP in the inferior (r = -0.5179, p = 0.0231) and middle turbinates (r = -0.5075, p = 0.0224) and lower IL-4 in the inferior turbinates (r = -0.5205, p = 0.0223) correlate with a greater improvement in SNOT-22 post-FESS.

CONCLUSION

TSLP and IL-4 are elevated in patients with CRSwNP and correlated with increased preoperative FeNO levels and decreased sinonasal quality of life benefit after FESS. Expression of TSLP and IL-4 may play a role in guiding postoperative expectations in patients with treatment refractory CRSwNP.

The comparation of different oral corticosteroids withdrawal methods for nasal polyp surgery

OBJECTIVES

To compare the efficacy and adverse events of different oral corticosteroids (OCSs) withdrawal methods for chronic rhinosinusitis with nasal polyp after endoscopic sinus surgery (ESS).

METHODS

This was a randomized prospective study conducted from Oct 2019 to Jan, 2021. 35 patients who underwent ESS were randomly divided into 2 groups. Regular group (n = 18) received 0.4mg/kg/day of methylprednisolone orally for 10 days, tapering group (n = 17) received 0.4mg/kg/day of methylprednisolone orally for 7 days, followed by progressive reduction of 8 mg of methylprednisolone per week for 3 weeks. The visual analogue scale (VAS) score, the Lund-Kennedy endoscopy (LKE) score, and the E score were assessed preoperatively and at half and 1, 2, and 12 months postoperatively. Statistical analyses were performed using SPSS.

RESULTS

There was no statistical difference in the baseline characteristics between the 2 groups. The postoperative VAS scores and LKE scores of patients were significantly improved from those preoperatively (P-values < 0.05). There was no statistical difference in the LKE score, E score, and VAS score between the 2 groups both preoperatively and postoperatively (P-values > 0.05). There was no statistical difference in adverse events between the 2 groups (P-values > 0.05).

CONCLUSIONS

The combination of OCSs and ESS can improve the clinical symptoms of patients and the recovery of nasal mucosa. There was no difference between the 2 drug withdrawal methods in efficacy and adverse events. Drug withdrawal gradually is more complicated therefore, in clinical practice, OCSs withdrawal directly would be the better option for patients.

Machine Learning Model Predicts Postoperative Outcomes in Chronic Rhinosinusitis With Nasal Polyps

OBJECTIVE

Evaluating the possibility of predicting chronic rhinosinusitis with nasal polyps (CRSwNP) disease course using Artificial Intelligence.

METHODS

We prospectively included patients undergoing first endoscopic sinus surgery (ESS) for nasal polyposis. Preoperative (demographic data, blood eosinophiles, endoscopy, Lund-Mackay, SNOT-22 and depression PHQ scores) and follow-up data was standardly collected. Outcome measures included SNOT-22, PHQ-9 and endoscopy perioperative sinus endoscopy (POSE) scores and two different microRNAs (miR-125b, miR-203a-3p) from polyp tissue. Based on POSE score, three labels were created (controlled: 0-7; partial control: 8-15; or relapse: 16-32). Patients were divided into train and test groups and using Random Forest, we developed algorithms for predicting ESS related outcomes.

RESULTS

Based on data collected from 85 patients, the proposed Machine Learning-approach predicted whether the patient would present control, partial control or relapse of nasal polyposis at 18 months following ESS. The algorithm predicted ESS outcomes with an accuracy between 69.23% (for non-invasive input parameters) and 84.62% (when microRNAs were also included). Additionally, miR-125b significantly improved the algorithm's accuracy and ranked as one of the most important algorithm variables.

CONCLUSION

We propose a Machine Learning algorithm which could change the prediction of disease course in CRSwNP.

Treatment Outcome Post Endoscopic Sinus Surgery(ESS) in Patients with Chronic Rhinosinusitis (CRS)

Chronic rhinosinusitis (CRS) is one of the most prevalent conditions in medicine causing a considerable amount of healthcare expenditure. This study was performed to clinically diagnose chronic rhinosinusitis with or without polyps and to measure the intensity of patients' symptoms and treatment outcomes. This was a prospective cohort study, which included 70 patients diagnosed with CRS according to the EPOS-2012 and were given SNOT-22 questionnaire preoperatively, which was repeated on 1st, 4th, and 12th weeks post-op to determine the treatment outcome. Patients were divided into three groups according to their predominant histopathological features and the treatment outcomes were assessed based on SNOT-22 scoring system. According to our study, ESS effectively raised the quality of life for CRS patients, and one week after surgery, there was a significant improvement in total symptoms (from 49.01 ± 14.83 to 21.91 ± 8.88). it was noted that there was a decrease in SNOT-22 scores at various intervals from baseline to week 12. The four subscales of the SNOT-22 test (rhinological symptoms, ear and facial symptoms, sleep function, and psychological difficulties) showed significant improvements in quality of life across all groups, and this relationship extended beyond the relationship with rhinological symptoms. These improvements were statistically significant after three months of post operative medical therapy. SNOT-22 is determined to be reliable and convenient to use. After ESS, all of the symptoms in our study showed a drop in SNOT-22 scores from week 1 to week 12, indicating an improvement in overall symptoms. Therefore, it can be used to monitor the success of surgical intervention in addition to medicinal therapy.

A randomized controlled trial on triamcinolone versus saline impregnated merocel post endoscopic sinus surgery: Our experience in a tertiary care centre

Purpose

To assess the potential benefit of impregnating Merocel (a non-absorbable nasal dressing) with a topical steroid solution, for use as a direct and slow local delivery system of steroids after sinus surgery to improve postoperative wound healing.

Methods

In this randomized controlled trial, 40 patients with bilateral chronic rhinosinusitis with nasal polyposis were subjected to functional endoscopic sinus surgery. Following the completion of the surgery, Merocel packs were inserted in the bilateral nasal cavities and infiltrated with 4 mL triamcinolone (40 mg/mL) in one nasal cavity (treatment group) and 4 mL normal saline in the other (control group). Nasal packs were removed on the third postoperative day and postoperative healing assessment was done on postoperative Weeks 1, 2, 4, and 12. The findings were noted as per Lund Kennedy (LKES) and perioperative sinus endoscopy (POSE) scores and compared on both sides.

Results

Significant (P < 0.05) improvement was noted in Lund Kennedy score for crusting and polyp at Week 12, for edema at Week 1, and nasal discharge at Weeks 1 and 12, but there was no significant improvement in scarring at any week. Overall, the difference between the treatment and control arms was statistically significant at all postoperative visits except at Week 4. Also, there was a significant improvement in POSE scores at Weeks 1, 2, and 12 but not at Week 4.

Conclusion

This study positively concludes that the nasal cavity packed with drug-soaked packs had less scarring and edema in the postoperative period and the overall wound healing was much better as compared to saline-soaked packs.

[Results of a survey on the current management of chronic rhinosinusitis with nasal polyps in Germany]

INTRODUCTION

With a prevalence of 0.55% to 4%, chronic rhinosinusitis with nasal polyps (CRSwNP) is a relevant part of the daily work of German otolaryngologists. The aim of the questionnaire-based data collection was to assess the current treatment status of CRSwNP in Germany.

MATERIAL AND METHODS

For this purpose, 24 questions within an anonymized online questionnaire were sent to all German ENT departments.

RESULTS

Of 160 contacted ENT departments, 50 participated in the survey (31.3%). Among these, 76% performed more than 100 sinus surgeries annually and 38% treated more than 50 patients with biologics. Saline irrigations (80%) and intranasal glucocorticoids (GCS, 96%) were the most common conservative therapies. Systemic GCSs (52%) and intranasal GCS irrigation (20%) were less common. 80% of departments used biologics in the therapy of CRSwNP with an overall preference for dupilumab (70%). For therapy of aspirin intolerance, biologics (52%) were preferred to aspirin desensitization (26%). Prior to treatment with biologics clinical workup included the nasal polyp score (90%), the SNOT-22 questionnaire (84%), surrogate markers of type 2 inflammation (60%-72%), and computer tomography (50%). Final treatment success was assessed after 24 weeks (50%).

CONCLUSION

Mostly, the responding departments followed German and European recommendations for diagnosis and therapy of CRSwNP. Therapy with biologics is widely used. The value of preoperative systemic GCS and the frequent performance of CT before initiation of therapy with a biologic should be debated in regard to its currently widespread use.

Bioabsorbable dressing impregnated with betamethasone and ciprofloxacin after endoscopic sinus surgery: A randomized, double-blind, placebo-controlled study

BACKGROUND

In addition to its hemostatic and stabilization role, biodegradable nasal packing can be used as a carrier for drugs after functional endoscopic sinus surgery (FESS). The aim of this study was to compare the influence of biodegradable synthetic polyurethane foam (NasoPore) soaked with ciprofloxacin, or betamethasone, or both to the same foam soaked with saline after FESS.

METHODS

120 adults with chronic rhinosinusitis, with and without polyps, directed for bilateral full-house FESS were enrolled for the study. The patients were randomized and blinded into 3 groups, depending on the type of postoperative procedure applied. Thus, NasoPore soaked with antibiotic was provided to the first group; in the second group, the steroid was used; and the combination of both, in the third group. In each case, the aforementioned procedure was administered on one side of the nose, while NasoPore was soaked in saline on the other, at the end of the surgery, respectively. The patients were requested to complete a questionnaire during their postoperative visits at 2, 10, 30, 90, and 180 days, scoring the level of complaints on the VAS scale, separately for each side. The evaluation of the healing process was performed at each visit using rigid endoscopy and subsequently rated on numerical scales.

RESULTS

Decreased mucosal edema and secretion; reduced Lund-Kennedy score; and favorable influences on facial pressure, nasal blockage, and smell were most evidently seen in the group receiving the antibioticsteroid combination.

CONCLUSIONS

The application of biodegradable nasal packing with betamethasone and ciprofloxacin in sino-nasal surgery has positive effects not only on the healing process but also impacts patient's comfort. To optimize it, however, further research is needed.

Sinonasal Symptom Correlation With the Postoperative Polyp Scale (POPS)

BACKGROUND

Commonly used endoscopic nasal polyp grading scales have been shown to correlate poorly with symptom scores and quality of life metrics. The recently described Postoperative Polyp Scale (POPS) is a grading system that more accurately characterizes polyp recurrence in postoperative sinus cavities by describing incremental recurrence in relation to the surgically opened sinus cavities.

OBJECTIVE

The objective of this study was to determine if the POPS correlated with sinonasal symptoms.

METHODS

CRSwNP patients were prospectively administered SNOT-22 questionnaires and graded according to the POPS starting at their 1-month postoperative appointments. Total POPS scores (sum of each side) and Max POPS score (larger value of left and right) were correlated with SNOT-22 total scores and subdomains using Kendall correlation testing.

RESULTS

A total of 127 patients were enrolled in the study. Both Total POPS or Max POPS were significantly correlated to the SNOT-22 total score (P < .001, P < .001), Rhinologic (P < .001, P < .001), Extra-Nasal Rhinologic (P < .001, P < .001), Ear/Facial (P < .001, P < .001), and Psychologic (P = .028, P = .017) subdomains. Kendall's tau indicated strong correlation (≥0.3) with Rhinologic subdomain, moderate correlation (.21-.29) with Extra-Nasal Rhinologic and Ear/Facial subdomains, and weak correlation (.1-.19) with Psychologic subdomain.

CONCLUSION

Previous endoscopic nasal polyp grading scales poorly correlate with symptoms and patient reported outcome measures. The new POPS moderately correlates with the total SNOT-22 score and strongly correlates with the Rhinologic subdomain, indicating that it may have good potential as a tool to evaluate postoperative CRSwNP patients.

Correlation of patient reported outcome measures with endoscopic findings in pediatric chronic adenoiditis and chronic rhinosinusitis

BACKGROUND

Studies in adult chronic rhinosinusitis (CRS) showed poor correlation between patient reported outcome measures (PROMs) and objective findings. Our goal is to study the correlation between the sinus and nasal quality of life (SN-5) and the 22-items sinonasal outcome test (SNOT-22) surveys with endoscopy findings in children with chronic adenoiditis (CA) and CRS.

METHODS

Cross-sectional study of all pediatric patients (age 2-18) presenting for CA or CRS was performed. Patients and caregivers were asked to fill the SN-5 and SNOT-22 questionnaires at initial and follow up visits. Demographics and comorbidities were collected. Objective findings included endoscopy Modified Lund-Kennedy (MLK) scores and adenoid tissue size.

RESULTS

124 children were included, with mean age of 9.9 years (SD = 4.8) and 46.8% female. 36.3% had allergic rhinitis, 23.4% had asthma, and 4% had obstructive sleep apnea. Moderate correlation was found between the rhinologic domain of SNOT-22 and MLK scores (r = 0.36, p = 0.001) and between SN5 scores and adenoid size in all patients (r = 0.39, p < 0.001). SNOT-22 scores showed moderate correlation with adenoid size (r = 0.42, p < 0.001) more specifically in CA patients (r = 0.54, p < 0.001). The correlation of SN5 and MLK scores were higher in children with allergic rhinitis or asthma. The correlation between SN5 and adenoid size was lower in children with allergic rhinitis or asthma.

CONCLUSION

There is discrepancy between the subjective measures and the objective findings in children with CA or CRS. The physical exam findings may not reflect the effect of CRS on the quality of life of children.

MicroRNA-125b Is a Potential Predictor of Surgical Outcomes in Chronic Rhinosinusitis with Nasal Polyps

BACKGROUND

Despite advances in surgical techniques, recurrence rates after endoscopic sinus surgery (ESS) for chronic rhinosinusitis with nasal polyps (CRSwNP) remain high and difficult to predict.

OBJECTIVE

This study aimed to evaluate the potential role of microRNA 125b (miR-125b) in predicting disease evolution following ESS.

METHODS

We conducted a prospective study including patients undergoing first ESS for CRSwNP in our department between January 2020 and November 2021. We determined miR-125b levels from nasal polyps and pursued a standardized follow-up for at least 18 months for each patient.

RESULTS

A total of 86 patients were included in the study. Higher postoperative endoscopy scores were associated with more severe disease at presentation on computed tomography scan, presence of concomitant asthma, and higher values of miR-125b. Even after multivariate repeated measures analysis and adjustments for confounders, miR-125b remained statistically significant. Moreover, miR-125 was the most important factor in predicting disease evolution at 18 months.

CONCLUSION

A clear, robust relation between nasal polyp control evaluated through objective measures and miR-125b values was observed. This finding indicates the potential role of miR-125b in predicting the course of the disease following ESS.

The efficacy of steroid-eluting stents on the local inflammation of chronic rhinosinusitis with nasal polyposis after endoscopic sinus surgery: a multicenter prospective longitudinal study

PURPOSE

Attenuating local inflammation of chronic rhinosinusitis with nasal polyps (CRSwNP) after endoscopic sinus surgery (ESS) was crucial. Corticosteroids were generally exploited to ameliorate the postoperative state of CRSwNP. This study aims to verify the efficacy of steroid-eluting stents on the local inflammation of CRSwNP following ESS.

METHODS

57 CRSwNP were enrolled from September 2021 to April 2022. 30 were with stents, and 27 were without stents after ESS. Eosinophilic cationic protein (ECP), myeloperoxidase (MPO), eosinophil, and neutrophil levels in nasal secretions, as well as visual analog scale (VAS) and modified perioperative sinus endoscopy (POSE) scores, were assessed preoperatively and after 2, 4, 8, and 12 weeks.

RESULTS

All subjects of CRSwNP exhibited reduced results of eosinophil levels, neutrophil levels, nasal obstruction, nasal discharge, loss of smell, and total VAS scores after 12 weeks compared to the preoperative ones (p < 0.05). Compared with control subjects, CRSwNP with stents acquired lower levels of ECP, MPO, loss of smell, total VAS, and POSE scores at four follow-up visits, as well as reduced eosinophil and neutrophil levels in nasal secretions after 12 weeks (p < 0.05). Correlation analysis revealed that postoperative ECP and MPO levels of CRSwNP in nasal secretions correlated strongly with eosinophil and neutrophil levels, respectively, as well as POSE scores (r > 0.6).

CONCLUSION

These findings indicated that steroid-eluting stents might be an acclaimed option for CRSwNP in alleviating local inflammation to acquire a superior state after ESS.

Postoperative Polyp Scale (POPS): Development of a New Sinonasal Polyp Grading Scale

OBJECTIVE

Commonly used endoscopic grading scales, such as the nasal polyp scale, inadequately describe the degree of polyposis found postoperatively in the paranasal sinus cavities. The purpose of this study was to create a novel grading system that more accurately characterizes polyp recurrence in postoperative sinus cavities, the Postoperative Polyp Scale (POPS).

METHODS

A modified Delphi method was utilized to establish the POPS using consensus opinion among 13 general otolaryngologists, rhinologists, and allergists. Postoperative endoscopy videos from 50 patients with chronic rhinosinusitis with nasal polyps were reviewed by 7 fellowship-trained rhinologists and scored according to the POPS. Videos were rated again 1 month later by the same reviewers, and scores were assessed for test-retest and inter-rater reliability.

RESULTS

Overall inter-rater reliability for the first and second reviews of the 52 videos was Kf = 0.49 (95% CI 0.42-0.57) and Kf = 0.50 (95% CI 0.42-0.57) for the POPS. Intra-rater reliability showed near-perfect test-retest reliability for the POPS with Kf = 0.80 (95% CI 0.76-0.84).

CONCLUSION

The POPS is an easy-to-use, reliable, and novel objective endoscopic grading scale that more accurately describes polyp recurrence in the postoperative state which will be useful in the future for measuring the efficacy of various medical and surgical interventions.

LEVEL OF EVIDENCE

5 Laryngoscope, 133:2885-2890, 2023.

Systemic corticosteroids in treatment of chronic rhinosinusitis-A systematic review

Purpose

When first-line chronic rhinosinusitis (CRS) treatment fails, patients can either be treated with oral or injected systemic corticosteroids. Although the EPOS and international guidelines for CRS do not mention injected corticosteroids, it is commonly used by ear, nose, and throat specialists. While the risks of systemic corticosteroids, in general, are known, the pros and cons of injected and oral corticosteroids (OCS) in CRS treatment are unclear.

Methods

A systematic review of studies that report the effects and/or side effects of injected and oral corticosteroids in the treatment of CRS was made according to the PRISMA guidelines.

Results

Altogether, 48 studies were included, only five studies reported on injected corticosteroids, and five attended with side effects. Three studies found beneficial effects of OCS perioperatively on sinus surgery, while four articles found no effect. Nineteen articles reported that OCS resulted in an improvement in symptoms. Two articles presented a longer-lasting effect of injected corticosteroids than OCS. Three studies reported adverse side effects of systemic corticosteroids, while two studies showed no adverse side effects. One study showed less adrenal suppression after injected corticosteroids compared to OCS. The evidence is not strong but shows a positive effect of systemic corticosteroids that lasts longer with injections.

Conclusion

Although systemic corticosteroids are widely used to treat CRS, there is a lack of studies comparing the OCS and injected corticosteroids. The evidence is sparse, however, injected steroids show longer effects with fewer side effects. An RCT study is needed to compare OCS and injected corticosteroids.

Efficacy of Triamcinolone Nasal Packing on Post-Operative Outcome in Endoscopic Sinus Surgery

Introduction: Endoscopic sinus surgery is a frequently performed surgery for sinonasal polyposis. This includes various complications such as Crusting and synechiae formation etc. which can be reduced or minimised by regular nasal douching and nasal toileting in immediate post operative period. Methods: This study was conducted to assess the quality of life using SNOT 22 score and the efficacy of Triamcinolone Acetate impregnated anterior nasal packing based on the Peri-Operative Sinus Endoscopic (POSE) score and Lund Kennedy score on short and midterm post operative outcomes in patients undergoing Endoscopic Sinus Surgery for sinonasalpolyposis. This study was a prospective observational study comprising of 80 patients diagnosed with sinonasal polyposis. Patients were divided into two groups with 40 patients in group A (non absorbable Triamcinolone Acetate impregnated nasal packing) and 40 patients in group B(non absorbable Saline impregnated nasal packing). Study setting: This study was conducted at a tertiary care centre in South India from July 2017 to July 2019 after EthicsCommitteeapproval. Results of this study showed Improvement in quality of life index in the postoperative period in both Group A (Triamcinolone Acetate) and Group B (saline). Lund Kennedy and Peri operative sinus endoscopy score (POSE) showed statistically significant results with better and early healing among Group A (Triamcinolone Acetate) patients. Conclusion: This shows Triamcinolone Acetate nasal packing in intaoperative period helps to reduce early post operative complications such as edema,crusting and synechiae formation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03496-9.

How to manage recurrences after surgery in CRSwNP patients in the biologic era: a narrative review

Objective

This narrative review analyses factors affecting recurrence of Chronic rhinosinusitis with nasal polyps (CRSwNP) after surgery, such as type, extension and completeness of endoscopic sinus surgery (ESS). We also described new implications in the management of recurrences after the advent of biologics.

Methods

We identified four topics: definition of disease state; factors linked to recurrence of polyps; evaluation and management of recurrence in clinical practice.

Results

We analysed the differences between exacerbation and recurrence, as well as the concept of "controlled disease". We focused on potential predictors of recurrence after ESS, such as type 2 inflammation, asthma, aspirin-exacerbated respiratory disease, incomplete initial surgery and lack of adherence to long-term post-operative local corticosteroids. We discussed the new aspects of diagnosis and treatment of recurrences after surgery, summarising our suggestions in a detailed algorithm for practical management of patients with recurrent disease.

Conclusions

The results emphasised the importance of accurate evaluation of patients with CRSwNP recurrence, focusing on the reasons of failure and risk of disease progression, in order to guide personalised interventions. It is crucial to define the concept of appropriate surgery, which affects the choice between starting a biologic or repeating surgery.

Liu D, A. Müller C, A. Stuck B, Welge-Lüssen A, Hähner A. Olfactory Dysfunction: Etiology, Diagnosis, and Treatment

BACKGROUND

Disorders of the sense of smell have received greater attention because of the frequency with which they occur as a symptom of SARS-CoV-2 infection. Olfactory dysfunction can lead to profound reduction in quality of life and may arise from many different causes.

METHODS

A selective literature review was conducted with consideration of the current version of the guideline issued by the Association of the Scientific Medical Societies in Germany.

RESULTS

The cornerstones of diagnosis are the relevant medical history and psychophysical testing of olfactory function using standardized validated tests. Modern treatment strategies are oriented on the cause of the dysfunction. While treatment of the underlying inflammation takes precedence in patients with sinunasal dysosmia, olfactory training is the primary treatment option for other forms of the disorder. The prognosis is determined not only by the cause of the olfactory dysfunction and the patient's age, but also by the olfactory performance as measured at the time of diagnosis.

CONCLUSION

Options for the treatment of olfactory dysfunction are available but limited, depending on the cause. It is therefore important to carry out a detailed diagnostic work-up and keep the patient informed of the expected course and prognosis.

Effect of postoperative systemic prednisolone on short-term and long-term outcomes in chronic rhinosinusitis with nasal polyps: A multi-centered randomized clinical trial

Introduction

The objective of this study was to determine whether postoperative additive systemic steroid administration in chronic rhinosinusitis with nasal polyps (CRSwNP) impacted selected endoscopic, subjective and objective outcome measures.

Methods

This was a prospective, randomized, double-blind, placebo-controlled, noninferiority multicenter trial of n=106 patients with CRSwNP. All patients underwent primary functional endoscopic sinus surgery (FESS) followed by topical nasal steroids. Patients were randomized to a systemic steroid or placebo for 1 month. Patients were followed up for 2 years over 9 time points. The primary outcome measures were the differences between groups with respect to the nasal polyp score (NPS) and sinonasal quality of life (SNQoL). Secondary outcome measures included interactions with respect to the Lund-Kennedy score (LKS), sinonasal symptoms, general quality of life (GQoL), 16-item odor identification test scores, recurrence rates, need for revision surgery and mucus biomarker levels.

Results

106 patients were randomized to either the placebo or the systemic steroid group (n=53 per group). Postoperative systemic steroids were not superior to placebo with respect to all primary (p= 0.077) and secondary outcome measures (p&gt;0.05 for all). Reported adverse events were similar between the two groups.

Conclusion

In conclusion, the addition of postoperative systemic steroids after primary FESS did not confer a benefit over topical steroid nasal spray alone with respect to NPS, SNQOL, LKS, GQOL, sinonasal symptoms, smell scores, recurrence rates, the need for revision surgery or biomarkers over a short-term follow-up of up to 9 months and a long-term follow-up of up to 24 months in CRSwNP patients. Functional endoscopic surgery did, however, show a strong effect on all outcome measures, which remained relatively stable up to the endpoint at 2 years.

Preservation versus resection of middle turbinate in endoscopic transnasal transsphenoidal pituitary surgery

BACKGROUND

The strategic position of the middle turbinate (MT) within the nasal cavity makes it the first kick start to resect pituitary pathology through Endoscopic Transnasal Transsphenoidal Surgery (ETTS). This research aimed to determine if the type of endonasal endoscopic approach, MT resection (MTres) versus MT preservation (MTpre), for pituitary surgery affects olfaction and sinonasal function within a subjective as well as objective manner.

PATIENTS & METHODS

A prospective cohort comparative study was conducted to compare the sinonasal and olfaction outcomes pre and post operatively for both groups. Sinonasal symptoms were evaluated subjectively by Sino-Nasal Outcome Test (SNOT-22), while objectively by Peri-Operative Sinus Endoscope Score (POSE) along with Lund-Mackay radiological scoring system (LMS), and a Sniffin Sticks Identification test (SIT) (Burghart, Germany) was used to measure the olfaction intensity. In both groups were used on a pre-operative period and after one, three, and six months post operatively.

RESULTS

96 patients were recruited within predetermined criteria. It is found that there are no significant differences in SIT between both groups with a ρ value 0.439 post operatively. The average change in score (delta) was an increase of 0.3, with changes ranging from -3 to +4. There was no significant difference in sinonasal symptoms score among both groups, with ρ 0.07 posts operatively. There was a minor upsurge in POSE score and LMS in the preservation group but without remarkable differences with ρ value 0.1 and 0.2 subsequently. It is found that there are no significant differences in SIT between both groups with a ρ value 0.439 post operatively.

CONCLUSION

Despite these amendments to the nasal cavity, we approved that these changes do not affect the sinonasal functions.

Hemostasis in endoscopic sinus and skull base surgery

PURPOSE OF REVIEW

Bleeding during endoscopic endonasal procedures can quickly obscure critical anatomic landmarks. This increases both the difficulty of the surgical procedure and the risk of complications faced by the patient. As the indications for surgical management of sinonasal pathology grow, it is important to review techniques to minimize bleeding and facilitate safe surgery.

RECENT FINDINGS

Evidence continues to accumulate for best practices in the surgical management of sinonasal disease. Recently, international guidelines have attempted to summarize this body of evidence, lending further support to several interventions which have been advocated as methods to decrease bleeding during endoscopic endonasal surgery. Additional studies have specifically investigated the safety of certain commonly employed techniques. The utility of preoperative corticosteroid therapy and the use of total intravenous anesthetic techniques in increasingly validated. Further evidence supports the safety of reverse Trendelenburg positioning for surgical management of inflammatory disease.

SUMMARY

Recent wide scale systematic review of the literature regarding perioperative and intraoperative management of hemostasis has reinforced the utility of certain interventions, while others remain ambiguous.

Clinically meaningful changes in efficacy outcomes in chronic rhinosinusitis with nasal polyposis

PURPOSE OF REVIEW

Chronic rhinosinusitis with nasal polyps (CRSwNP) carries a high disease burden, and many studies have been done investigating the efficacy of various medical and surgical therapies. However, outcome metrics have varied across these studies, making it difficult to compare therapeutic efficacy on a large scale. In this article, we discuss various outcome metrics used across prior studies as well as the relationship between these measures.

RECENT FINDINGS

Outcome metrics in CRSwNP studies include both clinically assessed and patient-reported outcome measures (PROMs). The former includes olfaction testing, scoring systems based on imaging and endoscopic evaluation, and histopathological and immunohistochemical evaluation of sinus tissue, and the latter includes quality-of-life instruments, symptom severity scales, and disease-control instruments. Recent studies evaluating the efficacy of new biologics have used a combination of both types of metrics.

SUMMARY

Both clinical metrics and patient-reported outcomes provide utility in evaluating disease severity and control in patients with CRSwNP, although there are nuances when comparing therapies in this population as patients with CRSwNP are heterogeneous and may have symptoms across several domains. However, PROMs in conjunction with clinical metrics provide useful information to assess patient symptoms and response to interventions.

Sinonasal Outcomes Using Oral Corticosteroids in Patients with Chronic Rhinosinusitis with Nasal Polyps and Positive Sinonasal Cultures

Introduction Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) and positive sinonasal bacterial cultures may be recalcitrant to topical therapy alone due to the additional local inflammatory burden associated with bacterial infection/colonization.

Objective To evaluate sinonasal outcomes in CRSwNP patients with a positive perioperative bacterial culture, who were treated with postoperative intranasal corticosteroids (INCS) alone versus INCS in combination with a short-term course of oral corticosteroids (OCS).

Methods This is a retrospective chart review of CRSwNP patients. A total of 59 patients met inclusion criteria, including positive perioperative bacterial culture and treatment with INCS with or without concomitant use of OCS. Two cohorts were formed based on the chosen postoperative medical treatment; 32 patients underwent postoperative INCS alone, while 27 underwent INCS plus a ≤ 2-week course of OCS. The 22-item sinonasal outcome test (SNOT-22) scores and Lund-Kennedy scores (LKS) were assessed preoperatively, and at 2-week, 4-week, and 4 to 6 months after endoscopic sinus surgery (ESS).

Results There were no statistically significant differences in postoperative sinonasal symptoms or endoscopic scores between the cohorts treated with INCS plus OCS versus those prescribed INCS alone (p > 0.05). Our regression model failed to demonstrate a relationship between the use of OCS and better sinonasal outcomes at 2-week, 4-week, and 4 to 6 months after ESS (p > 0.05).

Conclusion Our study suggests that in a cohort of CRSwNP patients with recent bacterial infections, the postoperative use of combined OCS and INCS did not result in a statistical improvement of endoscopic and symptomatic outcomes over INCS irrigation alone. However, both treatment groups had a clinically significant improvement based on the Minimal Clinically Important Difference.

A prospective longitudinal study of clinical outcome and quality of life assessment in patients with chronic rhinosinusitis after functional endoscopic sinus surgery using sino nasal outcome test-22

Chronic rhinosinusitis (CRS) significantly affect the quality of life (QoL) of patients. The study was conducted in CRS patients who were treated with functional endoscopic sinus surgery (FESS) after failure of medical treatment to analyze clinical outcome using prospectively collected data through a symptom-based rhinosinusitis outcome measure, the Sino-nasal Outcome Test-22 (SNOT-22). The aim of the study was to evaluate and compare the QoL in patients of chronic rhinosinusitis pre-operative and after FESS by SNOT-22. The prospective study was conducted on 40 patients of chronic rhinosinusitis with or without nasal polyposis. Demographic, clinical, diagnostic nasal endoscopy and radiological findings were recorded. Visual analogue scoring and SNOT-22 questionnaire scoring were done preoperatively and at 3rd and 6th months post-operatively. These scores were compared and a value of p < 0.01 was considered statistical significant. Nasal obstruction (80%) was the most commonly reported disabling condition followed by rhinorrhea (75%), facial pain-pressure (72.5%), headache and sneezing. The mean preoperative nasal endoscopy score was 8.08 ± 3.65. The mean preoperative Lund Mackay CT scan score was 11.725 ± 3.64. The mean preoperative SNOT-22 score was 46.25 ± 20.44. After FESS, nasal discharge was improved in 86% patients. Average VAS scores showed significant postoperative improvement at 6 months (p < 0.01). The mean postoperative diagnostic nasal endoscopy score improved to 2.80 ± 1.64 at 6 months (p < 0.01). The mean postoperative SNOT-22 scores decreased at postoperative follow up visits at 3 and 6 months to 14.58 ± 4.90 at 3 months and 22.38 ±7.93 at 6 months (p < 0.01). CRS patient refractory to medical treatment showed statistical significant improvement after FESS. The SNOT-22 scoring was easy to use scoring used for QoL assessment showed significant improvement after FESS.

Role of Triamcinolone Irrigation in Postoperative Outcomes in Patients Operated for Chronic Rhinosinusitis: A Matched-Pair Randomized Controlled Trial

PURPOSE

Endoscopic sinus surgery (ESS) is the standard treatment strategy for chronic rhinosinusitis (CRS) resistant to medical treatment, and it is known to have postoperative complications and recurrences, which in turn result in suboptimal outcomes. Several methods are used to prevent postoperative scarring, adhesions, oedema, infection or recurrences in cavities. The role of steroids in improving postoperative outcomes is well established. They can be administered systemically or locally to enhance drug delivery into paranasal sinuses. In this study, we used triamcinolone irrigation immediately following surgery on one side of the nose, in patients with bilateral disease. The objective of this study was to evaluate the effect of intra-operative triamcinolone irrigation on postoperative outcomes, in patients with bilateral pansinusitis.

METHODS

It was an interventional randomized controlled study, conducted at a tertiary care centre in North India. The analysis of 58 patients with bilateral pansinusitis was done from September 2020 to August 2021. At the conclusion of ESS, each patient was randomized to receive triamcinolone irrigation (4 ml of 40mg/ml solution) once and followed by merocel (polyvinyl acetal) packing on one side, while the contralateral side was packed with merocel soaked with saline. Nasal cavities were evaluated using a Hopkins rod endoscope in the postoperative 1st, 3rd, 8th and 12th weeks to look for the presence of postoperative crusting, oedema, polypoidal changes, and discharge. Perioperative sinus endoscopic scores (POSE) were used for endoscopic staging.

RESULTS

The most commonly affected age group was 31-45 years accounting for 39.7%. Males were affected more (63.7%) than the female population (36.3%). There was a reduction in the average POSE scores at the treatment site at all follow-up stages with a significant reduction in crusting, oedema, and scarring in the treatment site (P-value <0.001).

CONCLUSION

Triamcinolone irrigation effectively improves postoperative outcomes and reduces early postoperative complications in CRS patients.

Seeking an optimal dose of preoperative corticosteroids in chronic rhinosinusitis with nasal polyposis: A randomized controlled trial

BACKGROUND

Preoperative corticosteroids have been shown to improve surgical visibility and intraoperative blood loss for chronic rhinosinusitis with nasal polyposis (CRSwNP) patients undergoing endoscopic sinus surgery (ESS). However, there is no consensus on the optimal dosing regimen.

METHODS

A randomized, controlled trial was conducted to compare low, medium, and high dose corticosteroids prior to ESS. Patients with CRSwNP refractory to medical management were randomized to low (N = 8), medium (N = 10), or high (N = 5) dosing regimens of corticosteroids prior to ESS. Baseline disease severity was measured with the 22-item Sino-nasal Outcome Test and Lund-Mackay scores. Modified Lund-Kennedy endoscopic scores (MLKES) were measured at baseline and after corticosteroid treatment. Intraoperative parameters were measured including Boezaart surgical visibility score, intraoperative blood loss, and operative time.

RESULTS

Medium dose corticosteroids demonstrated a superior surgical visibility score to low dose and comparable results to high dose, but these results were not significant (p = 0.33). No significant difference was observed between groups for total blood loss (p = 0.15), operative time (p = 0.87), or change in MLKES (p = 0.27).

CONCLUSIONS

Current recommendations include the use of preoperative corticosteroids in patients with CRSwNP undergoing ESS, but there is no consensus on dose or duration. We did not find a statistically significant difference in surgical field visibility, intraoperative blood loss, or operative time between different dosing regimens. Further studies are needed to evaluate the efficacy of a low-dose preoperative regimen with the goal of reducing cumulative patient exposure to systemic corticosteroids.

Clinical Assessment of Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a common disease that affects >10% of the adult population in Europe and the United States. It has been delineated phenotypically into CRS without nasal polyps and CRS with nasal polyps. Both have a high disease burden and an overlapping spectrum of symptoms such as nasal obstruction, olfactory dysfunction, facial pain, pressure, and nasal discharge. Primary assessment includes evaluation of patient symptoms and impact on quality of life, nasal endoscopic examination, and imaging. Significant progress has been made in the understanding of CRS pathophysiology. There is a move toward describing CRS in terms of the predominant endotype or inflammatory pattern pathomechanism rather than the traditional classification of patients with and without nasal polyps. An increased elucidation of the disease endotypes, as characterized by their inflammatory pathways and mediators, is leading to a tailored more personalized treatment approach to the different disease subtypes.

Correlation of polyp grading scales with patient symptom scores and olfaction in chronic rhinosinusitis: a systematic review and meta-analysis

BACKGROUND

Various nasal polyp (NP) scoring systems have been proposed and used in the literature. However, no single system has been identified as superior. Correlations between NP scoring systems and patient symptoms, quality of life (QOL) or olfaction vary widely.

METHODS

A systematic search of PubMed, CINAHL, Scopus, and Cochrane Library was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Any study examining endoscopy scores and symptom, QOL or olfaction measures in cross sectional manner or after therapeutic intervention were included.

RESULTS

This review identified 55 studies for a pooled meta-analysis of Lund-Kennedy (LK-NP) polyp scores (N = 6), Meltzer scores (N = 6), Nasal polyp scores (NPS; N = 19), Total polyp score (TPS; N=8) Lilholdt scores (N = 8), Olfactory cleft endoscopy score (OCES; N =4), Discharge, inflammation, polyp/edema score (DIP; N = 2), and Perioperative sinus endoscopy score (POSE; N = 2). Meta-regression assessed correlations between NP grading systems and SNOT-22, nasal congestion scores, total nasal symptom scores (TNSS), and Smell Identification Test-40 (SIT40). None of the NP grading systems correlated significantly with any symptom, QOL or olfactory metric. In intervention studies of surgery or monoclonal antibody treatment, changes in NPS scores did not correlate with any patient reported outcome measure (PROM) or olfactory outcomes.

CONCLUSION

Current NP endoscopic scoring systems are not associated with PROMs such as SNOT-22, nasal congestion scores, and TNSS as well as objective measures of olfaction. NP grading systems with improved clinical utility are needed.

International consensus statement on allergy and rhinology: Olfaction

BACKGROUND

The literature regarding clinical olfaction, olfactory loss, and olfactory dysfunction has expanded rapidly over the past two decades, with an exponential rise in the past year. There is substantial variability in the quality of this literature and a need to consolidate and critically review the evidence. It is with that aim that we have gathered experts from around the world to produce this International Consensus on Allergy and Rhinology: Olfaction (ICAR:O).

METHODS

Using previously described methodology, specific topics were developed relating to olfaction. Each topic was assigned a literature review, evidence-based review, or evidence-based review with recommendations format as dictated by available evidence and scope within the ICAR:O document. Following iterative reviews of each topic, the ICAR:O document was integrated and reviewed by all authors for final consensus.

RESULTS

The ICAR:O document reviews nearly 100 separate topics within the realm of olfaction, including diagnosis, epidemiology, disease burden, diagnosis, testing, etiology, treatment, and associated pathologies.

CONCLUSION

This critical review of the existing clinical olfaction literature provides much needed insight and clarity into the evaluation, diagnosis, and treatment of patients with olfactory dysfunction, while also clearly delineating gaps in our knowledge and evidence base that we should investigate further.

Evaluation of the efficacy of postoperative triamcinolone in endoscopic dacryocystorhinostomy using lacrimal symptom questionnaire

PURPOSE

To evaluate the effect of postoperative nasal triamcinolone spray use in primary endoscopic dacryocystorhinostomy using The Lacrimal Symptom Questionnaire.

METHODS

This study included a series of 50 consecutive retrospective cases with primary endoscopic dacryocystorhinostomy and with silicone stent implantation who were followed up for 6 months postoperatively. Patients using nasal triamcinolone spray for 3 months postoperatively were included in the triamcinolone group. Patients not using triamcinolone were included in the control group. Lacrimal stents were removed 3 months postoperatively. The Lacrimal Symptom Questionnaire (Lac-Q) was performed in the preoperative and postoperative 6th month. Anatomical success, functional success, and changes in lacrimal symptom and social impact scores were compared between the two groups 6 months after surgery.

RESULTS

Results of 48 endoscopic dacryocystorhinostomies performed on 48 patients (23 triamcinolone group, 25 control group) meeting the inclusion criteria were analyzed. The anatomical success rate (95.7% vs. 84.0%, p = 0.350) and the functional success rate (91.3% vs. 76.0%, p = 0.249) were higher in the triamcinolone group, but this difference was not statistically significant. No complications were observed in the triamcinolone group, whereas complications developed in two patients in the control group (p = 0.490). The mean change in total lac-Q score was 11.0 in the triamcinolone group and 9.0 in the control group (p = 0.011). The mean change in social impact score was 4.0 in the triamcinolone group and 3.0 in the control group (p = 0.005). Mean change in lacrimal symptom score was 6.0 in the triamcinolone group and 6.0 in the control group (p = 0.368) CONCLUSIONS: Our study indicated that postoperative use of triamcinolone spray increases the success rate of endoscopic dacryocystorhinostomy and also revealed that triamcinolone may also lead to greater improvement in quality of life scores than the control group using a validated questionnaire.

The Effect of the Premedication with Systemic Corticosteroids and Antibiotics on Inflammation and Intraoperative Bleeding During Sinonasal Endoscopic Surgery for Chronic Rhinosinusitis with Nasal Polyps (CRSwNP)

INTRODUCTION

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a disease characterized by a variety of inflammatory mechanisms. Extensive genetic analyses have shown that among the molecules that are involved in its genetic base, interleukins (ILs) play a critical role in the development and progression of CRSwNP. ILs, such us IL-4 (5q31.1), IL-5 (5q31.1), IL-13 (5q31.11), and IL-25 (14q11.2) are found to be overexpressed.

PURPOSE

Our aim is to investigate, through a systemic review, the effect of the premedication with systemic corticosteroids and antibiotics on inflammation and intraoperative bleeding during sinonasal endoscopic surgery for CRSwNP.

MATERIALS AND METHODS

The search period covered January 1979 to February 2021, using the scientific databases PubMed, ScienceDirect, Scopus, Cochrane Library και Google Scholar. Search terms were "effect, premedication, systemic corticosteroids, antibiotics, intraoperative, bleeding, inflammation, sinonasal, endoscopic surgery, chronic rhinosinusitis, and nasal polypοsis."

RESULTS

From an initial 80 titles found in the above medline databases, the evaluations led to the final inclusion of 15 papers. Eighty titles found in the above medline databases. Eleven titles were excluded as they did not include a summary and full text in English language. Sixty-nine titles collected and duplicate references were searched. Twelve titles were excluded due to double reporting. Fifty-seven articles remained for systematic review. Fourty-two articles were excluded after systematic review and correlation with the research field. Fifteen articles were eventually included in the literature review.

CONCLUSIONS

The effect of corticosteroids and antibiotics on the size of nasal polyps, nasal symptoms, and systemic markers of inflammation is significant. Each of the above factors acts on different pathogenetic inflammatory mechanisms.The use of perioperative corticosteroids reduces blood loss and operation time and improves the quality of the surgical field. There are no other medications that have been shown to improve the surgical field and outcome. Whether there is an additive effect on systemic corticosteroids on top of nasal corticosteroids is unclear. The european position paper on rhinosinusitis and nasal polyps steering group advises to use (nasal) corticosteroids before endoscopic sinus surgery.However, it should be considered in future studies whether some minor differences are due to differences in the initial doses of corticosteroids or during treatment in the preoperative period. It is worth mentioning that although high doses of corticosteroids are required to control the progression of rhinosinusitis with nasal polyps, the optimal initial dosage and the total duration of the treatment have not yet been standardized in patients with CRSwNP and future studies are required to determine the 2 above parameters (optimal dosage and duration of treatment). There are, therefore, known risks from corticosteroid administration, and clinicians should consider them when evaluating each patient. Each patient should be considered as an individual case with individualized treatment.

Triamcinolone impregnated bioabsorbable middle meatus packing following endoscopic sinus surgery: a prospective randomized controlled trial

INTRODUCTION

Topical steroids are a mainstay in the treatment of chronic rhinosinusitis (CRS). Multiple delivery methods of topical steroids following sinus surgery have been investigated. The purpose of this trial is to evaluate the effect of triamcinolone impregnated absorbable nasal packing on healing following endoscopic sinus surgery.

METHODS

This is a prospective, randomized, double-blind, placebo-controlled trial. A total of 22 subjects (14 without polyps and 8 with polyps) were enrolled and were randomized to receive triamcinolone impregnated packing in one sinus cavity and normal saline soaked packing in the contralateral sinus cavity. Endoscopic evaluation was completed at the first two post-operative visits, and Lund-Kennedy (LK) endoscopic scores and perioperative sinus endoscopy (POSE) scores were calculated at each visit.

RESULTS

The results of this study found no significant difference in the appearance of the sinuses at either post-operative visit. Mean LK scores for the triamcinolone and saline groups at the first and second post-op visits were 2.09 ± 1.23 v. 2.18 ± 1.01 (p=0.79) and 1.79 ± 1.08 v. 1.68 ± 1.16 (p = 0.77) respectively. POSE scores were 2.59 ± 1.71 v. 2.68 ± 1.62 (p = 0.86) and 1.74 ± 1.15 v. 1.95 ± 1.22 (p = 0.59).

CONCLUSION

The results of this study demonstrated no significant difference in healing, crusting, polyps, edema, or secretions between the triamcinolone treated and non-triamcinolone treated sinuses. There were no adverse effects from use of triamcinolone impregnated absorbable packing. Further studies will be necessary to determine the impact of triamcinolone impregnated absorbable packing following endoscopic sinus surgery. This article is protected by copyright. All rights reserved.

Early postoperative endoscopic score can predict the long-term endoscopic outcomes in eosinophilic chronic rhinosinusitis (ECRS) patients

OBJECTIVE

Eosinophilic Chronic Rhinosinusitis (ECRS) is refractory and recurrent, requiring long-term follow-up after Endoscopic Sinus Surgery (ESS). Endoscopic evaluation is common during postoperative assessment, but how the findings vary over time in postoperative ECRS patients who were treated by the recent standardized management is unclear. We assessed the long-term change in postoperative endoscopic score in ECRS patients using a novel endoscopic scoring system (Escore).

METHODS

This retrospective study included 80 ECRS patients who underwent full-house ESS and were followed for longer than 1-year. Endoscopic procedures were repeated at every follow-up visit and postoperative Escores were assessed from 3-months up to 5-years (median follow-up period was 3-years).

RESULTS

The Escore did not significantly change from that at 3-months (3m-Escore). The Escore at the final observation point (f-Escore) among 80 patients was 9.2 ± 5.6 and there was no significant difference from the 3m-Escore (8.5 ± 4.1, p = 0.363). Twenty-one patients (21/80, 26.3%) were considered to have endoscopically uncontrolled ECRS at their final observation points and the 3m-Escore was identified as an independent predictive factor by multivariate logistic regression analysis. The 3m-Escore cut-off value that was able to predict endoscopically uncontrolled ECRS after long-term follow-up was ≥12.

CONCLUSION

We demonstrated the long-term endoscopic outcomes after full-house ESS and continuous outpatient treatment. Early endoscopic findings (3m-Escore) were a potential predictive factor for the later endoscopic outcome, and a 3m-Escore of 12 or higher may be an indicator of the poor long-term prognosis of sinus mucosa.

LEVEL OF EVIDENCE: 4

Efficacy of triamcinolone acetonide-impregnated Gelfoam nasal pack in management of chronic sinusitis with nasal polyps following endoscopic sinus surgery: a perfectly matched, placebo-controlled trial study

PURPOSE

This perfectly matched, double-blinded, placebo-controlled trial study was performed to investigate the efficacy of triamcinolone acetonide (TAA)-impregnated Gelfoam nasal pack in management of different endotypes of chronic rhinosinusitis with nasal polyps (CRSwNP) following endoscopic sinus surgery (ESS).

METHODS

One hundred and four patients with bilateral CRSwNP undergoing ESS were selected and randomized to receive TAA-soaked nasal packing in one nostril and saline-impregnated dressing contra-laterally. Validated Perioperative Sinus Endoscopy (POSE) scoring system was used to assess the participants' condition at postoperative months 1, 3, 6, 12, and 18.

RESULTS

The treatment side of eosinophilic CRSwNP (EosCRSwNP) group had significantly better endoscopic scores than the contralateral control side in all follow-up visits (P < 0.05 for all comparisons) except for the first postoperative month. No significant difference was detected between the TAA- and saline-treated nostrils in the non-eosinophilic CRSwNP (nonEosCRSwNP) subgroup during the follow-up period. Intergroup comparisons revealed a borderline better POSE score for the treatment side of the EosCRSwNP group compared with the treatment nostril of the nonEosCRSwNP group at months 12 (P = 0.041) and 18 (P = 0.044). At the end of the study period, the treatment side of the EosCRSwNP group demonstrated better clinical response than the saline-treated side in terms of the total POSE scores (P = 0.019), middle turbinate synechia (P = 0.008), middle meatal narrowing (P = 0.010), ethmoid polypoid changes (P = 0.039), ethmoid polyposis (P = 0.027), ethmoid cavity secretions (P = 0.042), and sphenoid severity (P = 0.018).

CONCLUSION

TAA-soaked Gelfoam dressing following bilateral ESS was found to be an effective method for treating CRSwNP particularly for the eosinophilic endotype of the disease.

Comparison between the endoscopic scores of bolgerization versus partial resection of the middle turbinate for management of the postoperative lateralization in the early follow-up period after endoscopic frontal sinusotomy: A randomized controlled study

BACKGROUND

Frontal sinusotomy is a challenging procedure that needs meticulous handling due to its unique anatomical position. Postoperative middle turbinate lateralization is critical comorbidity for the success rate, and many techniques are adopted to prevent it. The study aimed to compare the effect of middle turbinate bolgerization and partial resection on the postoperative endoscopic scores and assess their impact on the middle meatus and the frontal recess outcome.

PATIENT AND METHODS

This prospective study was conducted on forty-one patients undergoing bilateral frontal sinusotomy for chronic frontal sinusitis. Nasal cavities were randomized so that partial middle turbinate resection technique was done alternately with bolgerization approach in every patient. Each participant acted as their control. Both sides were compared using Lund Kennedy Endoscopic Score (LKES) and Perioperative Sinus Endoscopy Score (POSE) at the baseline, 1st, 3rd, and 12th-month intervals postoperatively. Also, middle turbinate status was assessed at the end of the 12th-month interval using POSE score.

RESULTS

The total frontal sinus patency rate was 82.9% (63/76 operated sinus). Baseline scores, LKES (3.79 ± 0.777 vs 4.05 ± 0.769, p = 0.142, for the side of resection and the side for bolgerization respectively) and POSE (1.79 ± 0.413 vs 1.82 ± 0.393, p = 0.777, for the side of resection and the side for bolgerization respectively). Regarding LKES, the differences between both operated sides were fluctuating with p values: 0.001*, 0.171, and 0.044* for the 1st, 3rd, and 12th months follow-up intervals, respectively. Regarding the POSE score of the frontal sinus, the difference between both groups was steadily increasing with p values: 0.318, 0.119, and 0.017* for the 1st, 3rd^, and 12th months follow-up intervals. The middle turbinate's POSE score at the 12th month was significantly higher in the side allocated for bolgerization (p-value = 0.008*).

CONCLUSION

Partial middle turbinate resection showed favorable endoscopic outcomes than bolgerization at the 12th month follow up period in patients undergoing primary ESS for chronic frontal sinusitis.

Assessment of Opioid Use and Analgesic Requirements After Endoscopic Sinus Surgery: A Randomized Clinical Trial

Importance

The opioid epidemic has generated interest in optimizing opioid prescribing after common surgeries. Recent studies have shown a broad range of analgesic prescription patterns following endoscopic sinus surgery (ESS).

Objective

To compare the efficacy of different analgesic regimens after ESS.

Design, Setting, and Participants

This multi-institutional, nonblinded randomized clinical trial was conducted at 6 tertiary centers across the US and Canada and included participants who underwent ESS for acute or chronic rhinosinusitis. The study was conducted from March 2019 to March 2020, and the data were analyzed in November to December 2020.

Interventions

All participants received acetaminophen, 650 mg, as the first-line analgesic. From there, patients were randomized to either oxycodone rescue (oxycodone, 5 mg, as second-line therapy) or ibuprofen rescue (ibuprofen, 600 mg, as second-line therapy, with oxycodone, 5 mg, reserved for breakthrough pain).

Main Outcomes and Measures

Baseline characteristics and disease severity were collected at enrollment. Medication logs, pain scores, and epistaxis measures were collected until postoperative day 7. The primary outcome was the postoperative visual analog scale score for pain. Brief Pain Inventory Pain Severity and Pain Interference Scores were also collected.

Results

A total of 118 patients were randomized (62 [52.5%] oxycodone rescue, 56 [47.5%] ibuprofen rescue; mean [SD] age, 46.7 [16.3] years; 44 women [44.0%]; 83 White [83.0%], 7 Black [7.0%], and 7 Asian individuals [7.0%]). After exclusions for loss to follow-up and noncompliance, 51 remained in the oxycodone rescue group and 49 in the ibuprofen rescue group. The groups had similar demographic characteristics and disease severity. Thirty-two (63%) in the oxycodone rescue group had adequate pain management with acetaminophen only, while 19 (37%) consumed at least 1 oxycodone dose. In the ibuprofen rescue group, 18 (16%) required only acetaminophen, 28 (57%) used only acetaminophen and ibuprofen, and the remaining 13 (26%) consumed 1 or more oxycodone doses. The groups had similar average acetaminophen (9.69 vs 7.96 doses; difference, 1.73; 95% CI, -1.37 to 4.83) and oxycodone (1.89 vs 0.77 doses; difference, 1.13; 95% CI, -0.11 to 2.36) use. Both groups had similar postoperative visual analog scale scores. A subanalysis that compared opioids users with nonusers showed clinically significant lower pain scores in nonusers at multiple postoperative points.

Conclusions and Relevance

In this randomized clinical trial, most patients who underwent ESS could be treated postoperatively using a nonopioid regimen of either acetaminophen alone or acetaminophen and ibuprofen. Ibuprofen as a second-line therapy did not reduce overall narcotic consumption, but the overall narcotic use was low in both groups.

Trial Registration

ClinicalTrials.gov Identifier: NCT03783702.

Chemosensory dysfunction in Cushing's syndrome

PURPOSE

Cushing's syndrome (CS) can lead to structural changes in the brain and cognitive impairment, but chemosensory function has not been investigated yet. The aim was to analyze sense of smell and taste in patients with CS and explore the effect of therapy.

METHODS

The study cohort comprised 20 patients with florid CS treated between 2018 and 2020 in the outpatient clinic of the LMU Munich. We compared these 20 patients with CS to 40 healthy subjects matched for age, sex, and smoking status. Patients' sense of smell and taste was examined at diagnosis and 3 months after successful therapeutic surgery leading to clinical and biochemical remission. Odor threshold, discrimination, and identification were measured with "Sniffin' Sticks", taste was measured with "Taste Strips". Perceived sense of smell and taste was retrieved via a questionnaire.

RESULTS

Patients with florid CS had significantly reduced smell (total smell score 30.3 vs. 34.4, p < 0.0005) and taste scores (9.5 vs. 12.0, p < 0.0005) compared to controls and significantly more frequently hyposmia (55 vs. 2.5%, p < 0.0005), hypogeusia (40 vs. 0%, p < 0.0005), and self-reported chemosensory impairment (60 vs. 0%, p < 0.0005). Three months after successful surgery, CS patients showed significant improvement of odor threshold (8.1 vs. 7.0, p < 0.0005), odor discrimination (12.0 vs. 11.0, p = 0.003), total smell score (33.4 vs. 30.3, p < 0.0005), and taste (11.5 vs. 9.5, p = 0.003).

CONCLUSIONS

Chemosensory dysfunction is a novel and clinically relevant feature of CS.

Conchopexy Suture versus Bolgerization in preventing middle turbinate lateralisation following FESS

Background: Middle turbinate lateralisation is the most common minor post-operative complication following functional endoscopic sinus surgery. This study aimed to compare the outcome between Conchopexy suture and Bolgerization method in preventing middle turbinate lateralisation. Methodology: This was a prospective, comparative and interventional study conducted from May 2018 to November 2019 at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. A total of 68 patients were divided equally into two groups. Following functional endoscopic sinus surgery, the middle turbinate was medialised either by Conchopexy suture or Bolgerization technique. Postoperative assessment was done on the second and 12th week of surgery, where the position of the middle turbinate and status of the sinus cavity were assessed using perioperative sinus endoscopic (POSE) score. Chi-square test and unpaired t test were used for comparison of postoperative results between two groups taking p value of < 0.05 as statistically significant. Results: Lateralised middle turbinate and mean POSE score was 5/34 (14.8%) and 2.1±1.25, respectively, in Conchopexy group whilst in Bolgerization group it was 6/34 (17.6%) and 2.5±1.46. However, the observed differences were not statistically significant. Conclusion: Conchopexy suture and Bolgerization techniques were equally effective in preventing middle turbinate lateralisation. Hence, either of these techniques could be used as an adjunct to FESS to avoid middle turbinate lateralisation.

Effects of implants with steroids after endoscopic sinus surgery: A systematic review with meta-analysis of randomized controlled trials

BACKGROUND

Chronic rhinosinusitis affects approximately 5%-2% of the general population worldwide. Steroid implants after endoscopic sinus surgery (ESS) have drawn considerable interest for their cost savings, but relevant guidelines indicate that evidence on this topic is of low quality with high heterogeneity. The purpose of this study was to examine the efficacy of steroid implants after ESS by synthesizing relevant randomized controlled trials (RCTs).

METHODS

Two authors independently assessed the eligibility of potential references from five biomedical databases. They further extracted relevant data from the included studies, including (a) mean, standard deviation, or standard error for Lund-Kennedy endoscopic (LKE) score and Perioperative Sinus Endoscopy (POSE) score and (b) events and sample sizes of each group for further intervention. Data were pooled in a random-effects model, and results were presented as the weighted mean difference (WMD) or risk ratio (RR) with 95% confidence interval (CI) and I² .

RESULTS

Eleven RCTs (n = 853) were included and showed that the steroid implant group had lower LKE scores (WMD, -1.19; 95% CI, -1.75 to -0.62; I²  = 0%) and POSE scores (WMD, -1.62; 95% CI, -2.47 to -0.76; I²  = 48%) than the placebo implant group at postoperative week 2. Moreover, the reoperation rate in the steroid implant group was also lower than in the placebo implant group (RR, 0.49; 95% CI, 0.30 to 0.80; I²  = 0%). However, no significant difference was observed in the postoperative oral steroid requirement between both groups.

CONCLUSIONS

Collectively, steroid implant decreases LKE and POSE among patients receiving ESS in the short term, but long-term effects remain unclear. Patient-based outcomes are worth further discussion in the future.

Efficacy of Triamcinolone-Soaked Nasal Packing on Endoscopic Dacryocystorhinostomy

PURPOSE

To evaluate the efficacy of triamcinolone-soaked nasal packing in endoscopic dacryocystorhinostomy (EDCR).

METHODS

Patients who underwent EDCR between September 2012 and August 2017 were included. They were assigned to triamcinolone (201 eyes) or control (206 eyes) group based on the order of surgery. Granulation occurrence and outcome were assessed at 3 and 6 months postoperatively, respectively.

RESULTS

The success rates were 94.3% (overall anatomical success), 90.4% (complete anatomical success), 92.1% (overall functional success), and 76.7% (complete functional success). The overall functional success rate was significantly higher in the triamcinolone group (95.0% vs. 89.3%, p = 0.033). The overall anatomical success rate (96.0% vs. 92.7%, p = 0.149) and complete functional success rate (79.6% vs. 73.8%, p = 0.166) were also higher in the triamcinolone group, but this difference was not statistically significant. Granulation occurred in 62 eyes (15.2%); the incidence was significantly lower in the triamcinolone group (10.0% vs. 20.4%, p = 0.003).

CONCLUSION

The authors suggest that use of triamcinolone-soaked nasal packing in EDCR is effective in significantly reducing the incidence of postoperative granulation and epiphora.

Oral Corticosteroids Following Endoscopic Sinus Surgery for Chronic Rhinosinusitis Without Nasal Polyposis: A Randomized Clinical Trial

Importance

Although oral corticosteroids are commonly prescribed following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) without nasal polyposis, there are little data to suggest that this is a beneficial practice.

Objective

To assess the efficacy of oral corticosteroids following ESS in CRS without polyps.

Design, Setting, and Participants

This prospective double-blinded, placebo-controlled, randomized noninferiority clinical trial conducted in a single academic tertiary rhinology practice included adults with CRS without polyps undergoing ESS. Of 81 patients recruited, 72 completed the study.

Interventions

Patients were randomized into 2 treatment groups: a 12-day postoperative taper of oral prednisone vs matched placebo tablets. All study patients also received a uniform 2-week postoperative regimen of oral antibiotics, fluticasone nasal spray, and saline rinses.

Main Outcomes and Measures

The primary outcome measures were Sinonasal Outcome Test-22 (SNOT-22) scores and Lund-Kennedy endoscopy scores, collected preoperatively and postoperatively at 1 week, 1 month, 3 months, and 6 months. Scores were compared between treatment groups at each time point using longitudinal difference between treatment groups and analyzed using 2-way, repeated measures analysis of variance. Secondary outcome measures included treatment-related adverse effects.

Results

Overall, 72 patients (mean [SD] age, 49.4 [14.9] years; 36 men, 36 women) completed the study, with 33 in the prednisone arm and 39 in the placebo arm. When comparing longitudinal differences between treatment groups, there was no clinically meaningful difference observed in SNOT-22 total (F[4254] = 1.71, η2 = 0.01 [95% CI, 0.00-0.05]) or Lund-Kennedy scores (F[4247] = 1.23, η2 = 0.02 [95% CI, 0.00-0.50]). In SNOT-22 subdomain analyses, there was no clinically meaningful difference between treatment groups for rhinologic, extranasal rhinologic, ear/facial, or sleep subdomains. However, the prednisone group had worse longitudinal scores for psychological dysfunction compared with the placebo group (F[4254] = 3.18, η2 = 0.05 [95% CI, 0.02-0.09]). Reported adverse effects were similar between the 2 treatment groups.

Conclusions and Relevance

In this randomized clinical trial of patients with CRS without polyps, oral prednisone following ESS conferred no additional benefit over placebo in terms of SNOT-22 total scores, SNOT-22 rhinologic subscores, or Lund-Kennedy endoscopy scores up to 6 months after surgery. Patients receiving prednisone, however, did demonstrate worse SNOT-22 psychologic subdomain scores. These results suggest that the risks of oral corticosteroids may outweigh the benefits; thus use of oral corticosteroids after ESS for CRS without polyps should be carefully considered.

Trial Registration

ClinicalTrials.gov Identifier: NCT02748070.

Postoperative Infection Rate and Associated Factors Following Endoscopic Sinus Surgery

OBJECTIVES

There is a paucity of data on postoperative infections after endoscopic sinus surgery and associated risk factors. Our objective was to evaluate a cohort of patients undergoing endoscopic sinus surgery (ESS) for chronic rhinosinusitis to determine which perioperative factors may be associated with infection in the 30-day postoperative period.

METHODS

A retrospective cohort study of adults who underwent ESS at a tertiary academic medical center from 2015 to 2018 was performed. The primary outcome was incidence of postoperative infection, defined by identification of sinus purulence on nasal endoscopy necessitating antibiotics within 30 days of surgery. Independent variables collated included the result of postoperative cultures and use of perioperative antibiotics, oral corticosteroids, packing, and steroid-eluting stents. Statistical analysis involved bivariate analysis to identify variables that correlated with postoperative infection and subsequent multivariate logistic regression to identify independent risk factors.

RESULTS

Three hundred seventy-eight unique ESS cases performed in 356 patients were reviewed. The mean age was 46 years (range, 18-87). The most common indication for surgery was chronic rhinosinusitis without nasal polyposis. The postoperative infection rate was 10.1%. The most commonly cultured pathogen was Staphylococcus aureus. Multivariate logistic regression analysis showed that postoperative systemic corticosteroid use was the only risk factor independently associated with infection (OR 3.47 [95% CI 1.23-9.76], P = .018).

CONCLUSION

The incidence of postoperative infection following ESS was 10.1%. The use of postoperative systemic corticosteroids independently increased the risk of infection by 3.47-fold.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Effect of oral steroids on olfactory function in chronic rhinosinusitis with nasal polyps

AIMS

The present study aimed to investigate the effects of oral steroids on olfactory disturbances in patients with chronic rhinosinusitis with nasal polyps (CRSwNP).

MATERIAL AND METHODS

This is a prospective randomized non-blinded study. Selected CRSwNP patients (n=140), with hyposmia, were devided into two groups; group A received a 7-day course of oral steroids with a 12-weeks course of nasal steroids and douching; group B received a 12-weeks course of nasal steroids and douching. Assessment included Sniffin' Sticks scores, visual analogue scale score for olfaction and discomfort (VASsmell, VASdis), the Sinonasal Outcome Test-22, Greek-version (SNOT22-Gr) and the endoscopic appearance (EAS).

OBJECTIVES

The main objective was to compare the olfactory effect of the different therapy in group A and group B, at 2, 12 and 24 weeks. Accessory objectives included the comparison of EAS, VASdis and SNOT22-Gr between groups, the evaluation of the therapeutic outcome duration, and, the investigation of potential correlation between the evaluated parameters.

RESULTS

The 2-weeks evaluation showed a significant statistical difference (P<0.001) for all parameters except VASdis. Olfactory outcomes (Sniffin' Sticks and VASsmell scale scores) were found significantly better in group A at the 24-weeks evaluation (P<0.001). Within groups, the therapeutic result remained stable between the 12-weeks and 24-weeks evaluation (P>0.05). Sniffin' Sticks score was strongly correlated at 12-weeks evaluation with EAS (rho=0.58, P<0.001).

CONCLUSION

Our results suggest that a combination treatment of oral and nasal steroids in well-selected patients with CRSwNP may result in early olfaction restoration with a possible long-term effect.

Efficacy of Absorbable Steroid-Impregnated Nasal Packing in Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis: A Systematic Review

OBJECTIVE

To evaluate the efficacy of absorbable steroid-impregnated nasal packing on postoperative outcomes following functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis (CRS).

METHODS

A systematic review of the literature was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve databases (including Journals@Ovid, Embase®, Medline®, EBM Reviews and Joanna Briggs Institute EBP Database) were searched using relevant keywords and expanded with corresponding MeSH/Emtree terms. Results were narrowed to English articles assessing the efficacy of absorbable packing impregnated with steroids post-production placed at time of surgery under general anesthetic, with hollow-lumen devices and devices inserted in-office excluded.

RESULTS

Eight studies met criteria and were included in this review. Five evaluated the efficacy of the intervention in only CRS with nasal polyposis (CRSwNP) patients, two included all subtypes of CRS, and one included only CRS without nasal polyposis (CRSsNP). Of the eight studies, four studied the efficacy of Nasopore®, three studied bioabsorbable gels, and one studied bioabsorbable calcium alginate. Four studies applied triamcinolone as the operative steroid, with the other studies utilizing betamethasone, budesonide, mometasone, and dexamethasone. Seven studies demonstrated statistically significant improvements in endoscopic outcomes using validated scoring scales, albeit at differing timepoints. The one study which included only CRSsNP patients failed to find a significant difference.

CONCLUSION

Steroid-impregnated nasal packing appears to have positive effects on postoperative endoscopic outcomes in CRSwNP patients undergoing FESS. Additional research is needed to evaluate the efficacy of these interventions in more recently defined subtypes of CRS, and whether these interventions differ in their efficacy in eosinophilic and non-eosinophilic CRS. Laryngoscope, 131:1704-1714, 2021.

CSO (Canadian Society of Otolaryngology - Head & Neck Surgery) position paper on rhinologic and skull base surgery during the COVID-19 pandemic

Healthcare services in many countries have been partially or completely disrupted by the Coronavirus (COVID-19) pandemic since its onset in the end of 2019. Amongst the most impacted are the elective medical and surgical services in order to conserve resources to care for COVID-19 patients. As the number of infected patients decrease across Canada, elective surgeries are being restarted in a staged manner. Since Otolaryngologists - Head & Neck Surgeons manage surgical diseases of the upper aerodigestive tract where the highest viral load reside, it is imperative that these surgeries resume in a safe manner. The aim of this document is to compile the current best evidence available and provide expert consensus on the safe restart of rhinologic and skull base surgeries while discussing the pre-operative, intra-operative, and post-operative care and tips. Risk assessment, patient selection, case triage, and pre-operative COVID-19 testing will be analyzed and discussed. These guidelines will also consider the optimal use of personal protective equipment for specific cases, general and specific operative room precautions, and practical tips of intra-operative maneuvers to optimize patient and provider safety. Given that the literature surrounding COVID-19 is rapidly evolving, these recommendations will serve to start our specialty back into elective rhinologic surgeries over the next months and they may change as we learn more about this disease.

Endoscopic polypectomy performed in clinic for chronic rhinosinusitis with nasal polyps: study protocol for the EPIC multicentre randomised controlled trial

INTRODUCTION

Chronic rhinosinusitis (CRS) is common, with a Canadian prevalence of 5%, and associated with significant morbidity. Understandably, CRS impairs workplace productivity but that productivity substantially increases following surgical treatment. CRS with nasal polyps (CRSwNP), the most common type of CRS, is usually treated with a combination of medications and endoscopic sinus surgery (ESS). Historically, surgical treatment has only been performed in the operating room at a cost of about $C3500. However, recent studies have shown that a de-escalated procedure, endoscopic polypectomy performed in clinic (EPIC), can provide an improvement in patient symptoms to levels equal to those for ESS. Moreover, EPIC has additional proposed advantages including shorter recovery time, significantly lower cost to the healthcare system and shorter wait time for the patient. There is currently insufficient evidence to draw conclusions about the superiority of polypectomy or ESS for the management of CRSwNP.

METHODS AND ANALYSIS

We designed a multicentre, open-label, randomised controlled trial to evaluate whether EPIC was non-inferior to the current clinical standard, ESS for the treatment of CRSwNP. The primary outcome is the Sinonasal Outcome Test-22 score measured at baseline and at 3 months after surgery. Other outcomes include peak nasal inspiratory flow, quality of life measured by the EuroQoL 5 Dimensions 5 Levels questionnaire and work impairment using the Work Productivity and Activity Impairment Questionnaire.We aim to recruit 140 patients from sites across Canada. Participants will be randomly assigned to EPIC or ESS and followed up for 3 months in clinic after the procedure. Additionally, participants will enter a 5-year long-term follow-up period.

ETHICS AND DISSEMINATION

This study was approved by the Ottawa Health Sciences Network Research Ethics Board for all sites in Ontario, Canada (study number CTO0801). Sites located outside of Ontario obtained approval from their local/institutional research ethics board.

TRIAL REGISTRATION NUMBER

NCT02975310.

Intraoperative Applications of Topical Corticosteroid Therapy for Chronic Rhinosinusitis

OBJECTIVES

To provide an overview of recent techniques and technologies for the application of topical corticosteroid therapy immediately following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS).

METHODS

A comprehensive search in the PubMed and Google Scholar databases was conducted to identify publications between January 2000 and December 2019 detailing clinical trials that have evaluated the efficacy and safety of intraoperative applications of topical corticosteroids for CRS.

RESULTS

A total of 21 articles, all of which highlight a variety of corticosteroid-infused products, including Propel corticosteroid-eluting stents, NasoPore, Merocel, SinuBand, calcium alginate, and bioresorbable gel-type products, are included for review. Propel stents are the only devices that have achieved level 1A evidence in terms of efficacy and have data to support their safety. The remaining products have shown mixed results in terms of efficacy and safety.

CONCLUSION

A wide range of techniques and technologies have been introduced to enhance the topical delivery of corticosteroids into the neosinuses after ESS for CRS. Regarding efficacy, there is level 1A evidence to support the use of Propel stents. Most of the remaining strategies show some degree of efficacy. Direct comparisons across the different strategies are limited owing to the varied uses of delivery vectors, corticosteroid choices, and doses of corticosteroids. Propel stents and SinuBand have sufficient data to support systemic and ocular safety, whereas the remaining products have limited data to support their safety.

Intranasal Application of Lactococcus lactis W136 Is Safe in Chronic Rhinosinusitis Patients With Previous Sinus Surgery

Objective: Modulation of the dysbiotic gut microbiome with “healthy” bacteria via a stool transplant or supplementation is increasingly practiced, however this approach has not been explored in the nasal passages. We wished to verify whether Lactococcus lactis W136 (L. lactis W136) bacteria could be safely applied via irrigation to the nasal and sinus passages in individuals with chronic rhinosinusitis (CRS) with previous undergone endoscopic sinus surgery, and whether this was accompanied by bacterial community flora modification.

Study Design: Prospective open-label pilot trial of safety and feasibility.

Setting: Academic tertiary hospital center.

Subjects and Methods: Twenty-four patients with CRS refractory to previous medical and surgical therapy received a 14-day course of BID sinus irrigations containing 1.2 × 10⁹ CFU live L. lactis W136. Patients were monitored for safety using questionnaire, sinus endoscopy, otoscopy, UPSIT-40 smell testing, and endoscopically-obtained conventional sinus culture and a swab for 16S microbiome profiling.

Results: All 24 patients receiving at least one treatment successfully completed treatment. L. lactis W136 probiotic treatment was safe, with no major adverse events or new infections. Treatment was associated with improvement in sinus symptoms, QOL, and mucosal scores, which remained improved during the subsequent 14-day observation period. Microbiome changes associated with treatment were limited to an increase of the pathobiont Dolosigranulum pigrum, a bacteria identified as potentially beneficial in the upper airways. Subgroup analysis suggested differences in microbiomes and responses for CRSsNP and CRSwNP phenotypes, but these did not attain significance.

Conclusion: Intranasal irrigation of live L. lactis W136 bacteria to patients with refractory chronic rhinosinusitis was safe, and was associated with effects on symptoms, mucosal aspect and microbiome composition. Intranasal bacteria may thus find a role as a treatment strategy for CRS.

Clinical Trials Registration:www.ClinicalTrials.gov. identifier: NCT04048174.