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

Orthonasal and retronasal olfactory function in patients with chronic rhinosinusitis without nasal polyps undergoing endoscopic sinonasal surgery

BACKGROUND

Olfactory dysfunction (OD) is a key symptom of chronic rhinosinusitis (CRS). Although extensively studied in CRS with nasal polyps (CRSwNP), OD in CRS without nasal polyps (CRSsNP) remains under-researched. This study aims to assess the prevalence of OD and its evolution in surgically naïve patients with CRSsNP undergoing endoscopic sinus surgery (ESS).

METHODS

This prospective study included 97 participants with CRSsNP (mean age, 46.5 years; 70.1% men) and 97 healthy controls (mean age, 46.5 years; 70.1% men). Participants underwent psychophysical evaluations of orthonasal (using the Sniffin' Sticks test) and retronasal olfaction (using powdered aromas) at enrolment and 6 months post-ESS.

RESULTS

Out of 97 patients, 81 (83.5%) completed all assessments. At enrolment, 23 (28.4%) CRSsNP patients had OD based on composite threshold, discrimination, identification scores, compared with 7 (8.6%) controls (absolute % difference, 19.8% [95% CI, 8.2-31.4]). Retronasal olfactory function was also significantly worse in CRSsNP patients. Six months post-ESS, 30 patients (37.0%) experienced a clinically significant improvement in olfactory, whereas nonsignificant changes were observed in retronasal olfactory score, and 3.7% of patients experienced a deterioration of the olfactory function.

CONCLUSIONS

In conclusion, although 37% of patients experienced a clinically significant improvement in their sense of smell following ESS, the overall prevalence of OD in this surgically naive population appears relatively low, especially when compared to that observed in patients with CRSwNP. Therefore, ESS may offer some benefits for enhancing orthonasal olfactory function, but the extent of these improvements appears to be limited.

A cost utility analysis for the management of acute exacerbations of chronic rhinosinusitis

BACKGROUND

The management of acute exacerbations of chronic rhinosinusitis (AECRS) is understudied and the most cost-effective management of AECRS has not been previously investigated. The aim of this study is to determine the most cost-effective strategy for the initial management of AECRS.

METHODS

The study design consisted of a decision-tree economic model comparing three different initial strategies for managing a patient perceived AECRS: observation, upfront rescue medications, or clinic visit with diagnostic nasal endoscopy (DNE). The primary study outcome was the disease burden of a single AECRS, which was determined by the health utility value and the duration of symptoms. Strategies with an incremental cost-effectiveness ratio < $50,000/quality-adjusted life year (QALY) or equivalently < $137/quality-adjusted life day (QALD) were considered cost-effective.

RESULTS

Observation was the most cost-effective strategy at a willingness to pay of $137 per QALD. One-way sensitivity analysis demonstrated that observation was more effective than upfront rescue medications when the probability of bacterial infection as the cause of AECRS was <24.0%. Upfront rescue medications wer more cost effective than observation when the probability of bacterial infection exceeded 49.0%. Clinic visit with DNE was the most effective strategy to manage an AECRS, but it was not considered cost-effective.

CONCLUSION

Observation is the most cost-effective strategy for the initial management of AECRS when there is a low likelihood of bacterial infection. When the probability of bacterial etiology of AECRS exceeds 49.0%, upfront rescue medications proved to be the most cost-effective strategy.

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.

Effect of Systemic Prednisone Treatment on Changes of Inflammation Markers in Chronic Rhinosinusitis

(1) Objective: We aimed to evaluate the effect of treatment with prednisone on nasal and systemic periostin and eotaxin expression, IgE in plasma and eosinophils in tissue. (2) Methods: We compared the values of nasal and systemic periostin, eotaxin, IgE and eosinophils in tissue in patients treated with only nasal steroids before FESS, group 1, with those treated with an oral steroid–prednisone, group 2. (3) Results: A statistically significant decrease in the level of periostin, eotaxin and IgE in plasma was achieved in patients treated with prednisone one week before and after surgery (in sequence: p < 0.0476, p < 0.0006, p < 0.0031). In patients treated with steroids, we also observed a lower level of periostin in the epithelium (p < 0.044), eotaxin in the stroma (p limit value < 0.075) and eosinophils (p < 0.031) in the tissues collected during the operation. (4) Conclusions: Systemic steroid treatment with prednisone distinctly decreases periostin, eotaxin and IgE expression in plasma. We also observed a lower level of periostin in the epithelium, eotaxin in the stroma and eosinophils in the tissues. We need more attempts to find inflammatory markers associated with chronic rhinosinusitis. Identifying drugs that decrease inflammatory parameters would allow for more targeted therapy.

Systemic Steroids for Otolaryngology-Head and Neck Surgery Disorders: An Evidence-Based Primer for Clinicians

OBJECTIVE

To offer pragmatic, evidence-informed guidance on the use of systemic corticosteroids (SCS) for common otolaryngologic disorders.

DATA SOURCES

PubMed, Cochrane Library, and American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guidelines.

REVIEW METHODS

A comprehensive search of published literature through November 2021 was conducted on the efficacy of SCS, alone or in combination with other treatments, for managing disorders in otolaryngology and the subdisciplines. Clinical practice guidelines, systematic reviews, and randomized controlled trials, when available, were preferentially retrieved. Interventions and outcomes of SCS use were compiled to generate summary tables and narrative synthesis of findings.

CONCLUSIONS

Evidence on the effectiveness of SCS varies widely across otolaryngology disorders. High-level evidence supports SCS use for Bell's palsy, sinonasal polyposis, and lower airway disease. Conversely, evidence is weak or absent for upper respiratory tract infection, eustachian tube dysfunction, benign paroxysmal positional vertigo, adenotonsillar hypertrophy, or nonallergic rhinitis. Evidence is indeterminate for acute laryngitis, acute pharyngitis, acute sinusitis, angioedema, chronic rhinosinusitis without polyps, Ménière's disease, postviral olfactory loss, postoperative nerve paresis/paralysis, facial pain, and sudden sensorineural hearing loss.

IMPLICATIONS FOR PRACTICE

Clinicians should bring an evidence-informed lens to SCS prescribing to best counsel patients regarding the risks, anticipated benefits, and limited data on long-term effects. Alternate routes of corticosteroid administration-such as sprays, drops, inhalers, and intralesional injections-may be preferable for many disorders, particularly those that are self-limited or require a prolonged duration of therapy. Prudent use of SCS reduces the risk of medication-related adverse effects. Clinicians who are conversant with high-level evidence can achieve optimal outcomes and stewardship when prescribing SCS.

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.

New Developments in Allergic Fungal Rhinosinusitis Pathophysiology and Treatment

BACKGROUND

Allergic fungal rhinosinusitis (AFRS) is an endotype of chronic rhinosinusitis (CRS) with nasal polyps characterized by eosinophilic mucin laden with fungal hyphae entrapped in expanded sinus cavities with an exaggerated hypersensitivity to fungal elements. The last decade has elucidated fungi-driven inflammatory pathways contributing to the pathophysiology of chronic inflammatory respiratory diseases. In addition, novel therapeutic biologic options have become available for CRS over the last several years.

OBJECTIVE

To review the current literature examining AFRS, focusing on recent developments in our understanding of its pathophysiology and implications for treatment options.

METHODS

Review article.

RESULTS

Fungi-driven respiratory inflammation has been linked to fungal proteinases and toxin activity. In addition, AFRS patients demonstrate a local sinonasal immunodeficiency in antimicrobial peptides and hence limited antifungal activity, along with an exaggerated type 2 inflammatory response, highlighting a possible imbalanced type 1, type 2, and type 3 profile. The elucidation of these dysregulated molecular pathways has highlighted novel potential therapeutic targets. As such, the clinical management of AFRS, which once included surgery and extended courses of oral corticosteroids, is transitioning away from long courses of oral corticosteroids to incorporate novel delivery mechanisms of topical therapeutic targets and biologics for recalcitrant disease.

CONCLUSION

AFRS is an endotype of CRS with nasal polyps (CRSwNP) for which the molecular pathways leading to its inflammatory dysfunction are beginning to be illuminated. In addition to affecting treatment options, these understandings may shape necessary changes to diagnostic criteria and the extrapolated effects of environmental changes on AFRS. More critically, a better appreciation of fungi-driven inflammatory pathways may have implications for the understanding of broader CRS inflammation.

The efficacy and safety of several interventions of corticosteroids for CRSwNP patients after endoscope sinus surgery: A protocol for systematic review and network meta-analysis

BACKGROUND

Corticosteroid has been a mainstay of chronic rhinosinusitis with nasal polyps (CRSwNP) medical therapy. While endoscopic sinus surgery (ESS) will be performed when patients had failed to respond to maximal medical therapy. Many studies shown that several corticosteroids of interventions (e.g., nasal spray, oral, atomization/nebulization, nasal irrigation, direct infiltration, and steroid-eluting stent, etc) have each demonstrated significant efficacy compared with placebo or no corticosteroids intervention except intranasal corticosteroids for the treatment of CRSwNP after ESS. The aim of this systematic review and network meta-analysis is to answer the following question: which 1 is the best corticosteroid of intervention for CRSwNP patients after ESS?

METHODS

A systematic review will be conducted to identify studies involving randomized controlled trials which compared several different interventions of corticosteroids (e.g., nasal spray, oral, atomization/nebulization, nasal irrigation, direct infiltration, steroid-eluting stent, etc) for CRSwNP patients after ESS. The primary outcomes are efficacy (e.g., effective rate or cure rate), visual analogic scale of symptom severity, Lund-Kennedy endoscopic score, adverse events, and so on. We will comprehensively search PubMed, Embase, Cochrane Library, ClinicalTrials.gov, Web of Science, Chinese National Knowledge Infrastructure, Wangfang and VIP journal database from inception to July, 2022. For studies which meet our inclusion criteria, 2 reviewers will extract data independently and assess the quality of literature using a revision of version 2 of the Cochrane risk of bias tool (RoB 2.0). A random effects model will be used for all pairwise meta-analyses (with a 95% confidence interval). Network meta-analyses will be conducted to generate estimates of comparative effectiveness of each intervention class and rankings of their effectiveness.

RESULTS

The results of this study expect to provide a high-quality, evidence-based recommendation on which 1 is the best corticosteroid of intervention for CRSwNP patients after ESS?

DISCUSSION

This study will provide evidence regarding the comparability of several interventions of corticosteroids for CRSwNP patients after ESS. Also, the data generated from this review will provide health-care providers with a clear evidence synthesis of CRSwNP patients after ESS management strategies. These data will be incorporated into the development of a patient decision aid to assist patients and clinicians in making a preference-based decision when faced with a CRSwNP patients after ESS as well.

Current Insight into Treatment of Chronic Rhinosinusitis: Phenotypes, Endotypes and Implications for Targeted Therapeutics

Chronic rhinosinusitis (CRS) is characterized by persistent locoregional mucosal inflammation of the paranasal sinuses and upper airway that has substantial associated health care costs¹. Personalized approaches to care that incorporate use of molecular biomarkers, phenotypes and inflammatory endotypes is a major focus of research at this time, and the concurrent rise of targeted therapeutics and biologic therapies has the potential to rapidly advance care and improve outcomes. Recent findings suggest that improved understanding of CRS phenotypic and endotypic heterogeneity, and incorporation of these characteristics into clinical care pathways, may facilitate more effective selection of surgical and/or therapeutic interventions². Ultimately, these personalized approaches have the potential to target specific inflammatory pathways, increase efficacy, reduce costs, and limit side effects. This review summarizes recent advances in the identification and characterization of CRS phenotypes, endotypes, and biomarkers and reviews potential implications for targeted therapeutics.

Corticosteroid Use in Otolaryngology: Current Considerations During the COVID-19 Era

OBJECTIVE

To offer pragmatic, evidence-informed advice on administering corticosteroids in otolaryngology during the coronavirus disease 2019 (COVID-19) pandemic, considering therapeutic efficacy, potential adverse effects, susceptibility to COVID-19, and potential effects on efficacy of vaccination against SARS-CoV-2, which causes COVID-19.

DATA SOURCES

PubMed, Cochrane Library, EMBASE, CINAHL, and guideline databases.

REVIEW METHODS

Guideline search strategies, supplemented by database searches on sudden sensorineural hearing loss (SSNHL), idiopathic facial nerve paralysis (Bell's palsy), sinonasal polyposis, laryngotracheal disorders, head and neck oncology, and pediatric otolaryngology, prioritizing systematic reviews, randomized controlled trials, and COVID-19-specific findings.

CONCLUSIONS

Systemic corticosteroids (SCSs) reduce long-term morbidity in individuals with SSNHL and Bell's palsy, reduce acute laryngotracheal edema, and have benefit in perioperative management for some procedures. Topical or locally injected corticosteroids are preferable for most other otolaryngologic indications. SCSs have not shown long-term benefit for sinonasal disorders. SCSs are not a contraindication to vaccination with COVID-19 vaccines approved by the US Food and Drug Administration. The Centers for Disease Control and Prevention noted that these vaccines are safe for immunocompromised patients.

IMPLICATIONS FOR PRACTICE

SCS use for SSNHL, Bell's palsy, laryngotracheal edema, and perioperative care should follow prepandemic standards. Local or topical corticosteroids are preferable for most other otolaryngologic indications. Whether SCSs attenuate response to vaccination against COVID-19 or increase susceptibility to SARS-CoV-2 infection is unknown. Immunosuppression may lower vaccine efficacy, so immunocompromised patients should adhere to recommended infection control practices. COVID-19 vaccination with Pfizer-BioNTech, Moderna, or Johnson & Johnson vaccines is safe for immunocompromised patients.