A randomized controlled study evaluating medical treatment versus surgical treatment in addition to medical treatment of nasal polyposis

Systematic Review of Long Term Sinonasal Outcomes in CRSwNP after Endoscopic Sinus Surgery: A call for Unified and Standardized Criteria and Terms

PURPOSE OF REVIEW

To present current evidence in long-term (> 5 years) results after endoscopic sinus surgery (ESS) focusing on Patients Reported Outcome Measures (PROMs) and other sinonasal outcomes while assessing the role of ESS in the treatment of CRSwNP, and identifying outcomes which affect the results of ESS and defining recommendations for future studies.

RECENT FINDINGS

Long-term results of ESS in CRSwNP can be branched in PROMs and other objective measurements. Despite the heterogeneity of reported outcomes make it difficult to perform comparisons and meta-analysis, ESS improves PROMs, including symptoms, QOL and olfaction. Objectives outcomes such as NPS, LMS, type of surgery, or recurrence and revision surgery don't have a clear role in long-term results. Clustering patients suggest asthma, N-ERD, allergy, eosinophil count and IL-5 could have a role in predicting recurrence and severe disease. Long-term studies of CRSwNP treated with ESS are scarce. There is a significant need to standardize the report of results. The use of tools as SNOT-22, NPS, validated smell tests, defined criteria for disease recurrence and control and ESS extension in a unified systematic way could allow better comparisons between treatments in the new era of biologics.

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.

Regeneration of olfactory neuroepithelium in 3-methylindole-induced anosmic rats treated with intranasal chitosan

Olfactory dysfunction significantly impairs the life quality of patients but without effective treatments to date. The previous report has demonstrated that chitosan mediates the differentiation of olfactory receptor neurons (ORNs) through insulin-like growth factors and insulin-like growth factor binding protein-2 axis in an in vitro model. However, whether chitosan can further treat olfactory dysfunction in vivo remains unexplored. This study aims to evaluate the therapeutic effect of chitosan on a 3-methylindole-induced anosmic rat model. Intraperitoneal injection of 3-methylindole is performed to induce anosmia in rats. Experimental results demonstrate that the food-finding duration after chitosan treatment gradually decrease to around 80 s, and both the olfactory neuroepithelium (ON) thickness and mature ORNs (expressing olfactory marker protein) are significantly restored. Furthermore, proliferating cells (expressing bromodeoxyuridine) are mainly co-expressed with immature ORNs (expressing βIII tubulin) below the intermediate layer of the ON in the chitosan-treated group on day 28 following 3-methylindole treatment. Conversely, proliferating cells are scattered over the ON, and co-localized with immature ORNs and sustentacular cells (expressing keratin 18) in the sham group, and even immature ORNs go into apoptosis (expressing DNA fragmentation and cleaved caspase-3), possibly causing incomplete regeneration. Consequently, chitosan regenerates the ON by regulating olfactory neural homeostasis and reducing ORN apoptosis, and serves as a potential therapeutic intervention for olfactory dysfunction in the future.

Predictors of efficacy for combination oral and topical corticosteroids to treat patients with chronic rhinosinusitis with nasal polyps

BACKGROUND

A short-course oral corticosteroid taper and topical intranasal corticosteroids may be used to maximize the success of medical management for chronic rhinosinusitis with nasal polyps (CRSwNP). In this study, we sought to identify characteristics that would be predictive of efficacy for this combination regimen.

METHODS

Sixty-four patients with CRS, bilateral polyps, a polyp score of at least 3, and a 22-item Sino-Nasal Outcome Test (SNOT-22) score ≥20 were prospectively enrolled and uniformly treated with a 15-day prednisone taper and twice daily dilute budesonide irrigations. Participants were assessed at enrollment and at follow up, 2 to 5 months later. Clinical and demographic characteristics were assessed at enrollment. At both time points, CRS symptoms were assessed with SNOT-22, and polyp score (range, 0 to 6) was assessed endoscopically. Associations were determined with regression.

RESULTS

Pretreatment SNOT-22 score (adjusted β = -0.83; 95% CI, -1.08 to -0.58; p < 0.001) and comorbid asthma (adjusted β = 15.75; 95% CI, 4.74 to 26.75; p = 0.007) were associated with a change in SNOT-22 experienced over the study period. Achieving a greater-than-1 minimal clinically important difference (MCID) improvement in SNOT-22 score was also associated with pretreatment SNOT-22 score (adjusted OR = 1.09; 95% CI, 1.04 to 1.14; p < 0.001) and comorbid asthma (adjusted OR = 0.13; 95% CI, 0.03 to 0.72; p = 0.019). SNOT-22 score ≥47 had 81.5% sensitivity and 78.4% specificity to detect patients experiencing 1 MCID improvement. Pretreatment polyp score was not associated with any outcome metric.

CONCLUSION

In treatment of CRSwNP with prednisone and budesonide irrigations, pretreatment endoscopy was not informative of treatment response. Pretreatment SNOT-22 and comorbid asthma may be more predictive.

Twelve-year follow-up study after endoscopic sinus surgery in patients with chronic rhinosinusitis with nasal polyposis

Background

Chronic rhinosinusitis with nasal polyposis (CRSwNP) is a therapeutic challenge because of the high recurrence rate. Surgical intervention should be considered in patients who fail to improve after medical treatment. We monitored recurrence and revision surgery over 12 years after endoscopic sinus surgery in CRSwNP patients.

Methods

In this prospective cohort study, 47 patients with CRSwNP, who underwent primary or revision extended endoscopic sinus surgery, were followed. Clinical symptoms and total nasal endoscopic polyp score were evaluated before, 6 years and 12 years after surgery.

Results

Twelve years after surgery, 38 out of 47 patients (80.9%) were available for examination. There still was a significantly better symptom score and total nasal endoscopic polyp score compared to before surgery (P < 0.001). Within the 12-year follow-up period, 30 out of 38 patients developed recurrent nasal polyps, of which 14 patients underwent additional revision surgery. Comorbid allergic sensitization and tissue IL-5 levels were found to be significant predictors for the need of revision surgery.

Conclusions

This long-term cohort study, investigating the outcome after surgery in CRSwNP, showed that, despite the low number of patients, 78.9% of patients with CRSwNP were subject to recurrence of the disease and 36.8% to revision surgery over a 12-year period.

In-office Placement of Mometasone Furoate Sinus Implants for Recurrent Nasal Polyps: A Pooled Analysis

Background

A mometasone furoate (MF) sinus implant (1350 mcg) was evaluated in 2 randomized controlled trials (RCTs) in 400 adults with nasal polyps (NP) who were candidates for revision endoscopic sinus surgery (RESS). We conducted a pooled analysis to evaluate the efficacy of MF implant in specific subgroups of NP patients.

Methods

Pooled data from 2 RCTs for 375 patients were analyzed across prespecified subjective and objective end points through day 90.

Results

At day 90, patients receiving implants and MF nasal spray (MFNS) experienced significant improvements in nasal obstruction/congestion (NO/C) score ( P = .0095), bilateral polyp grade (BPG, P = .0008), and ethmoid sinus obstruction ( P < .0001) compared to control using MFNS alone. Fewer treatment than control patients remained candidates for RESS (41.0% vs 69.3%, P < .0001). All subgroups experienced significant treatment effects, except NO/C in smokers ( P = .0509) and patients without altered smell ( P = .1873). Subgroups without asthma and with only 1 prior ESS experienced largest treatment effect on NO/C, and those with recent surgery <24 months and BPG >5 showed largest effect on endoscopic end points and RESS. Control patients with ESS <24 months were at 7 times highest risk for RESS ( P < .0001). One (0.4%) patient experienced implant-related serious adverse event (epistaxis).

Conclusion

On pooled analysis, MF implants with MFNS showed more favorable results than MFNS alone across several subjective and objective end points at day 90 and may play an important role in management of NP patients, especially those who have allergic rhinitis, expanded polyposis, altered smell, or had most recent ESS < 24 months.

A phase 3 trial of mometasone furoate sinus implants for chronic sinusitis with recurrent nasal polyps

Background

Topical intranasal corticosteroid sprays (INCSs) are standard treatment for nasal polyps (NPs), but their efficacy is reduced by poor patient compliance and impaired access of drug to the sinus mucosa. A corticosteroid‐eluting sinus implant was designed to address these limitations in patients with recurrent polyposis after sinus surgery by delivering 1350 μg of mometasone furoate (MF) directly to the ethmoid sinus mucosa over approximately 90 days.

Methods

A randomized, sham‐controlled, double‐blind trial was undertaken in 300 adults with refractory chronic rhinosinusitis with NPs (CRSwNP), who were candidates for repeat surgery. Eligible patients were randomized (2:1) and underwent in‐office bilateral placement of 2 implants or a sham procedure. All patients used the MF INCS 200 μg once daily. Co‐primary efficacy endpoints were the change from baseline in nasal obstruction/congestion score and bilateral polyp grade, as determined by an independent panel based on centralized, blinded videoendoscopy review.

Results

Patients treated with implants experienced significant reductions in both nasal obstruction/congestion score (p = 0.0074) and bilateral polyp grade (p = 0.0073) compared to controls. At day 90, implants were also associated with significant reductions in 4 of 5 prespecified secondary endpoints compared to control: proportion of patients still indicated for repeat sinus surgery (p = 0.0004), percent ethmoid sinus obstruction (p = 0.0007), nasal obstruction/congestion (p = 0.0248), and decreased sense of smell (p = 0.0470), but not facial pain/pressure (p = 0.9130). One patient experienced an implant‐related serious adverse event (epistaxis).

Conclusion

Significant improvements over a range of subjective and objective endpoints, including a reduction in the need for sinus surgery by 61%, suggest that MF sinus implants may play an important role in management of recurrent NP.

Oral corticosteroids in the management of chronic rhinosinusitis with and without nasal polyps: Risks and benefits

BACKGROUND

Oral steroids are synthetic mimics of adrenal cortex hormones and are considered a staple in the management of chronic rhinosinusitis due to their anti-inflammatory effects. Despite their common use, many providers are not familiar with the potential risks of the drugs.

METHODS

Literature review.

RESULTS

An overview of the existing data on the risks of oral steroids is presented as well as a review of the malpractice lawsuits with regard to oral steroid use and a discussion of the data that support the use of oral steroids in patients with chronic rhinosinusitis with and those without nasal polyps.

CONCLUSION

It is essential for providers to be aware of the potential complications of a medication, the medical jurisprudence of the drugs, and the data that support their use.

Short-course oral steroids alone for chronic rhinosinusitis

BACKGROUND

This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms.

OBJECTIVES

To assess the effects of oral corticosteroids compared with placebo/no intervention or other pharmacological interventions (intranasal corticosteroids, antibiotics, antifungals) for chronic rhinosinusitis.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids with placebo or no treatment or compared with other pharmacological interventions.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included eight RCTs (474 randomised participants), which compared oral corticosteroids with placebo or no intervention. All trials only recruited adults with chronic rhinosinusitis with nasal polyps. All trials reported outcomes at two to three weeks, at the end of the short-course oral steroid treatment period. Three trials additionally reported outcomes at three to six months. Two of these studies prescribed intranasal steroids to patients in both arms of the trial at the end of the oral steroid treatment period. Oral steroids versus placebo or no intervention Disease-specific health-related quality of life was reported by one study. This study reported improved quality of life after treatment (two to three weeks) in the group receiving oral steroids compared with the group who received placebo (standardised mean difference (SMD) -1.24, 95% confidence interval (CI) -1.92 to -0.56, 40 participants, modified RSOM-31), which corresponds to a large effect size. We assessed the evidence to be low quality (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). Disease severity as measured by patient-reported symptom scores was reported by two studies, which allowed the four key symptoms used to define chronic rhinosinusitis (nasal blockage, nasal discharge, facial pressure, hyposmia) to be combined into one score. The results at the end of treatment (two to three weeks) showed an improvement in patients receiving oral steroids compared to placebo, both when presented as a mean final value (SMD -2.84, 95% CI -4.09 to -1.59, 22 participants) and as a change from baseline (SMD -2.28, 95% CI -2.76 to -1.80, 114 participants). These correspond to large effect sizes but we assessed the evidence to be low quality.One study (114 participants) followed patients for 10 weeks after the two-week treatment period. All patients in both arms received intranasal steroids at the end of the oral steroid treatment period. The results showed that the initial results after treatment were not sustained (SMD -0.22, 95% CI -0.59 to 0.15, 114 participants, percentage improvement from baseline). This corresponds to a small effect size and we assessed the evidence to be low quality.There was an increase in adverse events in people receiving orals steroids compared with placebo for gastrointestinal disturbances (risk ratio (RR) 3.45, 95% CI 1.11 to 10.78; 187 participants; three studies) and insomnia (RR 3.63, 95% CI 1.10 to 11.95; 187 participants; three studies). There was no significant impact of oral steroids on mood disturbances at the dosage used in the included study (risk ratio (RR) 2.50, 95% CI 0.55 to 11.41; 40 participants; one study). We assessed the evidence to be low quality due to the lack of definitions of the adverse events and the small number of events or sample size, or both). Other comparisons No studies that compared short-course oral steroids with other treatment for chronic rhinosinusitis met the inclusion criteria.

AUTHORS' CONCLUSIONS

At the end of the treatment course (two to three weeks) there is an improvement in health-related quality of life and symptom severity in patients with chronic rhinosinusitis with nasal polyps taking oral corticosteroids compared with placebo or no treatment. The quality of the evidence supporting this finding is low. At three to six months after the end of the oral steroid treatment period, there is little or no improvement in health-related quality of life or symptom severity for patients taking an initial course of oral steroids compared with placebo or no treatment.The data on the adverse effects associated with short courses of oral corticosteroids indicate that there may be an increase in insomnia and gastrointestinal disturbances but it is not clear whether there is an increase in mood disturbances. All of the adverse events results are based on low quality evidence.More research in this area, particularly research evaluating patients with chronic rhinosinusitis without nasal polyps, longer-term outcomes and adverse effects, is required.There is no evidence for oral steroids compared with other treatments.

Short-course oral steroids as an adjunct therapy for chronic rhinosinusitis

BACKGROUND

This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms.

OBJECTIVES

To assess the effects of a short course of oral corticosteroids as an adjunct ('add-on') therapy in people with chronic rhinosinusitis who are already on standard treatments.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids to placebo or no treatment, where all patients were also receiving pharmacological treatment for chronic rhinosinusitis.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score, and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

Two trials with a total of 78 participants met the inclusion criteria. Both the populations and the 'standard' treatments differed in the two studies. Oral steroids as an adjunct to intranasal corticosteroids One trial in adults with nasal polyps included 30 participants. All participants used intranasal corticosteroids and were randomised to either short-course oral steroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 21-day treatment course) or no additional treatment. None of the primary outcome measures of interest in this review were reported by the study. There may have been an important reduction in the size of the polyps (measured by the nasal polyps score, a secondary outcome measure) in patients receiving oral steroids and intranasal corticosteroids, compared to intranasal corticosteroids alone (mean difference (MD) -0.46, 95% confidence interval (CI) -0.87 to -0.05; 30 participants; scale 1 to 4) at the end of treatment (21 days). This corresponds to a large effect size, but we are very uncertain about this estimate as we judged the study to be at high risk of bias. Moreover, longer-term data were not available and the other outcomes of interest were not reported. Oral steroids as an adjunct to antibiotics One trial in children (mean age of eight years) without nasal polyps included 48 participants. The trial compared oral corticosteroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 15-day treatment course) with placebo in participants who also received a 30-day course of antibiotics. This study addressed one of the primary outcome measures (disease severity) and one secondary outcome (CT score). For disease severity the four key symptoms used to define chronic rhinosinusitis in children (nasal blockage, nasal discharge, facial pressure, cough) were combined into one score. There was a greater improvement in symptom severity 30 days after the start of treatment in patients who received oral steroids and antibiotics compared with placebo and antibiotics (MD -7.10, 95% CI -9.59 to -4.61; 45 participants; scale 0 to 40). The observed mean difference corresponds to a large effect size. At the same time point there was a difference in CT scan score (MD -2.90, 95% CI -4.91 to -0.89; 45 participants; scale 0 to 24). We assessed the quality of the evidence to be low.There were no data available for the longer term (three months).

AUTHORS' CONCLUSIONS

There might be an improvement in symptom severity, polyps size and condition of the sinuses when assessed using CT scans in patients taking oral corticosteroids when these are used as an adjunct therapy to antibiotics or intranasal corticosteroids, but the quality of the evidence supporting this is low or very low (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). It is unclear whether the benefits of oral corticosteroids as an adjunct therapy are sustained beyond the short follow-up period reported (up to 30 days), as no longer-term data were available.There were no data in this review about the adverse effects associated with short courses of oral corticosteroids as an adjunct therapy.More research in this area, particularly research evaluating longer-term outcomes and adverse effects, is required.

WITHDRAWN: Oral steroids for nasal polyps

Review withdrawn from Issue 4, 2016. Replaced by new reviews 'Short‐course oral steroids alone for chronic rhinosinusitis' (Head 2016a) and 'Short‐course oral steroids as an adjunct therapy for chronic rhinosinusitis' (Head 2016b).

The editorial group responsible for this previously published document have withdrawn it from publication.

WITHDRAWN: Topical steroids for nasal polyps

Review withdrawn from Issue 4, 2016. Replaced by new reviews 'Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis' (Chong 2016a) and 'Different types of intranasal steroids for chronic rhinosinusitis' (Chong 2016b).

The editorial group responsible for this previously published document have withdrawn it from publication.

Intranasal corticosteroids for nasal polyposis : biological rationale, efficacy, and safety

Nasal polyposis, occurring in about 2% of the general population, is the ultimate form of inflammation of the upper airways. For unknown reasons, polyps develop preferentially in subtypes of inflammatory diseases and are associated with perennial non-allergic rhinitis, asthma, intolerance of aspirin (acetylsalicylic acid)/NSAIDs, allergic fungal rhinosinusitis, cystic fibrosis, and primary ciliary dyskinesia. In contrast to common beliefs, IgE-mediated allergy does not seem to play an etiological role in nasal polyposis.The polyps originate from the mucosa around the clefts of the lateral nasal wall, especially in the region of the ostiomeatal complex. The factors that determine the localization of the disease to a few square centimeters of the airways are not known.Polyps are edematous bags covered by respiratory epithelium and contain very few nerves, blood vessels, and glands that have undergone cystic degeneration. They contain degranulated mast cells, have a very high concentration of histamine, and are characteristically infiltrated by eosinophils. These cells accumulate due to the release of proinflammatory cytokines (in particular, interleukin-5).Nasal polyposis is preceded by a prolonged history of rhinitis accompanied by severe and persistent nasal blockage; typically, the sense of smell is seriously impaired when polyps develop. The diagnosis is based on anterior rhinoscopy or, preferably, endoscopy.Nasal polyposis is medically treatable. Surgical treatment is carried out when medication fails. Intranasal corticosteroids reduce rhinitis symptoms, improve nasal breathing, reduce the size of polyps, and prevent, in part, their recurrence, but this treatment has little effect on the sense of smell. Intranasal corticosteroids can, as basic long-term therapy, be used alone in mild cases or together with systemic corticosteroids and/or surgery in severe cases. Systemic corticosteroids administered for 2-3 weeks have a beneficial effect on all observed symptoms and pathology, including the sense of smell. When nasal blockage is a problem in spite of medical treatment, surgery is recommended. Simple polypectomy can be performed, but endoscopic surgery is recommended in more severe and persistent cases.

Surgical versus medical interventions in CRS and nasal polyps: comparative evidence between medical and surgical efficacy

CRS with nasal polyps (CRSwNP) is a subgroup of CRS, where polyps can be visualised in the middle meatus. In the general population, the prevalence is estimated to lie between 0.2 and 4 %. Up to 15 % of patients with asthma have nasal polyps and up to 45 % of patients with nasal polyps have asthma. The management of CRSwNP involves primary medical management, with surgery normally reserved for recalcitrant cases. Surgical techniques for CRSwNP range from simple polypectomy and endoscopic sinus surgery (ESS) to radical nasalisation with removal of the middle turbinates. We have reviewed the comparative literature regarding medical and surgical interventions in CRSwNP, with emphasis on outcomes, complications, cost-effectiveness and on the timing of surgery. Similar outcomes are reported for medical and surgical management, but there is sufficient evidence to support the role of surgery once symptoms have failed to adequately respond. There is insufficient evidence to define the optimal timing and extent of surgery.

[Olfactory disorders and their therapy]

Among the main causes of olfactory disorders are chronic rhinosinusitis, head trauma, acute infections of the upper respiratory tract and neurodegenerative diseases. Olfactory disorders can impose major restrictions on our lives. Although there are numerous approaches for the therapy of olfactory disorders, double-blind comparison studies are needed to distinguish between the effects of these therapies and spontaneous remission of olfactory disorders. The most significant aspects of treatments seem to be anti-inflammatory measures and the regenerative capabilities of the olfactory neuroepithelium.

Effect of steroids for nasal polyposis surgery: A placebo-controlled, randomized, double-blind study

OBJECTIVES/HYPOTHESIS

Although medical intervention is the first option for treatment of nasal polyps, surgery is still a therapeutic option for symptomatic cases that do not respond or partially respond to medical intervention. However, there is a need for high-level evidence for the preoperative use of steroids in nasal polyposis surgery. We aimed to assess the perioperative effect of preoperative use of oral prednisolone for advanced-stage diffuse nasal polyposis.

STUDY DESIGN

Prospective, double-blind, randomized, placebo-controlled study.

METHODS

A visual analog scale (VAS) was evaluated for smell, nasal discharge, nasal obstruction, facial pressure, headache, butanol smell threshold, and peak nasal inspiratory flow (PNIF) before and after the use of study drug. Perioperative bleeding volume, visibility of operative field, operative time, hospital stay, and complication rate were also evaluated.

RESULTS

The improvement in the corticosteroid group (CG) in the VAS scores, butanol thresholds, and PNIF values showed statistically significant differences compared to the placebo group (PG) (P < .05). The perioperative bleeding volume, visibility score, operative time, and hospital stay for CG/PG were 141 mL/384 mL, 2.4/3.4, 61 min/71.6 min, and 1.1 day/1.8 day, respectively (P < .05). The difference between the complication rates for the two groups did not show any statistically significant difference (P = .214).

CONCLUSIONS

Preoperative administration of systemic corticosteroids improves the perioperative visibility by reducing blood loss and shortens the operation time. We recommend the use of preoperative corticosteroid for the safety of the patients. The optimum dose and duration have not been established and require further studies.

LEVEL OF EVIDENCE

1b.

Quality of life outcomes after functional endoscopic sinus surgery for nasal polyposis

PURPOSE

The objective of this study is to determine the results of functional endoscopic sinus surgeries (FESS) for chronic rhinosinusitis with polyps and assess the association between surgery and specific quality of life outcomes.

MATERIALS AND METHODS

A prospective study was performed in a tertiary referral center. Fifty-eight patients affected by chronic rhinosinusitis with nasal polyposis underwent endoscopic sinus surgery from January 2011 to April 2013 and followed for 1 year. The rhinosinusitis disability index (RSDI), a validated disease-specific instrument, was used to quantify the patient's symptoms before and 12 months after surgery.

RESULTS

A strongly statistically significant reduction was seen between the mean scores on RSDI before and after FESS [86.43 (IQR=16.10) versus 51.16 (IQR=18.95), Wilcoxon signed-rank test, p<0.0001]. In multiple regression model, only four preoperative characteristics predicted the outcomes. The high mucosal eosinophilia density was the most important preoperative predictor.

CONCLUSIONS

There is evidence which supports the efficacy of FESS to improve long-term QOL outcomes in patients with CRS. The mucosal eosinophilia density and prior sinus surgery appeared to be the most predictive factors of surgical outcomes.

Evidence-based surgery for chronic rhinosinusitis with and without nasal polyps

Meta-analysis of both large outcome studies as well as cohort studies support the safety and efficacy of Endoscopic Sinus Surgery for Chronic Rhinosinusitis. The efficacy of endoscopic sinus surgery is demonstrated in the improvement of both disease-specific and generic QOL as well as objective measures. However, this must be interpreted together with a well-recognized long-term 15-20 % revision rate, seen more often in patients with ASA trias and cystic fibrosis as well as osteitis and previous surgery. The effect of surgery is higher in managing nasal obstruction (effect size 1.7) and less so hyposmia (effect size 0.8). Allergy has an additive role on the symptomatology of CRS; however, its role if any on the outcome of ESS for CRS is unclear. The concurrent presence of aspiring sensitivity and asthma is associated with increased disease burden and more revision surgeries. Improved phenotyping of CRS may lead in the future to better tailoring of surgical treatments.

Evaluation on quality of life in patients with nasal polyposis managed with optimal medical therapy

Nasal polyposis (NP) has a great impact on quality of life (QOL) and its management involves a combination of medical therapy and surgery. To the authors' knowledge, no publication has extensively examined NP after optimal medical treatment based on subjective evaluations. The aim of this prospective study was designed to evaluate the QOL in NP patients after (1) a short course of oral steroids, (2) initial 3-month course of macrolide, and (3) long-term treatment with intranasal steroids. A total of 55 patients with grades I and II NP were consecutively treated with oral prednisolone at 25 mg in a single dose for 2 weeks, macrolide at 250 mg daily for the first 3 months, and long-term intranasal steroids. Patients were followed up and evaluated at baseline and 3, 6, and 12 months for QOL measure. At baseline, patients with grade I and grade II NP showed significantly worse QOL scores on all Rhinosinusitis Disability Index domains, particularly for physical function (4.59 ± 1.41) and were significantly higher in social function (3.16 ± 1.17). At 3, 6, and 12 months of treatment, patients showed a significant improvement in all impaired QOL domains compared with baseline after optimal medical therapy (p < 0.05). These results suggest that the optimal medical treatment to improve QOL incorporates medical polypectomy with a short course of oral steroids in addition to macrolide and this can be maintained by long-term intranasal steroid therapy.

Objective olfactory outcomes after revision endoscopic sinus surgery

BACKGROUND

Patients who suffer from hyposmia and anosmia report a negative effect on their overall quality of life. Smell disturbance of patients with chronic rhinosinusitis (CRS) can improve after endoscopic sinus surgery (ESS). Although several studies have shown that 50-83% of patients may notice an improvement in olfactory function after ESS, the olfactory improvement after revision ESS (RESS), especially by objective measurements, is still lacking.

METHODS

Olfactory function was assessed by the traditional Chinese version of the University of Pennsylvania Smell Identification Test (UPSIT-TC) preoperatively and postoperatively, recorded as smell identification test (SIT) score. Olfactory outcomes from anosmia to hyposmia/normosmia, or from hyposmia to normosmia, were considered as "improvement." Postoperative assessments were divided into two periods: period 1 (P1) is defined as >6 but <12 months postoperatively; period 2 (P2) is defined as >12 but <24 months postoperatively.

RESULTS

Thirty-two patients with smell disturbance preoperatively (period 0 [P0]) and confirmed by UPSIT-TC were enrolled into this study. Mean SIT score at P0 was 13.3; mean SIT score at P1 was 18.6; mean SIT score at P2 was 20.4. The presence of nasal polyps blocking the olfactory cleft were associated with better olfaction improvements (p < 0.05) as was the degree of mucosal swelling. The overall improvement rates were 44.8 and 47.8% at P1 and P2, respectively.

CONCLUSION

RESS resulted in objective evidence of olfactory improvement in approximately one-half of our cohort over 16 months of follow-up and offers a treatment option for an otherwise poor prognosis condition.

Effectiveness of voriconazole in the treatment of Aspergillus fumigatus-associated asthma (EVITA3 study)

BACKGROUND

IgE sensitization to Aspergillus fumigatus and a positive sputum fungal culture result are common in patients with refractory asthma. It is not clear whether these patients would benefit from antifungal treatment.

OBJECTIVES

We sought to determine whether a 3-month course of voriconazole improved asthma-related outcomes in patients with asthma who are IgE sensitized to A fumigatus.

METHODS

Asthmatic patients who were IgE sensitized to A fumigatus with a history of at least 2 severe exacerbations in the previous 12 months were treated for 3 months with 200 mg of voriconazole twice daily, followed by observation for 9 months, in a double-blind, placebo-controlled, randomized design. Primary outcomes were improvement in quality of life at the end of the treatment period and a reduction in the number of severe exacerbations over the 12 months of the study.

RESULTS

Sixty-five patients were randomized. Fifty-nine patients started treatment (32 receiving voriconazole and 27 receiving placebo) and were included in an intention-to-treat analysis. Fifty-six patients took the full 3 months of medication. Between the voriconazole and placebo groups, there were no significant differences in the number of severe exacerbations (1.16 vs 1.41 per patient per year, respectively; mean difference, 0.25; 95% CI, 0.19-0.31), quality of life (change in Asthma Quality of Life Questionnaire score, 0.68 vs 0.88; mean difference between groups, 0.2; 95% CI, -0.05 to -0.11), or any of our secondary outcome measures.

CONCLUSION

We were unable to show a beneficial effect of 3 months of treatment with voriconazole in patients with moderate-to-severe asthma who were IgE sensitized to A fumigatus on either the rate of severe exacerbations, quality of life, or other markers of asthma control.

Comparison of the effect of endoscopic sinus surgery versus medical therapy on olfaction in nasal polyposis

Chronic rhinosinusitis is a common inflammatory condition in western countries. Nasal polyposis has different symptoms such as nasal obstruction, anterior or posterior nasal drip, reduced sense of smell, and facial pain. Medical and endoscopic treatments are the two main treatments for nasal polyposis. Our aim was to compare the efficacy of different methods on olfactory function. This is a non-randomized clinical trial study that was done on 60 patients who were divided into two groups (medical and surgical). Patients were matched based on age, history of smoking, and the severity of obstruction. The radiologist score of Lund-Mackay staging system was used to match patients in two arms of the trial based on the severity of nasal obstruction. Patients in surgery groups underwent functional endoscopic sinus surgery under general anesthesia and then received Fluticasone propionate nasal spray for 8 weeks (400 mcg bd). Patients in the medical group were only prescribed with Fluticasone propionate with the same duration and same dose as mentioned. As a result of treatment protocol, both medical and surgical group experienced improvement in olfactory function but statistical analyses revealed that surgery resulted in better resolution of symptoms. Our observation revealed that combined treatment had a better effect than medical treatment in restoring olfaction in patients with nasal polyposis.

Topical steroids for nasal polyps

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) represents inflammatory changes throughout the nose and sinuses from a group of disorders which all lead to swelling and overgrowth of the nasal mucosa. Topical corticosteroids have been the most widely used treatment, with each clinician using different regimes, at different doses, in different settings and with or without sinus surgery. CRSwNP requires ongoing medical management to prevent recurrence.

OBJECTIVES

To assess the effects of topical corticosteroids on CRSwNP and to analyse various subgroups, including patients who had sinus surgery immediately prior to the delivery of the corticosteroids, surgery any time prior to the topical corticosteroids or patients who had never had previous surgery. Also to assess the most effective dose and delivery methods for topical corticosteroids.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 10 April 2012.

SELECTION CRITERIA

Randomised controlled trials studying topical corticosteroids for patients with CRSwNP.

DATA COLLECTION AND ANALYSIS

At least two authors reviewed the search results and selected trials meeting the eligibility criteria, obtaining full texts and contacting authors. We documented our justification for the exclusion of studies. At least two authors extracted data using a pre-determined, standardised data form.

MAIN RESULTS

Forty studies (3624 patients) met the inclusion criteria. The trials were at low (21 trials), medium (13 trials) and high (six trials) risk of bias. The primary outcomes were sino-nasal symptoms, polyp size and polyp recurrence after surgery. When compared to placebo, topical corticosteroids improved overall symptom scores (standardised mean difference (SMD) -0.46; 95% confidence interval (CI) -0.65 to -0.27, P < 0.00001; seven trials, n = 445) and had a higher proportion of patients whose symptoms improved (responders) (risk ratio (RR) 1.71; 95% CI 1.29 to 2.26, P = 0.0002; four trials, n = 234). Topical corticosteroids also decreased the polyp score (SMD -0.73; 95% CI -1.00 to -0.46, P < 0.00001; three trials, n = 237) and had a greater proportion of patients with a reduction in polyp size (responders) (RR 2.09; 95% CI 1.65 to 2.64, P < 0.00001; eight trials, n = 785) when compared to placebo. Topical corticosteroids also prevented polyp recurrence after surgery (RR 0.59; 95% CI 0.45 to 0.79, P = 0.0004; six trials, n = 437). Subgroup analyses by sinus surgery status revealed a greater benefit in reduction of polyp score when topical steroid was administered any time after sinus surgery (SMD -1.19; 95% CI -1.54 to -0.83) compared to patients who had never had surgery (SMD -0.13; 95% CI -0.53 to 0.28, P < 0.00001). There was no difference between groups in terms of adverse events.

AUTHORS' CONCLUSIONS

Topical corticosteroids are a beneficial treatment for CRSwNP and the adverse effects are minor, with benefits outweighing the risks. They improve symptoms, reduce polyp size and prevent polyp recurrence after surgery. Patients having sinus surgery may have a greater response to topical corticosteroids but further research is required.

State of the art treatment of nasal polyposis

BACKGROUND

Nasal polyposis represents the end point of multiple inflammatory pathways and controversy continues as to the exact roles of medical and surgical approaches in the management of nasal polyposis.

METHODS

A combination of both is often required to manage polyps adequately with surgery and intranasal steroids remaining the mainstay of therapy.

RESULTS

Fortunately, new technological advances are making surgery safer and more efficient. In the postoperative period, debridement is effective in reducing the formation of adhesions, and topical medications may play a beneficial role in preventing polyp reformation.

CONCLUSION

Additional investigations into the optimal perioperative medical management is needed to ensure optimal surgical outcomes.

One year after endoscopic sinus surgery in polyposis: asthma, olfaction, and quality-of-life outcomes

OBJECTIVE

Nasal polyposis is a disease known to be associated with asthma. The long-term effects of surgical treatment on lower airways have not been sufficiently studied.

STUDY DESIGN

One-year follow-up of a double-blind, randomized, placebo-controlled study.

SETTING

The study was conducted at the Karolinska University Hospital, Stockholm, Sweden.

SUBJECTS AND METHODS

Fifty-one patients, age 18 years or older, with nasal polyposis and asthma were evaluated 1 year after endoscopic sinus surgery (ESS). Outcomes included dyspnea/cough scores, mean daily peak expiratory flow rate, spirometry, butanol test, olfaction scores, peak nasal inspiratory flow, polyp scores, and health-related quality of life (SF-36).

RESULTS

The short-term postsurgery improvements in asthma symptom scores, daily peak expiratory flow rate, all nasal parameters including olfaction, and quality-of-life scores were generally maintained 1 year after ESS.

CONCLUSION

Endoscopic sinus surgery had beneficial long-term effects on asthma, olfaction, and quality of life in patients with nasal polyposis. This is the first study to show long-term benefits of ESS on butanol tests in patients with nasal polyposis.

Oral steroids for nasal polyps

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2007.Benign nasal polyps are lesions that arise from the mucosa of the nasal cavity or one or more of the nasal sinuses. The presenting symptoms are nasal obstruction, watery anterior rhinorrhoea (excessive nasal secretions) or mucopurulent postnasal drip (or both), hyposmia and anosmia (reduced or absent sense of smell) with a concomitant alteration in taste and infrequently pain over the dorsum of the nose, forehead and cheeks. The main aim of treatment is to relieve these symptoms. The aetiology of polyps is uncertain, therefore treatment options differ, consisting of a combination of medical and surgical management. Medical therapy is mainly in the form of steroids, administered topically or systemically via the oral route.

OBJECTIVES

To assess the effects of oral steroids in patients with multiple nasal polyps.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 12 October 2010, following a previous search in April 2006.

SELECTION CRITERIA

Randomised controlled trials and controlled clinical trials comparing oral steroids with no intervention, or placebo, or comparing doses or schedules of oral steroids in patients with multiple nasal polyps.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality. We contacted study authors for additional information.

MAIN RESULTS

Three trials (166 patients) met our inclusion criteria and showed a short-term benefit of a short (two to four-week) course of oral steroids of variable doses and duration when compared to placebo. There was an objective reduction of polyp size and a subjective improvement of nasal symptoms and quality of life. However, due to the moderate to low quality of these trials it was not possible to quantify the overall size of this effect.There was no report of significant adverse effects of treatment with a short course of steroids.

AUTHORS' CONCLUSIONS

The authors found three randomised controlled trials, albeit of moderate to poor quality, that suggest a short-term benefit of oral steroids in patients with multiple nasal polyps. To address the issue more thoroughly well-designed, prospective, randomised controlled trials are still needed.

Management of nasal polyps in 'aspirin sensitive asthma' triad

PURPOSE OF REVIEW

Aspirin-sensitive asthma (ASA) triad is a challenging picture presenting to both the otolaryngologist and the respiratory physicians. Patients present with severe nasal polyposis with a high propensity to recur despite the modality of treatment - medical or surgical. They also often have poorly controlled severe adult onset asthma. We reviewed the scientific literature, focusing on the outcomes of these treatment modalities in the management of nasal polyposis in ASA triad.

RECENT FINDINGS

Although initial work described by Widal on the subject continues, in the last decade a number of prospective and retrospective studies on outcomes after aspirin desensitization as well as surgery have been reported. The extent of surgery has also been addressed in some of these studies. Medical as well as surgical treatments have a role but there has been increasing evidence to support the role of aspirin desensitization in achieving long-term control of this condition.

SUMMARY

Overall, with the limitation of data, it appears more is better in patients with ASA and nasal polyposis. There is a lack of level 1 evidence in the proposed treatment modalities. Questions on extent of surgery and dosage as well as length of aspirin desensitization require further research with minimally biased controlled studies.

Evidence-based management of nasal polyposis by intranasal corticosteroids: from the cause to the clinic

BACKGROUND

Nasal polyposis is an inflammatory disorder involving the mucosa of the nose and paranasal sinuses and affecting approximately 2-4% of the general population.

METHODS

A literature search of Medline and Embase was conducted to obtain an overview of the epidemiology, pathophysiology, and current treatment of nasal polyposis, focusing on evidence-based efficacy of intranasal corticosteroids (INSs) as primary and postoperative therapy. Recent research on INSs in nasal polyp treatment, along with notable historic findings, was reviewed.

RESULTS

Nasal polyps are mostly characterized by eosinophil infiltration, a complex inflammation of nasal mucosa, and possibly production of polyclonal IgE. Current treatment modalities include INSs, oral corticosteroids, and surgery; surgery is generally limited to those with an insufficient response to medical treatment. Because of their effects on eosinophil-dominated inflammation, INSs and oral corticosteroids are the primary medical treatment strategies. The very low (≤1%) systemic bioavailability of newer INSs minimizes the systemic adverse effects seen with oral corticosteroids.

CONCLUSION

Based on randomized, controlled trials, guidelines recommend INSs as first-line therapy for nasal polyps and for care after polypectomy. Clinical data suggest INSs are effective in reducing polyp size and relieving nasal symptoms. INS treatment has also reduced nasal polyp recurrence in patients undergoing functional endoscopic sinus surgery. Treatment with these mainstay options has been found to improve quality of life, which, along with symptom improvement, is a key factor in disease treatment.

Extensive endoscopic sinus surgery: does this reduce the revision rate for nasal polyposis?

Nasal polyps treated either medically or surgically have a high recurrence rate. It is hypothesised that the performance of an extensive endoscopic sinus surgery (EESS), involving complete removal of nasal polyps along with full ethmoid clearance, will decrease the recurrence rate and therefore be an advantage to the patient. This study is a retrospective review of 149 patients who underwent EESS in a district general hospital. Surgical revision rates and perioperative complication data were recorded. A comparison was made with patients enlisted with the UK National Comparative Audit who underwent polyp disease removal limited to the anterior ethmoid cavity. A further measure regarding quality of life was derived from sinonasal outcome test 22 (SNOT-22). At 36 months after surgery, five patients from the extensive surgery group had undergone a revision procedure, which was significantly less than the National Audit figure (4.0 vs. 12.3% P = <0.006). The perioperative adverse complication rate was similar (7.4 vs. 6.6% P = <0.774). There is a large improvement in SNOT-22 scores from the pre-operative period (mean 39) to the post-operative period (mean 8). This study provides some evidence that extensive sinus surgery performed by an experienced rhinologist can lead to a lower revision rate without compromising patient safety. If a further prospective study confirms this hypothesis then this may provide a basis for change.

Increasing olfactory bulb volume due to treatment of chronic rhinosinusitis--a longitudinal study

Differentiation of progenitor cells into neurons in the olfactory bulb depends on olfactory stimulation that can lead to an increase in olfactory bulb volume. In this study, we investigated whether the human olfactory bulb volume increases with increasing olfactory function due to treatment of chronic rhinosinusitis. Nineteen patients with chronic rhinosinusitis were investigated before and after treatment. For comparison, additional measurements were performed in 18 healthy volunteers. Volumetric measurements of the olfactory bulb were based on planimetric manual contouring of magnetic resonance scans. Olfactory function was evaluated separately for each nostril using tests for odour threshold, odour discrimination and odour identification. Measurements were performed on two occasions, 3 months apart. In healthy controls, the olfactory bulb volume did not change significantly between the two measurements. In contrast, the olfactory bulb volume in patients increased significantly from the initial 64.5 +/- 3.2 to 70.0 +/- 3.5 mm(3) on the left side (P = 0.02) and from 60.9 +/- 3.5 to 72.4 +/- 2.8 mm(3) on the right side (P < 0.001). The increase in olfactory bulb volume correlated significantly with an increase in odour thresholds (r = 0.60, P = 0.006, left side; r = 0.49, P = 0.03, right side), but not with changes in odour discrimination or odour identification. Results of this study support the idea that stimulation of olfactory receptor neurons impacts on the cell death in the olfactory bulb, not only in rodents but also in humans. To our knowledge, this is the first longitudinal study that describes an enlargement of the human olfactory bulb due to improvement of peripheral olfactory function.

Balloon Sinuplasty: balloon-catheter dilation of paranasal sinus ostia for chronic rhinosinusitis

More than 100 million patients worldwide suffer from chronic rhinosinusitis, and a considerable amount of money has been spent on research and treatments by healthcare providers. In the northern hemisphere, damp, temperate climates, along with higher concentrations of pollen, are associated with a higher prevalence of chronic rhinosinusitis. Owing to its persistent nature, the disease can become a significant cause of morbidity. If untreated, it can reduce quality of life and productivity. When medical treatment is not effective, surgery may offer an excellent outcome. Although functional endoscopic surgery has proven to be effective, many cases could be managed medically. Recent research has suggested that optimal medical treatment is as effective as surgery in patients with chronic rhinosinusitis at the end of 1 year. Balloon Sinuplasty (Acclarent, Inc., CA, USA) is a new technique in the management of sinusitis and is a hotly debated topic. It is a delicate, minimally invasive tool, and early research demonstrates promising outcomes in terms of safety and effectiveness. This novel technique has been approved by the US FDA. Recently, NICE raised no concerns regarding its safety and efficacy but will continue to review this procedure.

Endoscopic sinus surgery in the management of nasal obstruction

Nasal obstruction is the leading symptom observed among patients who have chronic rhinosinusitis (CRS) with or without nasal polyposis. After failure of medical therapy, functional endoscopic sinus surgery (FESS) has emerged as the preferred treatment of CRS. Interestingly, although patient-reported outcomes show unequivocal relief of nasal obstruction after FESS, studies measuring nasal airflow and resistance demonstrate more modest improvements. This article provides an overview of the physiology of nasal airflow sensation, the burden of nasal obstruction in patients who have CRS, and the efficacy of FESS in addressing nasal obstruction in this population. Additionally, advances in airflow modeling that may enable improved preoperative planning for the relief of nasal obstruction after FESS are discussed.

Functional endoscopic sinus surgery improved asthma symptoms as well as PEFR and olfaction in patients with nasal polyposis

BACKGROUND

Nasal polyposis is a disease known to be associated with asthma. The management is anti-inflammatory, with topical and oral corticosteroids as the first-line treatment. The effect of surgical treatment on lower airway inflammation has not been sufficiently studied.

AIM

The aim of this study is to investigate the effects of functional endoscopic sinus surgery (FESS) as well as fluticasone proprionate nasal drops (FPND) 400 microg b.i.d. on nasal and lower airway parameters in asthmatics with nasal polyposis.

METHODS

This was a prospective 21-week study of 68 patients with asthma and nasal polyposis, on the benefits of FESS on nasal '(butanol test, subjective olfaction, peak nasal inspiratory flow, congestion, rhinorrhoea, and polyp score)', and on the lower airway parameters (dyspnea, cough, mean daily peak expiratory flow rate (PEFR), and lung function tests). It also included a randomized, double-blind, placebo-controlled 14 weeks phase on FPND.

RESULTS

Functional endoscopic sinus surgery significantly improved mean asthma symptom scores and daily PEFR and all nasal parameters including subjective and objective olfaction tests. This is the first study that shows the benefits of FESS on butanol tests in patients with nasal polyposis. We found no significant difference between topical treatment with FPND or placebo in the nasal or lower airway variables.

CONCLUSION

Functional endoscopic sinus surgery improved nasal and asthma symptoms in patients with nasal polyposis. Functional endoscopic sinus surgery could be considered early in the natural course of nasal polyposis with concomitant asthma, as well as a second-line treatment in nasal polyposis patients with a reduced sense of smell. The potential benefits of FPND 400 microg b.i.d. were probably overshadowed by FESS.

A randomized prospective study comparing medical and medical-surgical treatment of nasal polyposis by CT

CONCLUSIONS

CT of the sinuses showed long-lasting improvement in the total and CT scores of the osteomeatal complex (OMC) after combined surgical and corticosteroid treatment as compared with medical treatment alone. However, the correlations between the improved CT scores and the patients' symptoms, olfactory thresholds or polyp scores were generally not significant.

OBJECTIVE

To evaluate CT scans as a method for comparing the effect of medical treatment versus combined surgical and medical treatment of nasal polyposis.

PATIENTS AND METHODS

Thirty-two patients with nasal polyposis were randomized to unilateral endoscopic sinus surgery after pretreatment with oral prednisolone for 10 days and nasal budesonide bilaterally for 1 month. Postoperatively, they were given nasal steroids (budesonide) bilaterally for 1 year. They were assessed with nasal endoscopy, symptom scores, and olfactory thresholds and followed for 12 months. CT of the sinuses was performed before and 1 year after operation. The CT scans were evaluated using the Lund staging system.

RESULTS

From before surgery to 1 year after surgery, we found a significant improvement on the operated side in the CT total scores, and scores of the OMC and the maxillary sinus, but no significant differences on the unoperated side. Significant correlations were also noted between the differences in olfactory thresholds between the operated and unoperated sides.

[Preoperative corticosteroid treatment and nasal polyposis]

OBJECTIVES

Impairment of the surgical view by bleeding in endoscopic ethmoidectomy for chronic rhinosinusitis with nasal polyps (CRSwNP) contributes to the risk of skull base injuries. The aim of this study was to investigate the effect of a short course of a systemic corticoid treatment on bleeding and surgical field quality during endoscopic ethmoidectomy for CRSwNP.

METHODS

A prospective study was conducted on 40 patients. Before surgery, 21 of them (group B) were treated with 1 mg/kg per day of prednisolone for seven days. They were compared with the 19 other patients (group A) on intraoperative blood loss and surgery duration.

RESULTS

The two groups shared identical clinical features (Lidholdt endoscopic grading). There was no statistical difference in terms of bleeding, although the Lund-Mackay CT score was higher in group B (19/24 vs. 21/24, p=0.05). The surgical procedure was shorter in group B (72 min vs. 85 min, p=0.05).

CONCLUSION

Preoperative treatment with systemic corticosteroids does not seem to reduce surgical blood loss. However, we noted a decrease in the procedure's duration. By reducing mucous inflammation, this treatment could improve the local conditions and help the surgeon in the mucous eradication.

Onset of symptomatic effect of mometasone furoate nasal spray in the treatment of nasal polyposis

BACKGROUND

The efficacy of the intranasal corticosteroid mometasone furoate nasal spray (MFNS) for treatment of nasal polyposis was demonstrated in 2 large clinical trials.

OBJECTIVE

To evaluate the onset of MFNS symptomatic effect, data from the 2 trials were pooled and analyzed to determine the first day subjects experienced significant symptom relief.

METHODS

Subjects with nasal polyposis randomized to MFNS 200 microg twice daily or placebo scored symptoms on a 3-point scale (0 = none; 3 = severe) and measured peak nasal inspiratory flow immediately before the morning dose. Onset of symptomatic effect was defined as the first day a statistically significant (P < .05) lasting response was observed for MFNS compared with placebo.

RESULTS

A total of 447 subjects with bilateral nasal polyps and clinically significant nasal congestion/obstruction were analyzed. Compared with placebo, MFNS 200 microg twice daily demonstrated statistically significant (P < .05) relief of anterior rhinorrhea by day 2 (-10.9% vs +5.7%), nasal congestion by day 3 (-15.1% vs -7.6%), postnasal drip by day 5 (+1.1% vs +4.6%), and sense of smell by day 13 (-9.6% vs -5.6%). Significant improvement in peak nasal inspiratory flow was seen by day 2 (increase of 6.22 L/min vs 1.48 L/min for placebo; P = .03).

CONCLUSION

Mometasone furoate nasal spray 200 microg twice daily rapidly improves the symptoms of nasal polyposis, leading to lasting relief of most major symptoms within 2 (24 hours after the first dose) to 5 days of initiating therapy.

Recent consensus on the classification of rhinosinusitis — a way forward for research and practice?

Prior classification of rhinitis was into three categories: acute, subacute and chronic rhinosinusitis. The advantages of this classification were obvious but they were offset by some disadvantages. For example, the previous classification did not take account of the mechanisms underlying the condition or the clinical outcome. Hence, there was a need for evidence-based sinusitis classification guidelines. The American Academy of Otolaryngology-Head and Neck Surgery and other related societies published a classification of the condition and suggested clinical research strategies for patients with rhinosinusitis. The main conclusion was that sinusitis should be divided into four categories: acute (bacterial) rhinosinusitis, chronic rhinosinusitis (CRS) without polyps, CRS with polyps, and allergic fungal sinusitis. The aim of this current paper is to discuss the consensus for nomenclature, outline the proposed classification of different types of rhinosinusitis and to suggest some ways that we may audit these guidelines.

Oral steroids for nasal polyps

BACKGROUND

Benign nasal polyps are lesions that arise from the mucosa of the nasal cavity or one or more of the nasal sinuses. The presenting symptoms of nasal polyps are nasal obstruction, watery anterior rhinorrhoea (excessive nasal secretions) or mucopurulent postnasal drip (or both), hyposmia and anosmia (reduced or absent sense of smell) with a concomitant alteration in taste and infrequently pain over the dorsum of the nose, forehead and cheeks. The main aim of treatment is to relieve these symptoms. Because of their uncertain aetiology treatment options differ, consisting of a combination of medical and surgical management. Medical therapy is mainly in the form of steroids, administered topically or systemically via the oral route.

OBJECTIVES

To assess the effects of oral steroids in patients with multiple nasal polyps.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2006), MEDLINE (January 1950 to April 2006), EMBASE (January 1974 to April 2006), CINAHL, LILACS, MEDCARIB, KOREAMED, INDMED, PAKMEDINET, SAMED, PANTELEIMON, ZETOC, Cambridge Scientific Abstracts, mRCT (metaRegister of Clinical Trials), NRR (National Research Register), ISI Web of Science and the reference lists of relevant articles. We also contacted leading experts in the field. The date of the most recent search was April 2006.

SELECTION CRITERIA

Randomised controlled trials and controlled clinical trials comparing oral steroids with no intervention, or placebo, or comparing doses or schedules of oral steroids in patients with multiple nasal polyps.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed study quality. Study authors were contacted for additional information.

MAIN RESULTS

Only one trial was identified which met the inclusion criteria. This trial showed a significant improvement in quality of life and nasal symptom scores (comprising nasal obstruction and loss of smell scores) and a significant reduction in polyp size after two weeks of treatment with oral steroids compared to no steroid treatment. However the trial was small and of low methodological quality.

AUTHORS' CONCLUSIONS

The authors found one small randomised controlled trial, albeit of poor quality, that suggests a short-term effect of oral steroids in patients with multiple nasal polyps. To address the issue more thoroughly a well designed, prospective randomised controlled trial is needed.