Budget Impact of a Steroid-Eluting Sinus Implant Versus Sinus Surgery for Adult Chronic Sinusitis Patients with Nasal Polyps

Assessing the effect of absorbable steroid sinus implant: a state-of-the-art systematic review

OBJECTIVES

Endoscopic sinus surgery is not a definitive treatment for chronic rhinosinusitis (CRS). The use of sinus stents after surgery to maintain sinus patency and deliver local steroids has gained popularity. The first steroid-eluting bioabsorbable implant (SEBI) approved for this indication, later Propel, was developed in 2011. This state-of-the-art review aims to summarize the available evidence, as well as to point out potential pitfalls and lack of specific analyses to guide future research on this new therapeutic option.

DATA SOURCES

Pubmed (Medline), the Cochrane Library, EMBASE, SciELO.

REVIEW METHODS

Nine research questions were defined: Are steroid-eluting Sinus implants useful for the control of CRS symptoms after surgery? Do they improve surgical field healing after CRS surgery? Do they decrease polyp regrowth after ESS? Do they decrease the need for ESS? Are they useful in symptom control as in-office procedure? Are they better than other steroid-impregnated resorbable materials? Do they have a positive impact on olfaction? Are they safe? Are they cost-effective? Retrieved articles were reviewed by two authors.

RESULTS

Twenty nine studies were included: 3 metanalysis, 1 systematic review, 10 randomized clinical trials, 4 quasi-experimental studies, 1 retrospective cohort study, 4 cost studies, 3 case series and 2 expert consensus. The review encompassed a population of 3,012 patients treated with SEBI and 2826 controls.

CONCLUSIONS

This is the first state-of-the-art review assessing steroid eluting bioabsorbable stent evidence. Despite the effort in recent years, still several questions remain unanswered. This review will hopefully guide future research efforts to better define the role of SEBI in the otolaryngology practice.

Systematic review and meta-analysis of the curative effects and safety of endoscopic sinus surgery in children with chronic sinusitis with nasal polyps

BACKGROUND

At present, the surgical treatment of sinusitis with nasal polyps has made great progress, but its recurrence rate is still high. Therefore, this time, meta-analysis is used to study the therapeutic effect of endoscopic sinus surgery on children with chronic sinusitis with nasal polyps, analyze its effectiveness and safety, and provide theoretical basis for clinical treatment.

METHODS

Boolean logic searching was adopted to retrieve articles from various databases, including PubMed, Medline, and Chinese National Knowledge Infrastructure (CNKI), published from the establishment of the database to December 30, 2021. The following search terms were used: "endoscopic sinus surgery", "antrochoanal polyps", "chronic sinusitis with nasal polyps", and "nasal polyps". Comparative studies on traditional surgical treatment and endoscopic sinus surgery were also screened out. Review Manager was utilized for meta-analysis.

RESULTS

A total of 9 references were included in the study, and most of them were low risk bias (medium and high quality). Meta-analysis showed that there was no statistical heterogeneity between the control group and the experimental group (Chi²=0.03, I²=0%, P=0.98). According to the fixed effect model analysis, the number of patients with polyp formation in the experimental group was significantly less than that in the control group (Z=2.65, P=0.008). Compared with the control group, there is no statistical heterogeneity in the postoperative recurrence (Chi²=1.59, I²=0%, P=0.45). According to the analysis of fixed effect model, the postoperative recurrence in the experimental group is significantly less than that in the control group (Z=2.92, OR =2.78, 95% CI: 1.40-5.52, P=0.004). Compared with the control group, the results of postoperative visual analogue scale (VAS) were statistically different (Chi²=12.63, I²=84%, P=0.002). According to the random effect model analysis, the VAS score of the experimental group was significantly lower than that of the control group (Z=18.06, MD =4.51, 95% CI: 3.96-5.05, P<0.00001).

DISCUSSION

Endoscopic sinus surgery could reduce the postoperative recurrence and pain of patients, and showed high curative effects and safety in the treatment of children with chronic sinusitis with nasal polyps.

Real-world evidence analysis of the impact of steroid-eluting implants on healthcare resource use among chronic rhinosinusitis patients undergoing sinus surgery

OBJECTIVE

To compare healthcare resource use (HCRU) in patients undergoing sinus surgery with or without steroid-eluting sinus implants.

METHODS

A retrospective, observational cohort study using real-world evidence data (OM1, Inc, Boston, MA, USA) was conducted on adult patients with chronic rhinosinusitis (CRS) with or without nasal polyps who underwent endoscopic sinus surgery between 2014 and 2019 and had at least 18 months of data both before and after surgery. Patients receiving implants ("implant cohort") were matched to patients who did not receive implants ("non-implant cohort") based on a propensity score developed using baseline characteristics. Chi-square for binary variables and analysis of variance tests for continuous variables were applied to compare HCRU measures.

RESULTS

Comparison of the implant (N = 1983) and non-implant (N = 1983) cohorts during the 18-month follow-up period demonstrated significantly lower HCRU in those receiving implants, including all-cause outpatient visits (94.3% vs. 96.6%, p < .001), all-cause otolaryngologist visits (47.3% vs. 59.6%, p < .001) and all cause ER/urgent care visits (9.2% vs. 11.8%, p = .007), as well as sinus-related endoscopies (39.1% vs. 43.8%, p = .003). Although not statistically significant, fewer patients in the implant cohort had undergone repeat surgeries (4.6% vs. 5.3%, p = .273).

CONCLUSION

Patients with steroid-eluting sinus implants had lower HCRU over a post-operative period of 18 months. These findings support the contention that reductions in HCRU may be achieved using steroid-eluting implants during sinus surgery.What is known on this topicChronic rhinosinusitis (CRS) causes severe symptoms that lead to poor quality of life.Endoscopic sinus surgery (ESS) is 76-98% effective in improving CRS patients' symptoms.Surgical outcomes can be compromised in the immediate post-operative period by scarring, adhesion formation, and early polyp recurrence.Oral and topical corticosteroid therapy has become integral to the maintenance of successful surgical outcomes, the management of post-operative scarring and edema, and the prevention of nasal polyp recurrence.Steroid-eluting sinus implants have been shown in clinical trials to improve postoperative outcomes after ESS by delivering localized, sustained release of corticosteroids directly onto inflamed sinus tissue.What this study addsThis observational study is one of the first to use real-world evidence to assess the effect of steroid-eluting sinus implants on healthcare resource use (HCRU) in patients with chronic rhinosinusitis who underwent sinus surgery with or without implants.Use of implants significantly reduced HCRU, including all-cause outpatient visits (94.3% vs 96.6%, p < .001), all-cause otolaryngologist visits (47.3% vs 59.6%, p < .001), and all-cause ER/urgent care visits (9.2% vs 11.8%, p = .007), as well as sinus endoscopy (39.1% vs 43.8%, p = .003).Use of implants had no significant effect on sinus procedures such as debridement and polypectomy, as well as sinus-related imaging such as CT, MRI, and x-ray.

Pharmacological, Technological, and Digital Innovative Aspects in Rhinology

Innovation refers to the introduction of a product, a process, a service or a solution resulting in something new or significantly improved compared to the already available alternatives. In the clinical context, it is strictly related to the identification of a new added value in terms of quality, therapeutic efficacy and safety. Over the years several innovative approaches have been introduced in the clinical practice, revolutionizing the treatment and the management of important rhinologic conditions. Innovative tools, including new drugs, biomaterials, and mobile applications seem to be able to improve the clinical outcomes and the quality of life of many patients affected by (often relapsing) rhinologic diseases. Among the main modern pharmacological innovations, mention must be made of the biological drugs like monoclonal antibodies (mAbs). Recently, new mAbs have been introduced and investigated as useful arms in the treatment of some inflammatory/infectious or oncological diseases affecting the nasal cavities and paranasal sinuses. The already approved or still investigated mAbs work inhibiting different type 2 inflammation pathways, including those mediated by IgE (omalizumab), IL-4/IL-13 (dupilumab), and IL-5 (mepolizumab). Moreover, considering the higher expression of PD-L1 in nasopharyngeal carcinoma, the use of PD-1 inhibitors, such as nivolumab, or a dual CTLA-4/PD-1 blockade (ipilimumab plus nivolumab) appear to be an effective strategy for the treatment of this cancer form. The implants with bio-absorbable biomaterials represent new interesting available technological innovations. Moreover, advanced technologies such as the artificial intelligence, the machine learning as well as the augmented or virtual reality have also proved useful in rhinologic field with main impacts on precision medicine and surgery. Finally, the development and use of mobile-Health tools represent a winning strategy in monitoring of the therapy success, safety and tolerability as well as the progress of chronic disease including chronic rhinosinusitis with nasal polyps. Supporting the research of innovative tools and strategies (including pharmacological, technologic, or digital ones) is essential to improve the management of chronic diseases that significantly affect the patients' quality of life.

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.