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Update on evidence based reviews in adult CRS
Recommendation for #2: LHB or LHL position when
using low-volume devices, which will only reliably dis-
tribute to the nasal cavity.
Intervention. Only prescribe low-volume devices with
concurrent education on the proper position in which
to administer them.
Effect of nasal anatomy.
Nasal cavity anatomy and nasal
congestion was seen to impact distribution of topical ther-
apies. Five studies examined this effect, although only 1
addressed sinus delivery. In balancing the potential ben-
efits and harms of altering nasal anatomy and/or using
longstanding decongestants to improve topical medication
delivery, the EBRR found data supporting this practice
lacking. It therefore recommended high-volume delivery to
overcome these effects:
Aggregate quality of evidence. C (Level 3b: 1 study; Level
4: 4 studies).
Benefit. High-volume irrigations are able to overcome
anatomic variations in the nasal cavity and achieve si-
nus delivery. Nasal cavity delivery with low-volume de-
vices can be overcome with pharmacologic decongestion
or LHL position. The impact of surgical correction of
unfavorable nasal cavity anatomy upon delivery to the
paranasal sinuses has not been studied.
Harm. Achieving better delivery by using high-volume
devices to overcome unfavorable nasal anatomy may be
associated with side effects. Use of the LHL position
to improve nasal cavity delivery of low-volume devices
carries little harm. The impact of chronic topical vaso-
constrictors upon nasal cavity delivery to the middle
turbinate/middle meatus is not proven and may result
in rhinitis medicamentosa.
Cost. Optimal head position with low-volume devices or
high-volume delivery devices to overcome unfavorable
nasal cavity anatomy are low. Nasal surgery cost.
Benefits-harm assessment. Proven benefit in using high-
volume devices; optimal head position with low-volume
devices has little harm.
Value judgments. Chronic topical vasoconstrictor use
or nasal surgery, in the absence of airflow obstruc-
tion, is unproven and carries the risk for harm and
cost.
Recommendation level. Recommend for: Use of high-
volume delivery devices to achieve sinus delivery in
patients with unfavorable nasal anatomy. Option for:
Short-term (3–4 days or less) use of topical vasocon-
strictor to improve nasal cavity delivery in cases of
turbinate hypertrophy. Recommend against: Long-term
use of topical vasoconstrictor to improve nasal cavity
delivery.
Intervention. Educate patients with unfavorable nasal
cavity anatomy regarding optimal delivery posi-
tion/device depending upon the desired site of topical
delivery.
Surgical therapy for CRS
Rhinologic literature over the last 30 years is rich with de-
scriptions of surgical therapies, with some outcome data for
individual methods. Current evidence indicates that stan-
dard ESS provides clinically significant QOL improvements
for CRS patients that have failed medical therapy.
14,15
Dif-
ferent approaches, devices, and techniques have been de-
scribed in an effort to reduce the significant morbidity as-
sociated with CRS. Comparative efficacy is largely lacking,
however, with knowledge gaps in extent of surgery, opti-
mal ostial size, resection vs dilation, hemostasis methods,
and postoperative packing. These and other areas would be
well served by additional evidence and, where appropriate,
a review of the available evidence with recommendations.
Two recent EBRRs have examined surgically-related top-
ics . Ramakrishnan et al.
16
examined the role of image guid-
ance in ESS, specifically addressing the ability of this tech-
nology to prevent complications and to improve outcomes.
Rudmik et al.
17
reviewed the evidence pertaining to a num-
ber of postoperative therapies following sinus surgery in
order to provide recommendations for the most beneficial
treatment strategy.
IGS in ESS
IGS has evolved to become a common adjunct to ESS but
has been challenged as having little evidence to support
it. Ramakrishnan et al.
16
addressed this topic in a recent
EBRR, acknowledging the relative paucity of evidence and
delineating the significant barriers to overcoming this gap.
Six studies were included in their analysis of complica-
tions associated with ESS; 4 were retrospective and 2 were
prospective nonrandomized studies. The available evidence
mostly showed nonsignificant trends and also showed some
conflicting results. Due to the low incidence of complica-
tions associated with ESS, most studies were significantly
underpowered to show a clinical difference. With regard
to complications, the EBRR found IGS to be a valuable
option:
Aggregate quality of evidence: C (Level 2b: 2 studies,
Level 4: 4 studies).
Benefit: Potential for fewer surgical complications,
particularly severe complications; provides additional
anatomic information, particularly for cases in which
anatomy can be significantly obscured.
Harm: Local skin irritation, potential for poor IGS reg-
istration/calibration/accuracy; potential for more exten-
sive surgery than otherwise necessary.
Cost: Disposable supplies, equipment costs, possible ex-
tra operating room (OR) time.
Benefits-Harm assessment: Preponderance of benefit over
harm.
Value judgments: IGS can provide critical information,
particularly in the setting of altered anatomy or severe
disease; avoiding major complications is essential; ideal
studies are neither practical nor feasible.
Policy level: Option.
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