Management of chronic rhinosinusitis with steroid nasal irrigations: A viable nonsurgical alternative in the COVID‐19 era

Abstract

Background High‐dose, high‐volume steroid nasal irrigations (NSI) have been incorporated into the medical management of recalcitrant CRS, primarily following surgical intervention. The objective of this study was to evaluate the role of NSI as a preoperative management and to identify the percentage of patients who ultimately underwent ESS for recalcitrant CRS despite being on NSI. Methods Retrospective chart review of patients presenting with CRS who underwent a trial of NSI for at least six weeks. Pre‐irrigation and post‐irrigation outcomes measured included Lund‐Mackay scores (LMS), SNOT‐22 scores, and whether or not the patient underwent ESS. Results Of the 90 patients who underwent NSI, 32 patients underwent ESS, while 58 patients had a significant enough improvement in symptoms to avoid ESS. The likelihood of decision for surgery did not differ between the mometasone and budesonide groups (p=0.3094), comorbid asthma status (p=0.3585), smoking status (p=0.2256), polyp status (p=0.7288), or history of prior ESS (p=0.5803). SNOT scores significantly improvement following NSI in the group of patients that did not go on to ESS (p<0.0001) and in the group that did (p<0.0001). LMS also improved following NSI, but this was only statistically significant in the patients that ultimately went on to ESS (p=0.0102). Conclusions After a trial of NSI, 64.4% of patients with CRS no longer met candidacy for ESS and had a significant improvement in SNOT‐22 scores. This supports the use of nasal steroid irrigations in the medical management of CRS with and without surgical intervention and with and without nasal polyposis. This article is protected by copyright. All rights reserved

International consensus statement on allergy and rhinology: rhinosinusitis 2021

“…Some fear discontinuing INCS may not only worsen symptoms but increase viral shedding due to coughing and sneezing. High volume nasal steroids are particularly efficacious in the treatment of CRS without necessitating surgical intervention 2492,2493 . One randomized, controlled trial in CRSsNP patients without history of sinus surgery showed greater improvements in SNOT‐22 and Lund‐Kennedy scores after using mometasone nasal irrigations compared to mometasone nasal spray for 8 weeks 2492 .…”

Challenges to medication adherence with intranasal corticosteroid irrigations

“…7 Corticosteroid irrigations have shown benefit in reducing the need for endoscopic sinus surgery (ESS) with 64% of surgery candidates avoiding the operating room in one recent pilot study. 21 Failure of this medication leads to treatment escalation to interventions such as ESS, steroid-eluting stents, or biologics, all of which are significantly more expensive than intranasal corticosteroids. 1 The overall economic burden of CRS is immense: direct and indirect annual costs in the United States are estimated to be $10 to $13 and $20 billion, respectively.…”

Coronavirus Disease-19 and Rhinology/Facial Plastics

“… 50 In a retrospective study, 64.4% of all patients with CRS treated with nasal steroid irrigations did not require surgical management after treatment for at least 6 weeks. 51 These studies are preliminary but promising given the likely prolonged COVID-19 environment.…”

“…Recent studies have shown efficacy in the use of high-volume nasal steroid irrigations in patients with CRS who had not previously undergone surgery. 50 , 51 A double-blinded, randomized controlled trial in CRS without nasal polyposis patients without prior surgical intervention demonstrated clinically meaningful improvement in SNOT-22 scores with high-volume nasal steroid irrigations compared with steroid sprays. 50 In a retrospective study, 64.4% of all patients with CRS treated with nasal steroid irrigations did not require surgical management after treatment for at least 6 weeks.…”