EDITORIAL

Topical steroid application to the mucosa of the nose and paranasal sinuses appears to be a key to controlling chronic rhinosinusitis (CRS) in a majority of cases, and is even more important in cases of CRS associated with polyposis. The lead article in this issue of the International Forum of Allergy and Rhinology evaluates the use of a steroideluting implant in patients with CRS with polyposis in the office setting. This randomized, controlled, blinded study offers level 1 evidence supporting the effectiveness of such topical therapy, particularly in patients with high polyp burden.1 However, the followup time frame is limited to 3 months and the product will likely be costly, similar to its FDAapproved predecessor. This cost is due, in part, to the rigors required for the FDA approval process (multiple studies and randomized, controlled study design required). Given all of the off-label use of steroids in the field of rhinology, it is nice to have products with proven safety and efficacy, but these products appear to come at significant expense. Several recent rhinology products (steroid-eluting implants, balloons) appear to be originating in the cardiology space before a retooling process and extrapolation to rhinology. Time will tell whether our current healthcare environment will continue to support this type of innovation; it is clear that cost-effectiveness will need to be demonstrated in future studies. Within the same general topic, Leung et al.2 address steroid therapy from a different perspective; ie, an evidencebased risk analysis to assist clinicians and patients in making decisions about the risks of repeated oral steroid therapy as compared to those of sinus surgery. In my practice, this topic consistently arises, and the subsequent discussion has often left more questions than answers. I think this particular study also leaves us with many questions— such as what does that equation in the methods section really mean?! More seriously, it is clear that risk analyses, like cost-effectiveness evaluations, hinge on many important assumptions. A small change in 1 of these assumptions can lead to vastly differing conclusions in the analysis. So as you read these types of studies, I suggest you analyze the authors’ assumptions to see if they have face validity (ie, they

make sense to you!) to determine if the study conclusions can be appropriately extrapolated to your practice. The next hot topic is that of hot saline irrigations and their effect on hemostasis.3 I first learned of this technique from my neurosurgery colleagues who commonly employ warm saline irrigations in our skull base cases to aid hemostasis. Anecdotally, I noticed some hemostatic effect in those cases, but this did not seem to extrapolate to my typical endoscopic sinus surgery (ESS) cases (not all the time at least). Gan et al.3 validate my anecdotal experience to some degree. It appears that hot saline irrigation has most benefit in cases of longer duration (over 2 hours), which would include all of the skull base cases and some substantial proportion of ESS cases. Zhang et al.4 demonstrate quality of life (QOL) improvements in patients with CRS, polyps, and/or asthma after ESS. More interesting, they demonstrate that patients with comorbid polyps and/or asthma actually had greater QOL improvement than patients without these comorbidities. It is important to note the QOL instrument used, the 22item Sino-Nasal Outcome Test (SNOT-22), which includes questions specific to nasal airway obstruction and probably accounts for the additional improvement of QOL in patients with polyps. As you read literature related to QOL in nasal and sinus disorders, it is important to take note of the different QOL instruments that are used (eg, SNOT22, Rhinosinusitis Disability Index [RSDI], Chronic Sinusitis Survey [CSS], Nasal Obstruction Symptom Evaluation [NOSE], etc.). While all of these instruments evaluate nasal and/or sinus related QOL, they do not all measure the exact same thing. Some QOL instruments (surveys) will be more sensitive to improvements in specific symptoms like nasal obstruction while others will be more sensitive to perhaps less obvious problems (though no less important!) such as sexual dysfunction resulting from nasal and sinus disease. A review of the specific questions in the instrument can help you understand the aspects of QOL that are being measured. I hope that you not only benefit from but also enjoy reading these excellent articles and others in this issue, as well as the additional articles available for Early View on the Journal Website.

DOI: 10.1002/alr.21441 View this article online at wileyonlinelibrary.com. How to Cite this Article: Smith TL. Int Forum Allergy Rhinol. 2014;4:859–860.

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International Forum of Allergy & Rhinology, Vol. 4, No. 11, November 2014

Timothy L. Smith, MD, MPH Associate Editor

References 1. Han JK, Forwith KD, Smith TL, et al. RESOLVE: a randomized, controlled, blinded study of bioabsorbable steroid-eluting sinus implants for in-office treatment of recurrent sinonasal polyposis. Int Forum Allergy Rhinol. 2014;4:861–870. 2. Leung RM, Dinnie K, Smith TL. When do the risks of repeated courses of corticosteroids exceed the risks

of surgery? Int Forum Allergy Rhinol. 2014;4:871– 876. 3. Gan EC, Alsaleh S, Manji J, Habib AR, Amanian A, Javer AR. Hemostatic effect of hot saline irrigation during functional endoscopic sinus surgery: a randomized controlled trial. Int Forum Allergy Rhinol. 2014;4:877– 884.

4. Zhang Z, Adappa ND, Doghramji LJ, et al. Quality of life improvement from sinus surgery in chronic rhinosinusitis patients with asthma and nasal polyps. Int Forum Allergy Rhinol. 2014;4:885–892.

International Forum of Allergy & Rhinology, Vol. 4, No. 11, November 2014

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Chronic rhinosinusitis.

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