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State of the Art : Evidence-Based Decision-Making in Rhinology

On any given day, as rhinologists we interact with patients who ask us questions that deserve answers. Those questions can be, “What is causing my symptoms?” or “How can I best get rid of my symptoms?” Sometimes we answer, “Chronic rhinosinusitis,” or, “Reduce inflammation,” but these responses don’t get to the heart of etiology or effective treatment, much less a personalized treatment for a particular patient’s pathophysiologic manifestations. In a sense, our patients’ questions become our own questions: “What does cause chronic rhinosinusitis?” and, “What are the most effective treatment options?” Evidence-based medicine (EBM) has played an increasingly prominent role in our clinical decision-making, especially in the last 10–15 years. As medical expenditures rise, it’s natural to take a hard look at the effectiveness of a particular intervention and often understanding the underlying etiology guides those interventions. There are varying views on what constitutes EBM and some consider it “cookbook medicine”, where pathways and algorithms are laid out in simplicity, based on various published research. This simplistic view of EBM fails to take into account the variations in pathophysiology, environmental conditions, comorbidities, socioeconomic issues, and a host of other patient factors which significantly impact the effectiveness and applicability of any therapeutic option. EBM is, therefore, best seen as a combination of three important factors: best external evidence published in peer-reviewed literature, individual clinician expertise based on experience and local practice factors, and patient values and expectations. Figure 1 shows the EBM “sweet spot” where these three elements overlap. We must explore our patients’ concerns and their priorities as we consider treatment for their conditions and we must as objectively as possible consider our own clinical expertise and experience. We certainly rely on the wisdom of our teachers and we continually learn about new developments in the scientific meetings of our societies and associations. We must also know the published literature well in order to apply it to our patients’ situation. Staying abreast of an increasingly large body of rhinologic “best available evidence” can be a significant challenge. While rhinosinusitis accounts for only 0.1% of articles pubState of the Art: Evidence-Based Decision-Making in Rhinology


Introduction -Evidence Based Medicine
On any given day, as rhinologists we interact with patients who ask us questions that deserve answers. Those questions can be, "What is causing my symptoms?" or "How can I best get rid of my symptoms?" Sometimes we answer, "Chronic rhinosinusitis," or, "Reduce inflammation," but these responses don't get to the heart of etiology or effective treatment, much less a personalized treatment for a particular patient's pathophysiologic manifestations. In a sense, our patients' questions become our own questions: "What does cause chronic rhinosinusitis?" and, "What are the most effective treatment options?" Evidence-based medicine EBM has played an increasingly prominent role in our clinical decision-making, especially in the last -years. As medical expenditures rise, it's natural to take a hard look at the effectiveness of a particular where these three elements overlap . We must explore our patients' concerns and their priorities as we consider treatment for their conditions and we must as objectively as possible consider our own clinical expertise and experience. We certainly rely on the wisdom of our teachers and we continually learn about new developments in the scientific meetings of our societies and associations. We must also know the published literature well in order to apply it to our patients' situation.
Staying abreast of an increasingly large body of rhinologic "best available evidence" can be a significant challenge. It must be remembered that the recommendations apply to routine situations and that the patient's individual circumstances must always be taken into consideration: -Saline irrigation appears to improve outcomes with minimal harm, according to multiple studies. It is recommended following ESS. Hopefully more studies in the future will delineate this balance better.
-Topical decongestants have been examined in one study, which showed no evidence of improved outcomes but did show increased pain. For this reason topical decon-gestants are not recommended following ESS.
-Leukotriene receptor antagonists have also been examined in only one study in the immediate postoperative period. Minimal improved outcomes were seen and there is significant potential harm and cost. For these reasons they are not recommended in the immediate postoperative period.
-Drug eluting spacers and stents have garnered much attention recently. There is early evidence for improved outcomes. There is also, however, significant cost associated with this intervention. Evidence continues to be produced examining the long-term value, change in outcome compared to cost, and this evidence will continue to guide our practices. For now drug-eluting spacers and stents are considered optional in the immediate postoperative period following ESS.
In summary, we have some evidence to guide our postoperative care following ESS, but much more is needed. -Glucose testing of rhinorrhea is sometimes used as an indicator of CSF leakage. There is, however, a high false-negative and false positive risk with this test. For this reason the evidence suggests that it not be used as a definitive diagnostic marker for CSF.
-Beta-transferrin testing is very reliable, based on the evidence, with a nearly % positive and negative predictive value. Moreover the evidence shows that the protein is stable at room temperature for days. Betatrace protein is similarly highly reliable.
-Radionucleotide cisternography, where pledgets are placed in the nose to capture radioactive fluid injected intrathecally is not as reliable and is invasive. Its routine use is therefore discouraged.
-Once the diagnosis of a CSF leak is made, the next issue is identifying the source. The evidence in the literature indicates that a fine cut CT scan in the coronal plane is the best first localizing test. -The use of nasal packing following repair to support the graft and hold it in place makes sense but interestingly there is very little evidence to examine this practice.
Packing is therefore an option following CSF leak repair.
-Bedrest is often used following repair to avoid Valsalva maneuver. There is however, no evidence, to indicate how long bedrest must be used and when regular activities may be resumed. Similarly, no studies have examined when it is safe to resume continuous positive airway pressure for patients with obstructive sleep apnea.

Summary and Conclusion
There has been a great deal of evidence published over the last few decades in the field of rhinology. As it increases in quantity, fortunately the evidence also continues to increase in its quality. As rhinologists, it's incumbent upon us to know this literature as we make evidence-based decisions in the treatment of our patients. Recent systematic reviews, including international consensus statements, have greatly facilitated the dissemination of the best available evidence in rhinology.
This review has examined three areas where the evidence can guide our treatment: decision-making in frontal sinus surgery, immediate postoperative care following ESS, and in the diagnosis and management of CSF leaks. Many more such areas are addressed in consensus documents such as ICAR-RS and EPOS. The reader is strongly encouraged to familiarize himself or herself with these documents in order to provide the best possible care for his or her patients.

Potential Conflicts of Interest
Dr. Orlandi is a consultant for Medtronic ENT, Lyra Therapeutics, and BioInspire Technologies