Previous BRSJ Papers

Welcome to the BRS Juniors Paper archive section of this website. Each previous months recommended paper will be archived in this section for your reference to enjoy in the future and to help you prepare for examinations.

If you would like more information on any of these papers, please do get in touch with us by clicking here.

November 2019 - Inaugural BRS Juniors recommended paper

Septoplasty with or without concurrent turbinate surgery versus non-surgical management for nasal obstruction in adults with a deviated septum: a pragmatic, randomised controlled trial.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30354-X/fulltext

This paper was published in the Lancet in June 2019 and is the first randomised-control study looking at the effectiveness of Septoplasty versus non-surgical treatment. This is an important study for the UK as we continue to face challenges in obtaining funding to perform Septoplasties, which impacts on surgical training and experience for BRS Junior Trainees.

2020 Paper - Biologics for chronic rhinosinusitis. 

Chong LY, Piromchai P, Sharp S, Snidvongs K, Philpott C, Hopkins C, Burton MJ. Cochrane Database of Systematic Reviews 2020, Issue 2. Art. No.: CD013513. DOI: 10.1002/14651858.CD013513.pub2.

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013513.pub2/information

 Summary:

·       Included 8 RCTs with 986 participants.

·       Almost all the patients studied in the trials had severe CRS with nasal polyps.

·       Dupilumab:

o    After 24 weeks treatment, dupilumab improves disease-specific HRQL compared to placebo and reduces the extent of disease as measured on CT scan.

o    On average, symptoms were improved in the treatment group.

o    It may reduce the need for further surgery.

o    Patients did not have more severe side effects compared to placebo.

·       Mepolizumab:

o    Studied in far fewer patients than dupilumab.

o    May improve both disease-specific and generic HRQL.

o    Uncertain whether it reduces the need for surgery or improves nasal polyp scores.

o    Uncertain if there is a difference in symptom severity and the risk of serious adverse events.

·       Omalizumab:

o    Very little data found so uncertain about the effects.

European Position Paper on Rhinosinusitis and Nasal Polyps 2020.

Executive summary: https://pubmed.ncbi.nlm.nih.gov/32226949/

Full paper: https://epos2020.com/Documents/supplement_29.pdf

Summary:

·       The EPOS 2020 guideline provides revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS.

·       EPOS 2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS 2012 position.

The 2019 BRS Juniors Committee recommended paper 

Efficacy and safety of dupilumab in patients with severe chronic rhinosinusitis with nasal polyps (LIBERTY NP SINUS-24 and LIBERTY NP SINUS-52): results from two multicentre, randomised, double-blind, placebo-controlled, parallel-group phase 3 trials.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31881-1/fulltext

Chronic rhinosinusitis with nasal polyps (CRSwNP) affects 4.2% of the European population, impacting significantly on quality of life and characterised by high rates of recurrent disease following surgery. Nasal polyp disease characterised by type 2 inflammatory cytokines and eosinophilia represents a particularly severe phenotype, where multiple courses of topical and systemic corticosteroid therapy often only provide short-lived resolution of symptoms. 

Exciting novel immune modifying therapies (monoclonal antibodies) that inhibit the cytokines that drive type 2 inflammation, such as Dupilumab, are demonstrating promising results in treating nasal polyps and are likely to play a key role in our future management and is therefore of importance for BRS Junior members to be aware.

2018 - BRS Juniors Paper Choices

Tranexamic acid for patients with nasal haemorrhage (epistaxis). 

Joseph J, Martinez‐Devesa P, Bellorini J, Burton MJ. Cochrane Database of Systematic Reviews 2018, Issue 12. Art. No.: CD004328. DOI: 10.1002/14651858.CD004328.pub3.

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004328.pub3/full

 Summary:

·       Included 6 RCTs with 692 participants.

·       Probably a reduction in the risk of re-bleeding with the use of either oral or topical TXA + usual care compared to placebo + usual care in adults with epistaxis (moderate quality)

·       Quality of evidence relating to topical TXA solely was low (one study only)

·       Topical TXA appears better than other topical haemostatic agents in stopping bleeding in the first 10 minutes (moderate quality)

-

Effect of Budesonide Added to Large-Volume, Low-pressure Saline Sinus Irrigation for Chronic Rhinosinusitis: A Randomized Clinical Trial. 

Tait S, Kallogjeri D, Suko J, Kukuljan S, Schneider J, Piccirillo JF. JAMA Otolaryngol Head Neck Surg. 2018 Jul 1;144(7):605-612. doi: 10.1001/jamaoto.2018.0667. PMID: 29879268; PMCID: PMC6145785.

https://pubmed.ncbi.nlm.nih.gov/29879268/

Summary:

·       80 adult patients with CRS were enrolled in this double-blind, placebo-controlled, RCT.

·       All study participants were given a sinus rinse kit with identical capsules containing either budesonide (treatment group) or lactose (control).

·       Participants were instructed to dissolve the capsules in the saline and use the solution to irrigate both nasal cavities once daily for 30 days.

·       Primary outcome measure was change in SNOT-22 scores. Secondary outcome measures included endoscopic examination scored by the Lund-Kennedy grading system.

·       Key findings:

o    Study suggests that budesonide in saline lavage results in clinically meaningful benefits beyond the benefits of saline alone for patients with CRS.

o    Average change in SNOT-22 score was 20.7 points for budesonide group vs. 13.6 points for control.

o    23 participants (79%) in budesonide group experienced a clinically meaningful reduction in SNOT-22 scores compared to 19 (59%) in the control.

o    The average change in endoscopic scores was 3.4 points for the budesonide group and 2.7 points for the control.

2016 BRS Juniors Paper Choices

Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis. 

Chong LY, Head K, Hopkins C, Philpott C, Schilder AGM, Burton MJ. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD011996. DOI: 10.1002/14651858.CD011996.pub2.

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011996.pub2/full

Summary:

·       Included 18 RCTs with 2738 participants.

·       Most of the evidence was from studies in patients with CRS with nasal polyps.

·       Quality of life: 

o    Little information available (very low quality evidence)

·       Disease severity: 

o    Seems to be improvement for all symptoms (low quality)

o    Moderate-sized benefit for nasal obstruction (moderate quality)

o    Small benefit for rhinorrhoea (moderate quality)

·       Risk of epistaxis: 

o    Increased, but data included all levels of severity (high quality)

·       Risk of local irritation:

o    Unclear (low quality)

 - 

Saline irrigation for chronic rhinosinusitis. 

Chong L, Head K, Hopkins C, Philpott C, Glew S, Scadding G, Burton MJ, Schilder AGM. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD011995. DOI: 10.1002/14651858.CD011995.pub2

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011995.pub2/full

 Summary:

·       Analysis of two randomised controlled trials (116 patients) which were very different in terms of included populations, interventions and comparisons.

·       No benefit of a low volume (5mL) nebulised saline spray over intranasal steroids.

·       Some benefit of high volume (150mL) hypertonic saline irrigation compared with placebo (low quality)

 -

Short‐course oral steroids alone for chronic rhinosinusitis. 

Head K, Chong LY, Hopkins C, Philpott C, Burton MJ, Schilder AGM. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD011991. DOI: 10.1002/14651858.CD011991.pub2.

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011991.pub2/full#CD011991-sec-0128

 Summary:

·       Included 8 RCTs with 474 participants.

·       Reviewed the evidence for the benefits and harms of a short course of corticosteroid given by mouth to people with CRS compared with giving placebo or no treatment, or another type of treatment.

·       For patients with CRS + nasal polyps, oral corticosteroid is beneficial compared to placebo for:

o    Reducing the size of polyps (low quality)

o    Reducing symptoms severity (low quality)

·       Difference between the groups appears to become smaller at longer-term outcomes, but evidence was inconclusive due to its low quality.

·       The quality of evidence for adverse effects was very low.

·       No available evidence found for patients with CRS without nasal polyps.

 -

Systemic and topical antibiotics for chronic rhinosinusitis. 

Head K, Chong L, Piromchai P, Hopkins C, Philpott C, Schilder AGM, Burton MJ.  Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD011994. DOI: 10.1002/14651858.CD011994.pub2

https://www.cochrane.org/CD011994/ENT_systemic-and-topical-antibiotics-chronic-rhinosinusitis

 Summary:

·       Included five RCTs with 293 participants.

·       No studies of topical antibiotics met the inclusion criteria.

·       Found very little evidence that systemic antibiotics are effective in patients with CRS.

·       Found some evidence of modest improvement in disease-specific quality of life in adults with CRS without polyps receiving 3 months of a macrolide antibiotic (moderate quality). Improvement was only seen at the end of the 3 month treatment and by 3 months later there was no difference.

 -

Different types of intranasal steroids for chronic rhinosinusitis. 

Chong LY, Head K, Hopkins C, Philpott C, Burton MJ, Schilder AGM. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD011993. DOI: 10.1002/14651858.CD011993.pub2.

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011993.pub2/full

Summary:

·       Included 9 RCTs with 911 participants.

·       Insufficient evidence to suggest that one type of intranasal steroid is more effective than another in patients with CRS.

·       Insufficient evidence to suggest that effectiveness of a spray differs from an aerosol.

·       No studies compared drops with sprays.

·       Unclear if higher doses result in better symptom improvement (low quality).

·       Increased risk of epistaxis when higher doses were used (moderate quality).

- 

Short‐course oral steroids as an adjunct therapy for chronic rhinosinusitis. 

Head K, Chong LY, Hopkins C, Philpott C, Schilder AGM, Burton MJ. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD011992. DOI: 10.1002/14651858.CD011992.pub2.

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011992.pub2/references

Summary:

·       Included two RCTs with 78 participants.

·       There was a lack of any high-quality evidence to be able to determine whether a short course of oral steroids is beneficial to patients with CRS on top of other treatments.

·       High risk of bias within the trials and many of the primary and secondary outcomes were not reported well. The time frame of evaluation was short (<3 months) and there was variation in the populations studied.

 -

Efficacy of olfactory training in patients with olfactory loss: a systematic review and meta-analysis. 

Pekala K, Chandra RK, Turner JH. Int Forum Allergy Rhinol. 2016 Mar;6(3):299-307. doi: 10.1002/alr.21669. Epub 2015 Dec 1. PMID: 26624966; PMCID: PMC4783272.

https://pubmed.ncbi.nlm.nih.gov/26624966/

Summary:

·       Included 10 studies with 639 participants.

·       Meta-analysis performed on 3 studies.

·       Olfactory dysfunction was due to multiple aetiologies within the studies and on the whole the studies did not separate them out.

·       Threshold, Discrimination and Identification (TDI) score was used as the primary endpoint in most of the studies, with >5.5 or 6 considered significant improvement.

·       Patients receiving olfactory training experienced a statistically significant improvement in TDI score compared to control patients.

·       Significant improvement in olfactory dysfunction was observed in discrimination and identification, but not in olfactory thresholds.

2012 BRS Juniors Paper Choices 

Impact of tobacco smoke on chronic rhinosinusitis: a review of the literature.

Reh DD, Higgins TS, Smith TL. Int Forum Allergy Rhinol. 2012 Sep-Oct;2(5):362-9. doi: 10.1002/alr.21054. Epub 2012 Jun 13. PMID: 22696460; PMCID: PMC3443524.

https://pubmed.ncbi.nlm.nih.gov/22696460/

Summary:

·       Systematic review

·       Literature search using the terms “sinusitis”, “rhinosinusitis”, “smoking”, “nasal epithelial”, “smoke”, “second-hand smoke” and “endoscopic sinus surgery”.

·       72 articles were reviewed on the pathophysiological effects of tobacco smoke.

·       31 articles analysed to determine correlation between second-hand smoke and CRS.

·       29 articles analysed the impact of smoking on surgical results.

·       Recommendations:

o    Evidence in the literature that cigarette smoke contributes to CRS

o    Active smoking was not found to be a contraindication to endoscopic sinus surgery

o    The impact of smoking volume and long-term smoking after endoscopic sinus surgery has not yet been evaluated

 -

Endoscopic skull base reconstruction of large dural defects: a systematic review of published evidence. 

Harvey RJ, Parmar P, Sacks R, Zanation AM. Laryngoscope. 2012 Feb;122(2):452-9. doi: 10.1002/lary.22475. Epub 2012 Jan 17. PMID: 22253060.

https://pubmed.ncbi.nlm.nih.gov/22253060/

Summary:

·       Systematic review and meta-analysis of 38 identified studies with extractable data regarding endoscopic endonasal reconstruction of the skull base.

·       12 described vascularized reconstruction, 17 described free graft, 9 described mixed reconstructions.

·       Key findings:

o    Evidence suggested that vascularised tissue was associated with a lower rate of CSF leaks compared to free tissue graft.

o    Overall CSF leak rate was 11.5% (70/609)

§  Free grafts leak rate – 15.6% (51/326)

Vascularised reconstruction leak rate – 6.7% (19/283)

2011 - BRS Juniors Paper Choice 

Early postoperative care following endoscopic sinus surgery: an evidence-based review with recommendations. 

Rudmik L, Soler ZM, Orlandi RR, Stewart MG, Bhattacharyya N, Kennedy DW, Smith TL. Int Forum Allergy Rhinol. 2011 Nov-Dec;1(6):417-30. doi: 10.1002/alr.20072. Epub 2011 Oct 29. PMID: 22144050.

https://pubmed.ncbi.nlm.nih.gov/22144050/

 Summary:

·       Systematic review

·       Study inclusion criteria: adult population (>18 years old) with CRS undergoing ESS following failed medical therapy.

·       Primary study objective: evaluate an ESS early post-operative care strategy

·       Recommendation: 

o    Use of nasal saline irrigation, sinus cavity debridement, and standard topical nasal steroid spray are recommended early postoperative care interventions.

Other options in postoperative management are antibiotics, systemic steroid, and drug-eluting spacers/stents.

2006 - Archived - BRS Juniors Paper Choices

A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap

Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, Mintz A. Laryngoscope. 2006 Oct;116(10):1882-6. doi: 10.1097/01.mlg.0000234933.37779.e4. PMID: 17003708.

https://pubmed.ncbi.nlm.nih.gov/17003708/

Summary:

·       Describes a neurovascular pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium based on the nasoseptal artery, a branch of the posterior septal artery.

·       Retrospective review of 43 patients undergoing endonasal skull base surgery repaired with this flap.

·       CSF leak in 5%; one episode of posterior epistaxis but no infectious or wound complications encountered in the series.

 -

The national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis

Hopkins C, Browne JP, Slack R, Lund V, Topham J, Reeves B, Copley L, Brown P, van der Meulen J. Clin Otolaryngol. 2006 Oct;31(5):390-8. doi: 10.1111/j.1749-4486.2006.01275.x. PMID: 17014448.

https://pubmed.ncbi.nlm.nih.gov/17014448/

Summary:

·       Prospective cohort study of patients undergoing surgery for nasal polyposis and/or chronic rhinosinusitis.

·       3128 consecutive patients enrolled across 87 hospitals in England and Wales.

·       SNOT-22 scores improved from pre-operative period (mean = 42.0) to 3 months post-operative (mean = 25.5)

·       Patients undergoing nasal polypectomy; scores improved from 41.0 pre-operatively to 23.1 at 3 months.

·       Patients undergoing surgery for CRS alone; scores improved from 44.2 to 31.2.

·       SNOT-22 scores at 12- and 36-months post-surgery were similar to those at 3 months.

·       Complication rate: 

o    Bleeding (5% intra-op, 1% post-op), orbital (0.2%).

·       Revision rate: 

o    11.4% of patients had undergone revision surgery at 36-month follow-up.