The Egyptian Clinical Practice Guidelines of Otorhinolaryngology, Audio-vestibular & Phoniatrics (ECPG-ORLAP)

1. Acute Rhinosinusitis: Adapted Egyptian Clinical Practice Guidelines Ahmed Ragab, Reda Kamel, Ashraf Khaled, Baliegh Hamdy, Ahmed Elfarouk, Mohamed Elsharnouby, Hossam Elsherif 2. Chronic Rhinosinusitis: Adapted Egyptian Clinical Practice Guidelines Ahmed Elfarouk, Magdy Eisa, Mohamed Osama Tomoum 3. Allergic Rhinitis: Adapted Egyptian Clinical Practice Guidelines Ahmed Ragab, Reda Kamel, Mohamed Gamea, Ayman Medani, Zeyad Mandour 4. Epistaxis: Adapted Egyptian Clinical Practice Guidelines Ibrahim Rezk Mohammed, Diaa Elhennawi, Mohamed Rifaat Ahmed 5. Cerebrospinal Fluid Rhinorrhea (CSF): Adapted Egyptian Clinical Practice Guidelines Ismail Elnashar, Mostafa A. El Taher, Ashraf Elhosini, Tamer Orabi 6. List of Contributors 7. Acknowledgement


Introduction and background
Rhinosinusitis affects about 1 in 8 adults. More than 1 in 5 antibiotics prescribed in adults are for rhinosinusitis, making it the fifth most common diagnosis responsible for antibiotic therapy. Rhinosinusitis is defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. The term rhinosinusitis is preferred because sinusitis is almost always accompanied by inflammation of the contiguous nasal mucosa. Therefore, rhinosinusitis is used in the remainder of the guideline.

Scope and purpose
The purpose of this guideline is to identify quality improvement opportunities in managing adult acute rhinosinusitis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy for acute rhinosinusitis, promote appropriate use of ancillary tests to confirm diagnosis and guide management, and promote judicious use of systemic and topical therapy specially for systemic antibiotic.

Methods
The adaptation cycle passed over: Set up phase, adaptation phase {search and screen, assessment of (currency, content and quality) and Decisions/selection} and finalization phase that include revision.

Results
Ten guidelines were assessed by 7 experts rhinologists and the International Consensus on Rhinosinusitis 2021 had the highest scores as regards to the currency, contents and quality. It was graded GRADE by 15 expert rhinologists and reviewed by 4 expert reviewers. 3 Grade Definition

High ++++
We are very confident that the true effect lies close to that of the estimate of the effect.

Moderate +++
We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.

Low ++
Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very Low + We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

Defined strategy for evidence quality and recommendation development according to (American Academy of Pediatric (AAP) on Quality Improvement and Management)
Evidence quality Preponderance of benefits over harm

Modified statements
Added statements D Option ++++

2.Diagnosis: Symptoms
Symptoms must include: 1-Mucopurulent nasal drainage/discharge (anterior/ posterior) and 2-Nasal blockage/obstruction/congestion or facial pain/ pressure or both Symptoms may include smell affection and headache in adults and cough in children.
All can be included in CPODS C: Congestion P: Pain O: Obstruction D: Drainage/Discharge S: Smell affection.

3.Diagnosis: Parameters
Diagnosis is clinical and depends on symptoms and signs rather than radiology. C Recommendation ++++

4.Diagnosis: Examination
A thorough physical examination that includes inspection, palpation of the maxillary and frontal sinus, as well as anterior rhinoscopy (evidence of inflammation, mucosal oedema, and discharge).

5.Diagnosis: Investigations
Objective evidence of ARS on nasal endoscopy, antral puncture, or radiographic imaging (X-ray, ultrasonography, or CT) is not required for the diagnosis in uncomplicated cases.

B
Recommendation Against ++++ Against use

6.Diagnosis: Investigations
ESR and CRP are inflammatory markers found to be elevated during ARS, but they are not routinely used for diagnosis because of their limited specificity.
They may have some role in COVID-19 related symptoms in Chinese guidelines for COVID-19: CRP test together with other clinical parameters for initial evaluation and follow-up of coronavirus infection. Cut-off for CRP: 40-50 mg/L (4).

7.Differentiating viral from bacterial
Differentiating between Acute bacterial rhinosinusitis (ABRS) and acute viral rhinosinusitis (AVR) can be challenging even in the setting of endoscopy and cultures. Close follow-up of patient symptomology can often help in making the diagnosis, especially for patients that do not improve with supportive care.
Duration is thought to be a key factor differentiating ABRS from AVR, with persistence of symptoms beyond 7-10 days or worsening of symptoms after 5 days being indicators of development of post-viral ABRS.
Clinical factors associated with symptoms and signs ABRS include: Timing of the disease, worsening of the disease, purulent nasal discharge on rhinoscopy, localized unilateral pain, severe pain over the teeth and maxilla, and fever > 38˚C.

-Odontogenic rhinosinusitis
The evidence for association between ARS and anatomic variants is conflicting and limited and largely inferred from a small number of studies.
-Population-based studies seem to support an association between allergic rhinitis (AR) and ARS.
The epidemiologic studies show that a subset of patients with viral URI will develop clinical ARS.
The current literature demonstrates an absence of a well-designed and published investigation into the role of odontogenic infections in ARS.

9.a. Treatment: Antibiotics
Consider initial watchful waiting in uncomplicated cases, with institution of antibiotic therapy if no improvement after 4-7 days or worsening at any time, or for mitigating circumstances with drug resistance e.g., including severe symptoms, immunocompromised state, concern for impending complications, suspected odontogenic source, prior antibiotics (1 month), prior hospitalization (5 days) and comorbidities.

11.Non responders managements
-First time non responders can be based on lack of clinical improvement following treatment within 5 days in adults and 3 days in children.
-Use second line antimicrobial agents.
-Second time non responders who fail to improve with second line antibiotic therapy should be evaluated for other diagnosis or considered for sinus aspiration or endoscopically guided middle meatus culture and sensitivity.

12.Complications
-In patients with ABRS suspected to have suppurative complications, axial, coronal and sagittal views with contrast-enhanced computed tomography (CT) is recommended to localize the infection and to guide further treatment.
-Magnetic resonance imaging (MRI) provides soft tissue visualization and is useful when there is concern for intracranial involvement. Magnetic resonance venography may be useful for evaluation of the cavernous sinus and other vasculature.
-The hallmarks of management are swift diagnosis, rapid initiation of broad-spectrum intravenous antibiotics, and in many cases surgical intervention.

Introduction and background
Chronic rhinosinusitis (CRS) is an inflammatory process of the nose and paranasal sinuses that persist for more than 12 weeks, with a significant impact on the quality of life of affected patients, and significant socioeconomic burden. Improved knowledge of the diagnostic criteria and evidence-based care will enhance diagnostic accuracy and ensure optimal CRS management.

Scope and purpose
The primary purpose of this guideline is to address the quality improvement for all otorhinolaryngologist to optimize patient care, promote effective diagnosis and treatment, and reduce harmful or unnecessary variations in care of CRS patients.

Methods
The adaptation cycle passed over: set-up phase, adaptation phase (search and screen, assessment: currency, content, quality & /decision/selection) and finalization phase that include revision.

Results
We assessed five chronic rhinosinusitis guidelines where the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 had the highest scores as a regard to the currency, contents, and quality. It was graded by 32 expert rhinologists and reviewed by 9 expert reviewers.
The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to Decision frameworks (GRADE Working Group 2013).

Strength after adaptation
Grade Definition

High ++++
We are very confident that the true effect lies close to that of the estimate of the effect.

Moderate +++
We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different

Low ++
Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.

Very Low +
We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

Strength
After adaptation

Remarks and
reviewer comment

1.Definition according to duration
≥12 weeks symptoms without complete resolution of symptoms. C Recommended ++++

2.Diagnosis
Twelve weeks or longer of two or more of the following signs and symptoms: Mucopurulent drainage.
Nasal obstruction, Facial pain-pressure-fullness, or Decreased sense of smell.
And inflammation is documented by one or more of the following findings:

4.Modifying factors
Clinicians should assess the patients for multiple chronic conditions e.g. asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia.

5.Multi-slice detector CT (MSCT) utilizing low dose protocols
It shortens the duration of the procedure without compromising anatomical accuracy. NR Recommended +++

Summary of Clinical Practice Guidelines (CPG)
Egyptian clinical practice guidelines of chronic sinusitis Specific test for our region. Objective test not available

9.Nasal brushing and cytology
It is not essential to do cytology (Either brushings or lavage) at initial presentation to ENT/ secondary Care.

Diagnostic criteria
Five of the major criteria in the original Bent-Kuhn diagnostic criteria should be met to make the diagnosis as three of the five are common in most cases of CRSwNP. These major criteria consist of the following: Nasal polyposis. Fungi on staining. Eosinophilic mucin without fungal invasion into sinus tissue. Type I hypersensitivity to fungi and.
Characteristic radiological findings with soft tissue differential densities on CT scanning and unilaterality or anatomically discrete sinus involvement.
The minor criteria include bone erosion, Charcot Leyden Crystals, unilateral disease, peripheral eosinophilia, positive fungal culture and the absence of immunodeficiency or diabetes.

NR
Recommended +++ CT shows densely packed hyperdensities in the sinuses with expansion and erosion of the bony walls whereas on MRI signal voids occur on both T1 and T2 sequences.

Management
The mainstay of treatment remains surgery as medical treatment alone is usually ineffective.

NR
Recommended ++++ Oral steroids both preand postoperatively are of benefit.

NR
Recommended ++++ A l l e r g e n immunotherapy was also helpful in atopic individuals.

NR
Option ++++ Oral antifungals may reduce recurrence but do not improve symptoms.

Investigation
There is no definitive test for sarcoidosis other than a positive biopsy.

Treatment
Systemic steroids remain the mainstay of treatment in sarcoidosis. NR Recommended ++++ Hydroxychloroquine, steroidsparing cytotoxic agents such as methotrexate and TNF-alpha antagonists such as infliximab are being used.

NR
Recommended ++++ Oral antifungals may reduce recurrence but do not improve symptoms.

Strength After adaptation
Remarks and reviewer comment 20.Short course of systemic corticosteroid (7-21 days) *One or two courses of systemic corticosteroids per year can be a useful addition to nasal corticosteroid treatment in patients with partially or uncontrolled disease. **A short course of systemic corticosteroid postoperatively does not seem to influence quality of life.
***Short course of systemic corticosteroid (7-21 days), with or without local corticosteroid treatment results in a significant reduction in total symptom score and nasal polyp score.

21.Nasal Corticosteroids
Nasal corticosteroids in patients with CRS. There is high-quality evidence that long term use of nasal corticosteroids is effective and safe for treating patients with CRS.

22.Corticosteroideluting sinus Implants
The placement of corticosteroideluting sinus implants in the ethmoid of patients with recurrent polyposis after sinus surgery has a significant but small (0.3 on a 0-3 scale) impact on nasal obstruction but significantly reduces the need for surgery and reduces nasal polyp score.
Expensive compared to proofed benifit
**Ringer's lactate potentially with the addition of Xylitol, sodium hyaluronate, and xyloglucan.
***Advises against the use of baby shampoo and hypertonic saline solutions due to side effects).

24.Short Course of Antibiotics
Uncertain whether the use of a short course of antibiotics has an impact on patient outcomes in adults with acute exacerbations of CRS compared with placebo.

25.Long-Term Antibiotics
Due to the low quality of the evidence, is uncertain whether the use of longterm antibiotics has an impact on patient outcomes in adults with CRS, particularly in the light of potentially increased risks of cardiovascular events. There is a need for the larger high-quality trials that are presently being undertaken in Europe.

26.Topical Antibacterial Therapy
Due to the very low quality of the evidence, is uncertain whether the use of topical antibacterial therapy has an impact on patient outcomes in adults with CRS compared with placebo. Topical antibacterial therapy does not seem to be more effective than placebo in improving symptoms in patients with CRS. However, it may give a clinically non-relevant improvement in symptoms, SNOT-22 and LK endoscopic score compared to oral antibiotics.

Strength After adaptation
Remarks and reviewer comment

27.Proton Pump Inhibitors
Advice against the use of proton pump inhibitors in the treatment of CRS.

28.Phototherapy
We identified two trials with opposing findings. The quality of the evidence for the use of phototherapy in patients with CRS is very low. Based on the evidence, the EPOS2020 steering group cannot make a recommendation on the use of phototherapy in patients with CRS.

29.Nasal Decongestants
Not using nasal decongestants in CRS. In situations where the nose is very blocked, the temporary addition of a nasal decongestant to the nasal corticosteroid treatment can be considered.

30.Muco-Active Agents
The quality of the data insufficient to advice on the use of muco-active agents in the treatment of patients with CRS.

31.Anti-Leukotrienes (Montelukast)
Based on the very low quality of the available evidence, It is unsure about the potential use of Anti-Leukotrienes (Montelukast) in CRS and does not recommend its use unless in situations where patients do not tolerate nasal corticosteroids.

32.Local and systemic antifungal treatments
Advises against the use of antimycotics in CRS. Local and systemic antifungal treatments do not have a positive effect of QOL, symptoms and signs of disease in patients with CRS. The EPOS2020 steering group advises against the use of these treatments in patients with CRS.

33.Probiotics
Advises against the use of probiotics for the treatment of patients with CRS. Ib (-) Not Recommended +++

34.Bacterial Lysates
There is one DBPCT from 1989 comparing the bacterial lysate Broncho-Vaxom to placebo in a large group of CRS patients resulting in a significant decrease in purulent nasal discharge and headache over the full six-month period compared to placebo and reduced opacification of the sinus X-ray. Based on this limited evidence, we cannot advise on the use of Broncho-Vaxom in the treatment of CRS.

Action recommendation
Level of Evidence

Strength After adaptation
Remarks and reviewer comment

35.Herbal treatment
Of five RCTs evaluating herbal treatment, a large DBPCT, using tablets, showed overall no effect, although a post-hoc sensitivity analysis, showed a significant benefit in major symptom score at 12 weeks of treatment over placebo in patients with a diagnosis of CRS for >1 year and a baseline MSS >9 (out of max 15). Of the four studies evaluating different local herbal treatment, three showed a favorable effect. However, not all studies were blinded, and the quality of the studies was variable.
The treatment does not show significantly more adverse events than placebo. The quality of the evidence for the local treatment is low.

36.Acupuncture and traditional Chinese medicine
There is no evidence that traditional Chinese medicine or acupuncture is more effective than placebo in the treatment of CRS. The safety of Chinese medicine is unclear because most of the papers are not (easily) accessible.
Minor and serious adverse events can occur during the use of acupuncture and related modalities, contrary to the common impression that acupuncture is harmless.

37.Filgastrim (r-met-HuG-CSF)
There is one study evaluating Filgastrim compared to placebo in CRS. There was no significant difference in effect on QOL between the two groups. Based on the evidence, we cannot make a recommendation on the use of Filgastrim in patients with CRS.

38.Collodial silver nasal spray
One very small study did not find differences between nasal colloidal silver spray and placebo. Based on the evidence, the EPOS2020 steering group cannot make a recommendation on the use of collodial silver nasal spray in patients with CRS.

39.Capsaicin
Capsaicin showed a significant decrease in nasal obstruction and nasal polyp score in two small studies, however data on other symptoms like rhinorrhea and smell are either nonsignificant or unreported. The quality of the evidence is low and the EPOS steering group concludes that capsaicin may be an option in treatment of CRS in patients with CRSwNP but that larger studies are needed. 1b Option +++

40.Nasal Furosemide
A recent DBPCT study showed significantly reduced QOL (SNOT-22) scores and polyp score (VAS), and significantly more patients with an NPS of 0 in the furosemide nasal spray treated group versus placebo.
There was no indication of a difference in adverse events between topical furosemide and placebo. However, the quality of the evidence is very low.

Strength After adaptation
Remarks and reviewer comment

41.Antihistamines
The quality of the evidence comparing antihistamines with placebo was very low. Evidence was downgraded because of the small number of studies and because the most important measures of efficacy were not reported.

42.Aspirin treatment after desensitization (ATAD) with oral aspirin in N-ERD
Oral ATAD has been shown to be significantly more effective and clinically relevant than placebo in improving QOL (measured with SNOT) and total nasal symptom score in patients with N-ERD.

43.Aspirin treatment after desensitization (ATAD) with nasal lysine aspirin in N-ERD
ATAD with lysine aspirin and platelet inhibitors (like Pradugrel) have not been shown to be an effective treatment in CRSwNP patients with N-ERD and are not advised.

44.Anti-IgE
Anti-IgE therapy has been proposed as a promising biologic therapy for CRS. Ib Option +

45.Anti-Il-5
There is only one large sufficiently powered study with Mepolizumab that showed a significant reduction in patients' need for surgery and an improvement in symptoms. There is no high-level evidence to support the efficacy of either shortor long-term antibiotics for CRS in children.

49.Nasal corticosteroids
There is no evidence regarding the efficacy of intranasal steroids in the treatment of CRS in children.
They have anti-inflammatory effects and excellent safety record in children.

50.Systemic Steroids
Adding a taper course of systemic steroids to an antibiotic (not effective on its own) is more effective than placebo in the treatment of pediatric CRS. Judicious use of this regimen is advised considering systemic side effects.

51.Saline Irrigation
There are a few clinical trials demonstrating the efficacy of saline irrigations in pediatric patients with CRS. It has excellent safety record in children, Addition of antibiotics to saline irrigations is not recommended.

53.FESS
(The treatment of older children with CRS refractory to medical therapy or previous adenoidectomy).

Introduction and background
The prevalence of allergic rhinitis AR world-wide is increasing. Approximately 10-30% of adults and 10-40% of children are affected. In Egypt the current prevalence is variable in different studies ranging from 3.6-34% in different studies. AR is estimated to affect nearly 1 in every 6 Americans.About 40-80% of patients with rhinitis may have a combination of AR and non-AR.

Scope and purpose
The purpose of this guideline is to identify quality improvement opportunities in managing patients with AR and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve diagnostic accuracy for AR, promote appropriate use of ancillary tests to confirm diagnosis and guide management, and promote judicious use of systemic and topical therapy.

Methods
The adaptation cycle passed over: set up phase, adaptation phase (Search and screen, assessment: Currency, Content and Quality and Decisions/selection) and finalization phase that include revision.

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to Decision frameworks (GRADE Working Group 2013) 18
Grade Definition

High ++++
We are very confident that the true effect lies close to that of the estimate of the effect.

Moderate +++
We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.

Low ++
Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.

Very Low +
We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect. Recommendations statements adapted/adopted/added/deleted

Modified statements
Added statements

Item Statements Egyptian comments
Def.
AR is defined as an immunoglobulin E (IgE)-mediated inflammatory nasal condition resulting from allergen exposure in a sensitized individual.
Sensitization to an allergen is indicated by a positive reaction on allergy skin test or antigen-specific IgE test, whereas clinical allergy is evidenced by active symptoms (characterized by nasal congestion, rhinorrhea (nasal drainage), sneezing, and/or nasal itching) upon allergen exposure in a sensitized individual. Not all sensitized individuals exhibit clinical allergy.

Classification
Assess severity and Classify it's type As regards the symptoms severity we can use the visual analogue scale (VAS): Mild less than 5 and Moderate/Moderate sever more than 5.
Classification of AR typically includes seasonal vs perennial and intermittent vs persistent.
-Seasonal allergic rhinitis (SAR): Disease caused by an IgE-mediated inflammatory response to seasonal aeroallergens. The length of seasonal exposure to these allergens is dependent on geographic location and climatic conditions.
-Perennial allergic rhinitis (PAR): Disease caused by an IgE-mediated inflammatory response to year-round environmental aeroallergens. These may include dust mites, mold, animal allergens, or certain occupational allergens.
-Intermittent allergic rhinitis: Disease caused by an IgE-mediated inflammatory response and characterized by frequency of exposure or symptoms (<4 days per week or <4 weeks per year).
-Persistent allergic rhinitis: Disease caused by an IgE-mediated inflammatory response and characterized by persistent symptoms (>4 days per week and >4 weeks per year).

Recommendation level Interpretation Egyptian Gradings
Surgical therapy: Whereas AR is typically considered a medical disease, surgical therapies are sometimes offered. Surgical treatment of the septum, inferior and/or middle turbinates, and possibly vidian/posterior nasal neurectomy, may be considered in both allergic and nonallergic patients.

C Option
Turbinate reduction with or without septoplasty may be considered in AR patients who have failed medical management, and have anatomic features that explain symptoms of nasal obstruction. Pending additional studies, ILIT may be a viable option for AR treatment in the clinical population. Not to be used in Egypt except after other studies confirm its benefits.

++
•AIT = allergen immunotherapy; AR = allergic rhinitis; ILIT = intralymphatic immunotherapy; SCIT = subcutaneous immunotherapy; SLIT = sublingual immunotherapy. Evidence for an association is of low grade, with substantial defects in study design. + Cough 9 C Low level evidence for an association between AR and cough. ++++

Laryngeal disease 18 C
There is some evidence for an association between AR and laryngeal disease.

C
Limited observational data suggests a potential association between aeroallergens and EoE pathogenesis.

Introduction and background
Epistaxis or bleeding from the nose is defined as acute haemorrhage from the nostril. Epistaxis can be divided into 2 categories, anterior bleeds and posterior bleeds, on the basis of the site where the bleeding originates. Epistaxis is a frequent emergency department (ED) complaint and often causes significant anxiety in patients and clinicians. Epistaxis etiological causes can be divided into local causes, systemic causes and idiopathic causes. Epistaxis is the most common rhinological emergency seen in the emergency department accounted for approximately 1 in 30 visits to the ED and 77 out of a population of 100,000 nearly 60% of the population experience a nosebleed at least once. One-tenth of these patients eventually seek medical advice/intervention, and 0.16% will need hospitalization.

Scope and purpose
The purpose of this guideline is to identify quality improvement opportunities in managing Epistaxis and to create explicit and actionable recommendations to implement these opportunities in clinical practice. Specifically, the goals are to improve management of epistaxis to identify quality improvement opportunities in the management of nosebleeds and to create clear and actionable recommendations to implement these opportunities in clinical practice. Specific goals of this guideline are to promote best practices, reduce unjustified variations in care of patients with nosebleeds, improve health outcomes, and minimize the potential harms of nosebleeds or interventions to treat nosebleeds.

Methods
Use of the simplest method to stop nosebleeds, reduce morbidity, protect airway, reduce need for blood products, improve patient satisfaction, allow for further assessment and management. Improve access to effective treatment options, raise awareness of effective treatment options, provide effective and timely control of bleeding, reduce length of stay and overall cost for the patient, allow opportunity for shared decision making about methods more invasive than cautery to control nosebleed. The adaptation cycle passed over: set up phase, adaptation phase (Search and screen, assessment: Currency, Content and Quality and Decisions/ selection) and finalization phase that include revision.

Results
Ten guidelines were assessed by 3 experts rhinologists and the International Consensus on Clinical Practice Guideline: Nosebleed (Epistaxis) published in the January 2020 (The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) 8 had the highest scores as regards to the currency, contents and quality. It was graded GRADE by 14 expert rhinologists and reviewed by 10 expert reviewers.

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to Decision frameworks (GRADE Working Group 2013)
Grade Definition

High ++++
We are very confident that the true effect lies close to that of the estimate of the effect.

Moderate +++
We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different

Low ++
Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.

Very Low +
We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect Recommendations statements (from 10-20 recommendations in a Table) Accepted statements

3.Prompt management
Cautery/coagulation of the bleeding site with (chemical cautery, electrocautery, or electrocoagulation) or nasal packing.
-At the time of initial contact, the clinician should distinguish the epistaxis patient who requires prompt and emergency ABCD management.
-If there is only minor active bleeding without airway or hemodynamic issues, the patient may be assessed in an ambulatory setting that has the clinical expertise and supplies necessary to diagnose and control bleeding.
If active bleeding is not reported or seen but there is concern for recurrence of severe bleeding, the clinician should direct the patient to an emergency department or hospital.
-Assess the patient severity of bleeding as they need promptint ervention through: 1. Bleeding duration 30 minutes over a 24-hour period 2.A history of hospitalization for nosebleed, prior blood transfusion for nosebleeds, or recent episodes of nasal bleeding 3. evidence of or suspicion for a prolonged or large volume bleeding, bleeding from both sides of the nose or from the mouth, or any signs of acute hypovolemia (ie, tachycardia, syncope, orthostatic hypotension).

5.Nasal compression
The clinician should treat active anterior epistaxis for patients in need of prompt management with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5-10 minutes or longer.
If hemostasis is not achieved or leads to postnasal bleeding, it should be discontinued, and an attempt made to clear blood and visualize the site with suction, to identify the bleeding site.

6.Nasal packs
A. For patients in whom bleeding precludes identification of a bleeding site despite nasal compression, the clinician should treat ongoing active bleeding with nasal packingunder its related clinical Setting.
B. nasal packing is anterior, posterior or both according to the site of bleeding whether anterior or posterior.
C. The clinician should use resorbable packing for patients with a suspected bleeding disorder or for patients who are using anticoagulation or antiplatelet medications.
D. Once a pack is inserted, it is usually recommended that it is left in place for 48 hours, necessitating admission (specially for posterior nasal packing), although care at home with packs has been described for anterior nasal packing. Use prophylactic antistaph. Antibiotics during the time of packing.

9.Risk factors
The clinician should document factors that increase the frequency or severity of bleeding for any patient with a nosebleed, including medical or family history of bleeding disorders, drug use as anticoagulant or antiplatelet or intranasal drug use, Nasal cannula oxygen use and CPAP use (continuous positive airway pressure) specially in COVID-19 patients.

10.Anterior rhinoscopy to identify location of bleeding
The clinician should perform anterior rhinoscopy to identify a source of bleeding after removal of any blood clot. The side of bleeding as well as whether predominantly anterior, or posterior should be determined and localized point bleeding or diffuse.

11.Examination using nasal endoscopy
The clinician should perform, or should refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding.

12.Investigations
After patient stabilization and control of bleeding: -A full blood count will facilitate assessment of blood loss and shock -coagulation profiles -A biochemistry profile may indicate circulatory effects on renal function or the break-down products of a large volume of ingested blood.

13.Advanced investigation
Angiography has an essential but infrequent role in excluding potentially fatal carotid aneurysms in trauma and in cases of heavy post-surgical bleeding.
Grade C Medium Very Low +

14.Appropriate interventions for identified bleeding site
The clinician should treat patients with an identified site of bleeding with an appropriate intervention, which may include one or more of the following: topical vasoconstrictors, nasal cautery, and moisturizing or lubricating agents.

15.Nasal cautery or coagulation
-When nasal cautery is chosen for treatment, the clinician should anesthetize the bleeding site and restrict application of cautery only to the active or suspected site(s) of bleeding.
C.Electrocoagulation with diathermy which is prefered.
Grade C Medium High ++++ B. EUA, examination under anesthesia and SPA, sphenopalatine artery ligations are the first option of surgical treatment in such cases.

Ministry of Higher
C. AEA ligation has an essential role in traumatic or postsurgical epistaxis, in which nasal or ethmoid bony injury leads to bleeding beyond the SPA distribution.
D. Selective embolization of the maxillary or facial arteries should be considered in cases where surgical ligation fails, or is impossible because of anesthetic concerns or nonavailability.

17.Management of life-threatening bleeding in patients using anticoagulation and antiplatelet medications
In the absence of life-threatening bleeding, the clinician should initiate first-line treatments prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/ antiplatelet medications for patients using these medications.

18.Management of recurrent nose bleeds with possible Hereditary hemorrhagic telangiectasia (HHT) identification
The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds to diagnose hereditary hemorrhagic telangiectasia syndrome.

Grade B
High Very low +

19.Patient education and prevention
The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care.

20.Nosebleed outcomes
The clinician should document the outcome of intervention within 30 days or document transition of care in patients who had a nosebleed treated with non-resorbable packing, surgery, or arterial ligation/embolization.

Grade C Medium
Very Low +

21.Refractory Acute Epistaxis
Refractory Acute Epistaxis will continue (usually slowly or intermittently), despite all conservative measures, good nasal packs, examination under anesthetic, and even arterial ligations.
Evaluate the following: -History of trauma, with or without anterior ethmoid laceration, or acarotid aneurysm?
-Role for further ligations of the bilateral sphenopalatine, or anterior and posterior ethmoid arteries.
Grade C Medium Very Low +

Introduction and background
CSF rhinorrhea, results from an osseous defect in the skull base with an associated dural fistula. If untreated, it can lead to serious complications. Many controversies exists in the management of CSF rhinorrhea.
The purpose of this work is to search for the most suitable guidelines to provide clinicians with best evidence based medicine (EBM) practice in management of CSF rhinorrhea regarding diagnosis and treatment. Also, to formulate these guidelines in a simplified algorithm trying to solve controversies in the management in the best way that suits Egyptian circumstances.

Methods
The adaptation cycle passed over the setup phase, the adaptation phase (search and screen assessment: currency, content, quality and decisions/ selection) and finalization phase that includes revision.

Results
The guidelines were chosen and formulated by the authors and graded by 13 experienced rhinologists and reviewed by three highly experienced reviewers.
The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to decision framework assessment.
High ++++: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate +++: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it's substantially different Low ++: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low +: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate effect. Lumbar drains may shorten the interval to traumatic CSF leak cessation during conservative management.

3
The evidence for acetazolamide in traumatic or iatrogenic CSF leaks is lacking.

4
Prophylactic antibiotics There is a lack of evidence to support prophylactic antibiotics administration in patients with a traumatic CSF leak.

5
Defects of the ethmoid roof and sphenoid Non-iatrogenic (after conservative measures fail) and iatrogenic traumatic CSF (generally not treated conservatively) leaks can be repaired endoscopically with high success rates.

Frontal sinus defects
The transnasal endoscopic approach to frontal sinus CSF leaks is safe and effective in select patients, but may have higher rates of failure than other locations.

Spontaneous CSF rhinorrhea 7
The relationship between idiopathic intracranial hypertension (IIH) and spontaneous CSF rhinorrhea.
There is a direct relationship between spontaneous CSF leaks and IIH; most spontaneous leaks represent a variant of IIH.

8
Confirmation of leak by Lab testing.
After clinical examination, B2transferrin and beta trace protein are the initial preferred methods of detection of CSF leaks. NR ++ Recommendation 9 Site of leak localization.
The chronological order of the investigations is: -High resolution CT (HRCT), (non invasive).
-CT cysternography with intrathecal dye injection (Invasive) if the above measures failed.

10
Role of perioperative ICP management with lumbar drains.
Perioperative lumbar drains are not necessary for the successful repair of most spontaneous CSF leaks. Lumbar drains remain an option for adjunctive measures such as administration of intrathecal fluorescein or high-risk cases.

Recommendation
against except in high risk cases (option given the preponderance of benefit over harm).

11
Role of postoperative ICP management with acetazolamide or shunting.
Postoperative ICP management should be considered in patients with spontaneous CSF leaks and elevated ICPs. Acetazolamide can be used as an effective ICP-lowering medication with an option of CSF shunting procedures in patients unable to tolerate medical management or with recalcitrantly elevated ICPs or recurrent CSF leaks. C Recommendation for acetazolamide with option for VP shunt given the preponderance of benefit over harm.

12
Technique of reconstruction and reconstruction materials.
Reconstructive technique should be left to the discretion of the surgeon with consideration of defect location, size and etiology.
Intrathecal application is an off-label use of fluorescein for which informed consent must be obtained from the patient.
Recommendations are to inject 0.05 to maximally 0.1 ml per 10 kg body weight; in no case however, more than 1.0 ml, not even in a massively overweight patient must be applied.
NR +++ Option (Benefit is high and risk is minimal according to most studies). The aggregate grade of evidence in the original guidelines was determined according to the following table: (based upon the guidelines from the American Academy of Pediatrics Steering Committee on Quality Improvement and Managements (AAP SCQIM). 7,8 Grade

Research quality
A Well-designed randomized controlled trials B Randomized controlled trials with minor limitations; overwhelming consistent evidence from observational studies C Observational studies (case control and cohort design) D Expert opinion; case report; reasoning from first principles The following is an algorithm summarizing the statements