Reply to Letter to the Editor regarding “The benefits and risks of non‐steroidal anti‐inflammatory drugs for postoperative analgesia in sinonasal surgery: A systematic review and meta‐analysis”

To the Editor: We thank Ding and colleagues for their interest in our work and are pleased with the discussion prompted by our recent systematic review and meta-analysis on the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the context of sinonasal surgery.1 We appreciate the opportunity to respond to the questions they have raised, several of which we acknowledge within our own critique of the original article in its Discussion section. In general, it is true that more data is better and allow for more focused questions to be answered by systematic reviews and meta-analyses. It follows that nuanced specifics of clinical practice would be best informed by a systematic review and meta-analysis of a single dose, of a single drug, at a single time point. However, as was evident from our comprehensive literature search, that is not always achievable with the amount and quality of the existing literature. As an example, only three studies reported on the secondary outcome of epistaxis among patients randomized to NSAIDs or no NSAIDs.1 It is therefore not feasible to perform a pooled analysis investigating the relationship between NSAID dosage and the rate of epistaxis. The art of a systematic review and meta-analysis stems from identifying which meaningful questions can be answered within the constraints of the available data, which are not already answered by a large individual trial. Similar analyses to ours have been performed in other surgical arenas, reflecting similar constraints.2, 3 Having said this, in our unpublished work, we did perform subgroup analyses probing the question of when it may be optimal to time the dose of administered NSAIDs. However, because there are so few small studies within each subgroup, the confidence intervals were generally too wide to be clinically useful. The trend was that preoperative/intraoperative dosing appeared superior to postoperative dosing for pain and rescue medication requirement. We provide forest plots illustrating the relationship between dose timing and complications/adverse events, and the requirement for rescue medication (Figure 1), demonstrating wide confidence intervals and heterogeneous data. Given these limitations, we felt that the presently available data was insufficient to inform clinical practice; the question of dose timing remains an important one to be answered by future scholarship. Ding and colleagues discuss that our study would benefit from examining subgroups of different surgical techniques and the utility of NSAIDs in each. However, this was already demonstrated in Figures 2 and 3 of our original study, and described further in the Results section.1 We agree that there are important challenges in selecting the exact regimen and specific dosage of NSAIDs, and this continues to be a priority area for future research. At this point, our systematic review does demonstrate that NSAIDs, considered broadly, provide analgesic benefits without necessarily affecting complication rates. We feel that, based on available literature and our meta-analyses, we can safely recommend that the NSAIDs should be considered for sinonasal surgery. This aligns with the recent expert statement from the American Rhinologic Society.4 Our work sets an empirical foundation for the routine incorporation of NSAIDs in sinonasal surgery, and we hope that it may inspire future trials specifically exploring the timing and dosage of administered NSAIDs for these operations. Again, we appreciate the interest in our article regarding the use of NSAIDs in sinonasal surgery, and express our gratitude for the opportunity to respond to the commentary.

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