Sinus surgery and delivery method influence the effectiveness of topical corticosteroids for chronic rhinosinusitis: systematic review and meta-analysis

Assessing the ideal microwave duration for disinfection of sinus irrigation bottles-A quantitative study

OBJECTIVES

Saline irrigation of the nasal cavity and paranasal sinuses has a recognised role in the management of chronic rhinosinusitis. However, bacterial recontamination of irrigation bottles through backflow from the sinonasal cavity is a concern in recurrent sinus cavity infections. While patients are encouraged to clean the irrigation bottles regularly, there remains significant concern that the use of contaminated bottles may perpetuate chronic rhinosinusitis. This study assesses the optimal microwave duration to achieve decontamination for each irrigation bottle component part (reservoir, tube and nozzle) using a standard, commercially available microwave. In addition, the irrigation fluid was also tested for contamination after each microwave cycle.

STUDY DESIGN

Laboratory-based experimental study.

PARTICIPANTS

No patients were involved in this study.

MAIN OUTCOME MEASURES

The percentage in vitro decontamination of the bottles' components was determined following 30, 60, 90, 120, 150 seconds of microwave cycles.

RESULTS

Complete decontamination of the bottles was not achieved at any of the tested microwave cycles. Levels of decontamination differed for the different bottle components, and the greatest degree of decontamination for all bottle components occurred at 90 seconds. Although higher levels of decontamination were observed at microwave durations exceeding 90 seconds, this was at the expense of thermal degradation and deformation of the reservoir plastic component of the irrigation bottle. Similarly, lowest contamination of irrigation fluid was observed at 120 seconds.

CONCLUSIONS

This study highlights the importance of establishing precise decontamination procedures and recommends a microwave cycle of 90 seconds for optimal decontamination.

The effects of nasal lavage with betamethasone cream post-endoscopic sinus surgery: clinical trial

Background:

Steroid nasal irrigation for chronic rhinosinusitis patients following endoscopic sinus surgery reduces symptom recurrence. There are minimal safety data to recommend this treatment. This study evaluated the safety of betamethasone nasal irrigation by measuring its impact on endogenous cortisol levels.

Methods:

Participants performed daily betamethasone nasal irrigation for six weeks. The impact on pre- and post-intervention serum and 24-hour urinary free cortisol was assessed. Efficacy was evaluated using the 22-item Sino-Nasal Outcome Test.

Results:

Thirty participants completed the study (16 females and 14 males; mean age = 53.9 ± 15.6 years). Serum cortisol levels were unchanged (p = 0.28). However, 24-hour urinary free cortisol levels decreased (47.5 vs 41.5 nmol per 24 hours; p = 0.025). Sino-Nasal Outcome Test scores improved (41.13 ± 21.94 vs 23.4 ± 18.17; p < 0.001). The minimal clinical important difference was reached in 63 per cent of participants.

Conclusion:

Daily betamethasone nasal irrigation is an efficacious treatment modality not associated with changes in morning serum cortisol levels. The changes in 24-hour urinary free cortisol levels are considered clinically negligible. Hence, continued use of betamethasone nasal irrigation remains a viable and safe treatment option for chronic rhinosinusitis patients following functional endoscopic sinus surgery.

Stability of a novel corticosteroid nasal irrigation solution: betamethasone 17-valerate added to extemporaneously prepared nasal irrigation solutions

BACKGROUND

There are no commercially available nasal irrigation solutions containing corticosteroids. Instead, such preparations are extemporaneously prepared by adding existing corticosteroid formulations to nasal irrigation solutions. The stability of the corticosteroid betamethasone 17-valerate (B17V), in nasal irrigation solutions of different compositions and pH and stored under different temperatures, was studied to determine the optimal choice of solution and storage conditions.

METHODS

Triplicate extemporaneous preparations made with B17V were prepared by adding a predetermined volume of B17V lotion to each nasal irrigation solution: normal saline (NS), sodium bicarbonate (NaHCO₃ ) powder dissolved in tap water, and a commercially available powder mixture (FLO Sinus Care Powder), dissolved in tap water or pre-boiled tap water. Preparations were stored at 30°C and 4°C. Sampling was carried out at 0, 1, 2, 6, and 24 hours. The concentrations of B17V and its degradation compound, betamethasone 21-valerate (B21V), were determined by high-performance liquid chromatography.

RESULTS

Preparations stored at 30°C contained a lower amount of B17V and higher amount of B21V than those stored at 4°C. B17V stability in nasal irrigation solutions decreased in the following order: NS, FLO in fresh tap water, FLO in pre-boiled tap water, and NaHCO₃ . The degradation rate of B17V increased with higher storage temperature and higher pH.

CONCLUSION

B17V is most stable when added to NS and least stable in NaHCO₃ solution. FLO solution prepared with either cooled boiled water or tap water is an alternative if administered immediately. Storage at 4°C can better preserve stability of B17V, over a period of 24 hours.

Prevention of sinonasal inflammation by a synthetic glycosaminoglycan

BACKGROUND

Glycosaminoglycans (GAGs) are polysaccharides that are distributed on respiratory epithelial cells, endothelial cells, and submucosal glands. Uniquely positioned, certain GAGs exhibit anti-inflammatory properties in respiratory diseases and serve important roles in repairing mucosal surfaces and modulating mucociliary clearance. We hypothesized that topical administration of a synthetic GAG (GM-0111) would prevent sinonasal inflammation in a mouse model of rhinosinusitis (RS).

METHODS

To test our hypothesis, C57BL/6 mice were intranasally administered fluorescent GM-0111, and sinonasal tissues were examined for coating and penetration ability. To test therapeutic feasibility, mice (n = 6) were given GM-0111 or hyaluronic acid (HA; 800 μg dose) prior to inducing RS with inflammatory molecule LL-37 (115 μg dose). After 24 hours, sinonasal tissues were harvested for histological and biochemical analysis of inflammatory markers (inflammatory cell infiltration, lamina propria [LP] thickening, and neutrophil enzyme myeloperoxidase [MPO]) and cell death.

RESULTS

GM-0111 was observed within sinonasal tissues 1 hour and 24 hours after intranasal administration, indicating rapid and effective coating and penetration. GM-0111 prevented sinonasal tissues from developing inflammatory changes, with significant reductions in mast cell infiltration (p < 0.05), LP thickening (p < 0.001), and MPO levels (p < 0.01) when compared to tissues treated with LL-37 and those pretreated with HA. GM-0111 reduced cell death within sinonasal tissues in contrast to LL-37-treated tissues.

CONCLUSION

We report a new synthetic GAG (GM-0111) that uniformly coats and penetrates into the sinonasal mucosa to prevent sinonasal inflammation and cell death in a mouse model of RS.

Chronic sphenoid rhinosinusitis: management challenge

Chronic sphenoid rhinosinusitis is a spectrum of inflammatory diseases in isolated sphenoid sinus which may persist over a period of 12 weeks. It is a different entity from other types of rhinosinusitis because clinical presentations include headache, visual loss or diplopia, and patients may or may not have nasal obstruction or nasal discharge. Nasal endoscopic examination is useful, and computed tomography is mandatory. The disease requires comprehensive knowledge and appropriate imaging technique for diagnosis. To treat patients with chronic sphenoid rhinosinusitis, surgical treatment with endoscopic transnasal sphenoidotomy is often required. As there are no recent updated reviews of chronic sphenoid rhinosinusitis, in this article, we review the anatomy of the sphenoid sinus and its clinical relationship with the clinical signs and symptoms of the disease, the imaging findings of each diagnosis and the comprehensive surgical techniques.

Effect of sodium hyaluronate added to topical corticosteroids in chronic rhinosinusitis with nasal polyposis

BACKGROUND

Available medical treatments for chronic rhinosinusitis (CRS) with nasal polyposis (CRSwNP) comprise systemic and topical therapies. Although topical corticosteroids are effective in the treatment of CRS, they are not completely devoid of adverse effects. Thus, care has to be taken when long-term treatments are prescribed. There is recent evidence that sodium hyaluronate (SH), the major component of many extracellular matrices, promotes tissue healing, including activation and moderation of the inflammatory responses, cell proliferation, migration, and angiogenesis.

OBJECTIVE

The aim of the study was to evaluate clinical outcomes and quality of life in two groups of patients with CRSwNP treated with topical corticosteroids alone or in combination with 9 mg of high-molecular-weight SH.

METHODS

The impact of treatments was determined by using nasal endoscopy and validated quality of life questionnaires (Short Form-36, 22-item Sino-Nasal Outcome Test, visual analog scale [VAS]). Eighty subjects who had CRS with grade IV nasal polyposis: 40 diagnosed with allergic rhinitis (AR) and 40 with non-allergic-eosinophilic rhinitis (NARES) based on skin-prick test and nasal cytology results, were divided in two groups. Group I comprised 40 subjects (20 AR and 20 NARES), who received mometasone furoate plus SH; group II comprised 40 subjects (20 AR and 20 NARES), who received mometasone furoate plus saline solution alone. All the patients were followed up for 3 months.

RESULTS

At baseline, no statistically significant differences were observed between the groups and the VAS score showed a moderate-to-severe degree of disease. After treatments, Lund and Kennedy, Short Form-36, 22-item Sino-Nasal Outcome Test, and VAS scores were statistically significant in both groups but slightly in favor of the group I and in the subjects with allergic CRSwNP.

CONCLUSION

Analysis of our data indicated that an SH supplement to standard corticosteroid seems to play an important role in improving the severity of symptoms, the endoscopic appearance, and discomfort associated with CRSwNP. This effect seems to be strongest in patients with allergic CRSwNP.

Airflow in the Human Nasal Passage and Sinuses of Chronic Rhinosinusitis Subjects

Endoscopic surgery is performed on patients with chronic inflammatory disease of the paranasal sinuses to improve sinus ventilation. Little is known about how sinus surgery affects sinonasal airflow. In this study nasal passage geometry was reconstructed from computed tomographic imaging from healthy normal, pre-operative, and post-operative subjects. Transient air flow through the nasal passage during calm breathing was simulated. Subject-specific differences in ventilation of the nasal passage were observed. Velocity magnitude at ostium was different between left and right airway. In FESS, airflow in post-surgical subjects, airflow at the maxillary sinus ostium was upto ten times higher during inspiration. In a Lothrop procedure, airflow at the frontal sinus ostium can be upto four times higher during inspiration. In both post-operative subjects, airflow at ostium was not quasi-steady. The subject-specific effect (of surgery) on sinonasal interaction evaluated through airflow simulations may have important consequences for pre- and post-surgical assessment and surgical planning, and design for improvement of the delivery efficiency of nasal therapeutics.

Clinical implications of mucosal remodeling from chronic rhinosinusitis

BACKGROUND

Prognostic implications of mucosal remodeling in chronic rhinosinusitis (CRS) remain unclear. Remodeling of respiratory mucosa in asthma is associated with greater medication use and decreased function. This study investigates the implications of mucosal remodeling on long-term clinical outcomes in patients with CRS.

METHODS

A case-control study of adult patients with CRS undergoing endoscopic sinus surgery (ESS) was performed. Mucosal remodeling was defined by squamous metaplasia, subepithelial fibrosis, and/or basement membrane thickening. The presence of remodeling changes were assessed relative to clinical and treatment outcomes at a minimum of 12 months postoperatively. Clinical outcomes were assessed at baseline and 12 months using a Nasal Symptom Score (NSS) and 22-item Sino-Nasal Outcome Test (SNOT-22). Treatment outcomes were assessed by oral corticosteroid usage (burst/continuous), topical corticosteroid irrigation frequency, and further surgical intervention.

RESULTS

A total of 110 patients (48.73 ± 14.75 years, 48.2% female) were assessed. Significant improvements where seen for the entire population, in both NSS (2.64 ± 1.06 to 1.34 ± 1.08, p < 0.001) and SNOT-22 (2.05 ± 0.96 to 1.06 ± 0.79, p < 0.001). Patients with remodeling (n = 88) were younger (47.2 ± 14.8 vs 54.7 ± 13.5 years, p = 0.03), but had similar symptom scores. Remodeling was seen in CRS with nasal polyposis (CRSwNP) (54.5%) and eosinophilic chronic rhinosinusitis (eCRS) (59.8%). Symptom improvement at 12 months was similar between remodeled and non-remodeled groups (NSS: Δ1.34 ± 1.20 vs Δ1.12 ± 1.31, p = 0.395; SNOT-22: Δ1.05 ± 0.91 vs Δ0.73 ± 0.95, p = 0.124); however, patients with remodeling had greater corticosteroid irrigation frequency (64.0% vs 31.6% daily use, Kendall's tau-b p = 0.004).

CONCLUSION

Established mucosal remodeling predicts a greater reliance on topical therapies to reach similar clinical endpoints as those without remodeling.

Safety of long-term high-volume sinonasal budesonide irrigations for chronic rhinosinusitis

BACKGROUND

Off-label high-volume sinonasal budesonide irrigations are commonly used during the management of chronic rhinosinusitis (CRS). Although short-term use (4 to 8 weeks) has been demonstrated to be safe, the long-term effects on the hypothalamic-pituitary-adrenal (HPA) axis remain unclear. The objective of this study is to determine whether CRS patients using long-term (minimum greater than 12 months) budesonide sinonasal irrigations have evidence of HPA axis suppression.

METHODS

Patients with CRS being managed with high-volume sinonasal budesonide irrigations were recruited from 2 tertiary level rhinology clinics between March 2014 and July 2015. Inclusion criteria were as follows: (1) adult (age greater than 18 years); (2) guideline-based diagnosis of CRS; (3) previous endoscopic sinus surgery; (4) minimum of twice daily high-volume sinonasal budesonide irrigation (concentration of 1 mg per irrigation; total daily dose of 2 mg); and (5) a minimum of 12-month duration. Exclusion criteria included systemic corticosteroid use within 3 months of HPA axis testing. The primary outcomes were morning (am) serum cortisol levels and, when indicated, cosyntropin stimulation levels.

RESULTS

A total of 35 patients fulfilled eligibility criteria and underwent HPA axis testing. Mean duration of budesonide sinonasal irrigation therapy use was 38.2 months (2.9 years). The mean ± standard deviation (SD) am serum cortisol was 431.2 ± 146.9 nmol/L (normal, 200 to 650 nmol/L). Subsequent cosyntropin stimulation tests, in indicated patients (n = 19), demonstrated no evidence of HPA axis suppression.

CONCLUSION

Outcomes from this study suggest that daily high-volume sinonasal budesonide irrigations fail to produce evidence of HPA axis suppression with prolonged courses lasting longer than 2 years.

Mechanisms of Glucocorticoid Action in Chronic Rhinosinusitis

The innate immune system and its complex interplay with the adaptive immune system are increasingly being recognized as important factors in the pathogenesis of chronic rhinosinusitis (CRS). Adaptive immune components, including resident and inflammatory cells, and their associated mediators, have been the subject of most research in CRS. For this reason, theories of CRS pathogenesis have involved the concept that inflammation, rather than infection, is the dominant etiologic factor in CRS. Therefore, glucocorticoids are increasingly used to treat CRS. This review will outline our current knowledge of action mode of glucocorticoids in CRS.

Sinus irrigations before and after surgery-Visualization through computational fluid dynamics simulations

OBJECTIVES/HYPOTHESIS

Topical sinus irrigations play a critical role in the management of sinonasal disease, and the improvement in irrigant penetration into the sinuses postoperatively greatly contributes to the success of endoscopic sinus surgery. Prior investigations on postoperative sinus irrigations have been mostly limited to cadaver studies, which are labor intensive and do not capture the full dynamics of the flows. A pilot study was conducted to investigate the impact of surgery on sinus irrigation through computational fluid dynamics (CFD) simulations.

STUDY DESIGN

Retrospective computational study.

METHODS

Pre- and postoperative computed tomography (CT) scans were obtained on a patient who underwent standard endoscopic surgeries for all sinuses, including a Draf III frontal sinusotomy. CT-based pre- and postoperative CFD models then simulated irrigations of 120 mL saline per nostril at 12 mL/s (typical of Sinugator) and 60 mL/s (SinusRinse Bottle), in two head positions: face parallel and at a 45° angle to the ground.

RESULTS

Overall, surgery most significantly improved frontal sinus irrigation, but surprisingly resulted in less maxillary and ethmoid sinuses penetration. This may due to the partial removal of the septum during the Draf III, causing most fluid to exit prematurely across the resected septum. Higher flow rate slightly improved ethmoid sinus irrigation, but resulted in less preoperative contralateral maxillary sinus penetration.

CONCLUSIONS

CFD modeling of sinonasal irrigations is a novel technique for evaluating irrigant penetration of individual sinus cavities. It may prove useful in determining the optimal degree of surgery or the ideal irrigation strategy to allow for maximal and targeted sinus irrigant penetration.

LEVEL OF EVIDENCE

NA Laryngoscope, 126:E90-E96, 2016.

State of the art: a systematic review of the surgical management of aspirin exacerbated respiratory disease

BACKGROUND

Endoscopic sinus surgery is an important modality to the armamentarium of the otolaryngologist managing chronic rhinosinusitis (CRS). Within the spectrum of CRS, there exists a subset of patients who are recalcitrant to conventional treatment strategies, including those with aspirin-exacerbated respiratory disease (AERD). Although surgery is frequently undertaken in this group, there has been no general consensus on the efficacy or optimal extent of surgery.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of published studies was conducted. Inclusion criteria included original publications of adult patients with AERD undergoing surgery, cohorts of greater than five subjects, a minimum follow-up of 3 months, and measurable clinical outcomes. An electronic search was performed using OVID MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science.

RESULTS

Sixteen studies met the criteria for analysis. For our primary objective, sinus surgery appeared to improve patient-reported quality of life (QoL) and symptom profile in AERD. Overall, most studies reported a decrease in radiographic grading, endoscopy scores, and asthma severity. Compared with aspirin-tolerant asthmatic patients, AERD patients may have worse objective measures of disease severity both pre- and postoperatively; however, patient-reported QoL and symptom improvement may be similar after sinus surgery. Finally, this review showed that patients with AERD required revision surgeries sooner and more frequently compared with other subtypes of CRS. We also discussed the role of maximal surgical techniques and additional benefit of postoperative adjunctive therapies in the management of this disease entity.

CONCLUSION

The state of the art in the management of AERD patients suggests that surgery does play an important role in helping establish symptomatic control. In the future, more rigorous studies evaluating the comprehensiveness of surgery and postoperative adjuncts are required to understand their impact on long-term patient outcomes.

Nasal cytological assessment after crenotherapy in the treatment of chronic rhinosinusitis in the elderly

Chronic rhinosinusitis (CRS) determines irreversible alterations of the nasal mucosa with consequent impairment of ciliary movements and, therefore, mucociliary clearance (MCC). People of all ages can be affected by CRS but the elderly are subjects at the highest risk. CRS in the elderly with an age-related physiological impairment of nasal respiratory function, often accompanied by other chronic diseases, requires additional therapies to be added to the numerous daily medications. Since the currently available therapies for CRS include the use of drugs that can have adverse effects and contraindications, crenotherapy could represent a therapeutic option. Indeed, because the adverse effects and contraindications of crenotherapy are scarce, it can be safely used in elderly patients with comorbidities. The aim of this study is to evaluate the nasal cytological assessment after crenotherapy in elderly subjects with CRS. Two groups, comprising a total of 84 elderly subjects with CRS, were treated with crenotherapy with sodium chloride sulphate hyperthermal water rich in mineral salts (group I, n=49) and saline solution (group II n=35). Cytological assessment for both groups took place at baseline (T0) and 1 month after treatment (T30). At T30 the nasal cytological assessment showed statistically significant improvements in the ciliary motility and in the count of neutrophils and spores in group I, but not in group II. Conversely, there were no significant differences in the count of eosinophils, mast cells, bacteria and biofilm in either group. Our data for the first time focused on the role of crenotherapy in the improvement of cytological assessment of CRS in the elderly.

Olfactory performance after crenotherapy in chronic rhinosinusitis in the elderly

OBJECTIVE

To evaluate the effectiveness of crenotherapy on the olfactory performance of elderly patients with chronic rhinosinusitis (CRS).

STUDY DESIGN

A longitudinal case-control study of a cohort of elderly patients affected by CRS and olfactory dysfunction assessed with the Sniffin' Sticks (Burghart Medical Technology, Wedel, Germany) (SS) olfactory test.

METHODS

One hundred and thirty-seven elderly subjects with CRS were divided into two groups. The investigational arm (n = 69) underwent crenotherapy with hyperthermal water, rich in mineral salts, and the control group (n = 68) underwent NaCl 0.9% both for 12 days. At baseline and at 1 and 6 months after treatment, both groups underwent ear nose and throat assessment and SS. Self-report questionnaires were administered at baseline to evaluate the patients' own olfactory response, and after treatment to evaluate their degree tolerability. Olfactory performance was then evaluated in elderly subjects with hyposmia without CRS (n = 40) and in younger subjects with both hyposmia and CRS (n = 40).

RESULTS

No adverse reactions were reported after crenotherapy. The SS total score showed that crenotherapy induced a statistically significant improvement in the olfactory function of both the elderly and the younger subjects with hyposmia and CRS. By contrast, no improvement was observed in the control arm and in the elderly with hyposmia without CRS. All subjects showed a good degree of tolerability.

CONCLUSIONS

We demonstrated that crenotherapy effectively improves olfactory function in elderly patients with CRS. Finally, our study suggests that crenotherapy represents a safe therapeutic strategy for the treatment of CRS and olfactory dysfunction in the elderly.

The fate of chronic rhinosinusitis sufferers after maximal medical therapy

BACKGROUND

Many chronic rhinosinusitis (CRS) treatment regimes revolve around "one-off" maximal medical therapy (MMT) protocols, and although many patients initially respond, long-term control is unpredictable. The value of imaging, endoscopy, and patient progress after MMT for CRS is assessed.

METHODS

Symptomatic CRS patients with computed tomography (CT)-confirmed disease were recruited at a tertiary rhinology clinic. All patients received at least a 3-week oral prednisone course as part of their MMT. Pretreatment and posttreatment nasal symptoms scores (NSS), quality of life (22-item SinoNasal Outcomes Test [SNOT-22]), and CT (Lund-Mackay [LM]) scores were recorded along with post-MMT endoscopy status.

RESULTS

A total of 86 patients (38% female, age 46 ± 13 years) met inclusion criteria. Pre-MMT and post-MMT LM scores were 10.9 ± 5.3 and 8.3 ± 5.5 (change 2.6 ± 3.8, p < 0.001). Median follow-up after their initial post-MMT assessment was 6.3 (interquartile range [IQR] 17) months. At initial post-MMT review, 43 (50%) were symptomatic with persistent radiologic disease ("symptomatic CRS"), 12 (14%) were asymptomatic with no radiologic disease ("resolved CRS"), 21 (24%) were asymptomatic with persistent radiologic disease ("asymptomatic CRS"), and 10 (12%) were symptomatic with no radiologic disease ("alternate diagnosis"). Pre-MMT NSS and SNOT-22 were similar among groups. The "asymptomatic CRS" group had the highest age (52 ± 11 years, p = 0.07). The "alternate diagnosis" group had the lowest initial LM scores (5.2 ± 2.9, p = 0.001). Of the "asymptomatic CRS" patients, 43% relapsed between 3 and 23 months (median 6; IQR 4.4 months) post-MMT and 29% eventually underwent surgery.

CONCLUSION

Although MMT for CRS achieved symptomatic relief in 38% patients, objective evidence of disease was associated with clinical relapse. The concepts of "response" to medical therapy and the need to "control" long-term inflammatory burden need to be balanced.

Chapter 4: Chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is the second most common chronic medical condition in the United States. It represents a group of disorders characterized by inflammation of the nasal mucosa and paranasal sinuses of at least 12 weeks duration. CRS with or without nasal polyps is defined as inflammation of the nose characterized by two or more symptoms, one of which should be either nasal blockage, obstruction, congestion, or nasal discharge (anterior/posterior nasal drip); with or without facial pain/pressure; and/or with or without reduction or loss of smell. Symptomatology should be supported by obvious disease evident in either nasal endoscopy or computed tomography imaging. Although CRS is not likely to be cured by either medical or surgical therapy, it can generally be controlled. Best medical evidence supports maintenance therapy with intranasal corticosteroids and saline irrigation. For exacerbations, short to intermediate courses of antibiotics (up to 4-weeks) with or without oral corticosteroids are recommended. For patients with difficult-to-treat CRS, functional endoscopic sinus surgery provides an adjunctive therapeutic option.

Validity of European position paper on rhinosinusitis disease control assessment and modifications in chronic rhinosinusitis

OBJECTIVES

To develop a chronic rhinosinusitis (CRS) disease control staging system that predicts patient and physician opinion. This involved exploring the predictive capacity of the proposed European Position Paper on Rhinosinusitis (EPOS) 2012 staging system and other potential scoring systems based on patient symptoms and objective criteria.

STUDY DESIGN

Prospective study.

SETTING

Tertiary hospitals.

SUBJECTS AND METHODS

Adults CRS patients undergoing sinus surgery were prospectively enrolled from a tertiary clinic. The Sino-Nasal Outcome Test 22, endoscopy score, and systemic medication were recorded at 6 and 12 months. A physician and patient report of their condition as either "controlled,""partly controlled," or "uncontrolled" was also recorded. Ordinal regression was used for modeling a staging system. The EPOS criteria and various combinations were assessed. Kappa agreements between the staging systems and patient/physician reports were analyzed.

RESULTS

One hundred six patients were assessed. Nasal obstruction (P = .02), endoscopic mucosal inflammation (P < .001), and thick and/or purulent discharge (P = .01) associated with progress reports. A modified staging system of Nasal Obstruction, Systemic medication used, and Endoscopic inflammation (NOSE) was selected on predictive strengths. The EPOS and NOSE had significant agreement with physician's (k = 0.29, P < .01, and k = 0.45, P < .01) and patient's report (k = 0.18, P = .01, and k = 0.32, P < .01).

CONCLUSIONS

The disease control assessment by EPOS has slight agreement with patients and a physician. A simpler NOSE system using nasal obstruction, mucosa, and discharge is proposed.

Azithromycin add-on therapy in high-risk postendoscopic sinus surgery patients failing corticosteroid irrigations: A clinical practice audit

BACKGROUND

Chronic rhinosinusitis (CRS) has a high potential for recurrence after endoscopic sinus surgery (ESS), despite a postoperative therapy of topical corticosteroid irrigations. Azithromycin (AZI) is a macrolide antibiotic with anti-inflammatory properties that may be of benefit in such steroid-unresponsive patients. Follow-up study was performed to (1) review the effectiveness of the management strategy of adding AZI in high-risk post-ESS patients failing standard management and (2) identify predictive factors for steroid nonresponsiveness.

METHODS

A retrospective audit of the postoperative evolution of all patients undergoing ESS for CRS in 2010 by a single surgeon was undertaken. Patients deemed at high risk of recurrence based on preoperative history and/or perioperative findings received nasal irrigation with 0.5 mg of budesonide (BUD) in 240 mL of saline twice daily after ESS. Patients showing signs of endoscopic recurrence at 4 months, despite BUD, had AZI at 250 mg three times a week added to their treatment regimen.

RESULTS

A total of 57 high-risk patients underwent ESS during this period. At 4 months, 63.2% (36/57) had a favorable outcome solely with BUD. Twelve of the 21 nonresponders received AZI, with an additional 66.7% (8/12) subsequently showing a favorable response. Failure of BUD was associated with female gender (p = 0.048), having elevated alpha-1-antitrypsin levels (p = 0.037) and lower recovery rates of Staphylococcus aureus (p = 0.063). Although the AZI subgroup was too small for statistical analysis, female gender was more frequently associated with failure of both BUD and AZI, while IgE was not useful.

CONCLUSION

A significant subgroup of high-risk patients showing disease recurrence after ESS despite topical corticosteroid therapy may respond to the addition of AZI as part of their therapy. These findings suggest that topical steroid-unresponsive CRS may represent a distinct entity and that alternate anti-inflammatory agents may be required for optimal management.