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Shipman PA, Yathavan B, Gill AS, Pollard CE, Yellepeddi V, Ghandehari H, Alt JA, Pulsipher A, Smith KA. Quantification of Budesonide Retained in the Sinonasal Cavity After High-Volume Saline Irrigation in Post-Operative Chronic Rhinosinusitis. Am J Rhinol Allergy 2024; 38:169-177. [PMID: 38456692 PMCID: PMC11145513 DOI: 10.1177/19458924241237839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Budesonide high-volume saline irrigations (HVSIs) are routinely used to treat chronic rhinosinusitis (CRS) due to improved sinonasal delivery and efficacy compared to intranasal corticosteroid sprays. The off-label use of budesonide is assumed to be safe, with several studies suggesting the systemically absorbed dose of budesonide HVSI is low. However, the actual budesonide dose retained in the sinonasal cavity following HVSI is unknown. The objective of this study was to quantify the retained dose of budesonide after HVSI. METHODS Adult patients diagnosed with CRS who had undergone endoscopic sinus surgery (ESS) and were prescribed budesonide HVSI were enrolled into a prospective, observational cohort study. Patients performed budesonide HVSI (0.5 mg dose) under supervision in an outpatient clinic, and irrigation effluent was collected. High-performance liquid chromatography was employed to determine the dose of budesonide retained after HVSI. RESULTS Twenty-four patients met inclusion criteria. The average corrected retained dose of budesonide across the cohort was 0.171 ± 0.087 mg (37.9% of administered budesonide). Increased time from ESS significantly impacted the measured retained dose, with those 3 months post-ESS retaining 27.4% of administered budesonide (P = .0004). CONCLUSION The retained dose of budesonide in patients with CRS after HVSI was found to be significantly higher than previously estimated and decreased with time post-ESS. Given that budesonide HVSI is a cornerstone of care in CRS, defining the retained dose and the potential systemic implications is critical to understanding the safety of budesonide HVSI.
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Affiliation(s)
- Paige A. Shipman
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Bhuvanesh Yathavan
- Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
- Utah Center for Nanomedicine, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | - Amarbir S. Gill
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Chelsea E. Pollard
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Venkata Yellepeddi
- Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
- Utah Center for Nanomedicine, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Hamidreza Ghandehari
- Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
- Utah Center for Nanomedicine, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | - Jeremiah A. Alt
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
- Utah Center for Nanomedicine, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | - Abigail Pulsipher
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
- Utah Center for Nanomedicine, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | - Kristine A. Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Ahamed S, Samson D, Sundaresan R, Balasubramanya B, Thomas R. Double Blinded Randomized Controlled Trial Comparing Budesonide and Saline Nasal Rinses in the Post-operative Management of Chronic Rhinosinusitis. Indian J Otolaryngol Head Neck Surg 2024; 76:408-413. [PMID: 38440477 PMCID: PMC10909031 DOI: 10.1007/s12070-023-04173-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 08/20/2023] [Indexed: 03/06/2024] Open
Abstract
Post-operative management of chronic rhinosinusitis is very crucial for outcomes following surgery, Normal saline nasal irrigation and steroid spray form the standard treatment of care in this period. However nasal irrigation may not be adequate and spray is usually started after 2 weeks of surgery which in any case does not deliver optimum dosage of drug to the paranasal sinus mucosa. Budesonide nasal irrigation in a high-volume low-pressure system could be the solution for a better outcome. A double blinded randomized control trial with 88 patients in 2 groups of 44 each received normal saline or Budesonide nasal irrigation (0.5 mg in 200 ml) twice daily. Patients were followed up at 2 weeks post-operatively and 3 months, a SNOT 22 and Lund Kennedy Endoscopic scores were assessed for subjective and objective assessment. Subset analysis of only CRS patients (55) were done, and results presented. Patient reported subjective score at 3 months post operatively, SNOT22 was significantly (p < 0.0001) improved with the use of Budesonide irrigation (26.69 ± 2.92) as compared to Normal saline (30.54 ± 2.81) and objective assessment score, LKES was significantly (p = 0.0031) better in Budesonide group (4.06 + 0.74) in comparison to Normal saline in the saline (4.50 + 0.67) respectively. The mean scores 3 months post op visit was significantly lower for both subjective SNOT (p < 0.001) and objective score LKES (p < 0.0001) in Budesonide groups. Budesonide nasal irrigation with positive pressure high volume device has better patient benefits and wound healing when compared to normal saline irrigation in the post-operative management of chronic rhinosinusitis.
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Affiliation(s)
- Shameer Ahamed
- Unit-1(Head&Neck, Skull base surgery) Department of ENT, Christian Medical College, Vellore, Tamil Nadu India
| | - Divyan Samson
- Unit-1(Head&Neck, Skull base surgery) Department of ENT, Christian Medical College, Vellore, Tamil Nadu India
| | - Rajan Sundaresan
- Unit-1(Head&Neck, Skull base surgery) Department of ENT, Christian Medical College, Vellore, Tamil Nadu India
| | - Bhavya Balasubramanya
- Unit-1(Head&Neck, Skull base surgery) Department of ENT, Christian Medical College, Vellore, Tamil Nadu India
| | - Regi Thomas
- Unit-1(Head&Neck, Skull base surgery) Department of ENT, Christian Medical College, Vellore, Tamil Nadu India
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Silva BRC, Tyler MA, Ma Y, Wang J, Nayak JV, Patel ZM, Hwang PH. Incidence of hypocortisolism with long-term budesonide irrigation for chronic rhinosinusitis. Int Forum Allergy Rhinol 2024; 14:78-85. [PMID: 37389470 DOI: 10.1002/alr.23227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/05/2023] [Accepted: 06/28/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Budesonide irrigations (BIs) are commonly used to control inflammation in chronic rhinosinusitis (CRS). In 2016 we reported an analysis of long-term BI with regard to hypothalamic-pituitary-adrenal axis function. We present a follow-up analysis in a larger cohort of patients with longer follow-up. METHODS Patients were candidates for stimulated cortisol testing after regularly performing BI for CRS at least daily for ≥6 months. We retrospectively evaluated all patients who received stimulated cortisol testing at our center between 2012 and 2022. We correlated cortisol levels with the use of BI and other forms of corticosteroids. RESULTS We analyzed 401 cortisol test results in 285 patients. The mean duration of use was 34 months. Overall, 21.8% of patients were hypocortisolemic (<18 ug/dL) at first test. In patients who used only BI, the rate of hypocortisolemia was 7.5%, whereas in patients who also used concurrent oral and inhaled corticosteroids, the rate was 40% to 50%. Lower cortisol levels were associated with male sex (p < 0.0001) and concomitant use of oral and inhaled steroids (p < 0.0001). Duration of BI use was not significantly associated with lower cortisol levels (p = 0.701), nor was greater dosing frequency (p = 0.289). CONCLUSION Prolonged use of BI alone is not likely to cause hypocortisolemia in the majority of patients. However, concomitant use of inhaled and oral steroids and male sex may be associated with hypocortisolemia. Surveillance of cortisol levels may be considered in vulnerable populations who use BI regularly, particularly in patients using other forms of corticosteroids with known systemic absorption.
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Affiliation(s)
- Bruna R C Silva
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Matthew A Tyler
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Yifei Ma
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jane Wang
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jayakar V Nayak
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Zara M Patel
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Peter H Hwang
- Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
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Rathi VK, Sawicki NW, Schlosser RJ, Soler ZM, Scangas GA, Workman AD, Gray ST. Adverse events associated with budesonide nasal irrigation reported to the US Food and Drug Administration: 2007 to 2022. Int Forum Allergy Rhinol 2024; 14:123-126. [PMID: 37394843 DOI: 10.1002/alr.23232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/27/2023] [Accepted: 06/30/2023] [Indexed: 07/04/2023]
Abstract
KEYPOINTS Between 2007 and 2022, the FDA received 119 US-based reports mentioning budesonide nasal irrigation. Most reports were submitted by patients and alerted FDA to off-label usage of budesonide. Notable adverse events reported to the FDA included headache, dyspnea, and blurred vision.
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Affiliation(s)
- Vinay K Rathi
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Rodney J Schlosser
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
- Department of Surgery, Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
| | - Zachary M Soler
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - George A Scangas
- Department of Otolaryngology, Harvard Medical, School, Boston, Massachusetts, USA
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts, USA
| | - Alan D Workman
- Department of Otolaryngology, Harvard Medical, School, Boston, Massachusetts, USA
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts, USA
| | - Stacey T Gray
- Department of Otolaryngology, Harvard Medical, School, Boston, Massachusetts, USA
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts, USA
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Calvo-Henriquez C, Viera-Artiles J, Rodriguez-Iglesias M, Rodriguez-Rivas P, Maniaci A, Yáñez MM, Martínez-Capoccioni G, Alobid I. The Role of Corticosteroid Nasal Irrigations in the Management of Chronic Rhinosinusitis: A State-of-the-Art Systematic Review. J Clin Med 2023; 12:jcm12103605. [PMID: 37240711 DOI: 10.3390/jcm12103605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/19/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
Chronic rhinosinusitis (CRS) is a highly prevalent condition. CRS is usually managed with intranasal corticosteroids, useful both before as well as after endoscopic sinus surgery (ESS). However, the greatest drawback of these low-volume sprays is the inadequate delivery into the paranasal sinuses, even after ESS. Recent studies have shown that high-volume steroid nasal rinse (HSNR) has a significantly better penetration of the paranasal sinuses. The purpose of this state-of-the-art review is to systematically overview the current literature about the role of nasal rinses with steroids in CRS. Four authors examined four databases (Embase, Pubmed, Scielo, Cochrane). This review identified 23 studies answering 5 research questions. It included 1182 participants, 722 cases, and 460 controls. Available evidence suggests a potential positive effect of HSNR, which seems to be higher in CRS with nasal polyps. More well-designed studies are needed in order to obtain solid conclusions. The evidence is solid regarding the safety of this treatment modality in the short and long-term. We expect that this lack of severe negative effects will facilitate the acceptance of this treatment modality and the development of future studies.
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Affiliation(s)
- Christian Calvo-Henriquez
- Rhinology Study Group of the Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), 70123 Paris, France
- Service of Otolaryngology, Hospital Complex of Santiago de Compostela, 15701 Santiago de Compostela, Spain
| | - Jaime Viera-Artiles
- Rhinology Study Group of the Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), 70123 Paris, France
- Service of Otolaryngology, Rhinology and Skull Base Department, Marqués de Valdecilla Hospital, PC 39008 Santander, Spain
| | - Miguel Rodriguez-Iglesias
- Rhinology Study Group of the Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), 70123 Paris, France
- Service of Otolaryngology, Hospital Complex of Santiago de Compostela, 15701 Santiago de Compostela, Spain
| | - Paula Rodriguez-Rivas
- Rhinology Study Group of the Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), 70123 Paris, France
- Service of Otolaryngology, Hospital Complex of Santiago de Compostela, 15701 Santiago de Compostela, Spain
| | - Antonino Maniaci
- Rhinology Study Group of the Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), 70123 Paris, France
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia" ENT Section, University of Catania, 95123 Catania, Italy
| | - Miguel Mayo Yáñez
- Rhinology Study Group of the Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), 70123 Paris, France
- Service of Otolaryngology, Hospital Complex of La Coruña, PC 15001 La Coruña, Spain
| | - Gabriel Martínez-Capoccioni
- Rhinology Study Group of the Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies (YO-IFOS), 70123 Paris, France
- Service of Otolaryngology, Hospital Complex of Santiago de Compostela, 15701 Santiago de Compostela, Spain
| | - Isam Alobid
- Service of Otolaryngology, Rhinology and Skull Base Department, Clinic Hospital, PC 08036 Barcelona, Spain
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Staricha KL, Ali HM, Stokken JK. State of the Art Medical Management of Nasal Polyps. Am J Rhinol Allergy 2023; 37:153-161. [PMID: 36848283 DOI: 10.1177/19458924221145256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Chronic rhinosinusitis with nasal polyposis (CRSwNP) is an inflammatory disease with a treatment goal of controlling symptoms and limiting disease burden. While endoscopic sinus surgery is effective for removing polyps and aerating sinuses, proper medical management remains necessary for reducing inflammation and limiting polyp recurrence. OBJECTIVE This article aims to summarize the literature regarding medical treatment of chronic rhinosinusitis with nasal polyposis, with a specific focus on developments in the past 5 years. METHODOLOGY We conducted a literature review using PubMed to identify studies assessing medical treatment strategies for patients with CRSwNP. Articles focusing on chronic rhinosinusitis without nasal polyposis were excluded unless specifically stated. Surgical treatment and biologic therapies for CRSwNP will be covered in subsequent chapters and are therefore not included. RESULTS Intranasal saline irrigations and topical steroids are mainstays of CRSwNP treatment in the pre-surgical, post-surgical, and maintenance phases of the disease. Alternative steroid delivery methods and adjunctive treatments with antibiotics, anti-leukotrienes, and other topical therapies have been investigated and may benefit certain patient populations, but convincing evidence does not exist to warrant addition of these treatments to the standard of care for CRSwNP. CONCLUSIONS Topical steroid therapy is clearly effective for CRSwNP, and recent studies demonstrate the safety and efficacy of high-dose nasal steroid rinses. Alternate delivery methods for local steroids may be useful for patients who are not responding to or who are noncompliant with conventional intranasal corticosteroid sprays and rinses. Future studies are needed to clarify if oral or topical antibiotics, oral anti-leukotrienes, or other novel therapies are significantly effective in decreasing symptoms and improving the quality of life in patients with CRSwNP.
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Affiliation(s)
- Kelly L Staricha
- Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Hawa M Ali
- Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Janalee K Stokken
- Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Rochester, MN, USA
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Bernstein JA, White AA, Han JK, Lang DM, Elkayam D, Baroody FM. Review of evidence supporting the use of nasal corticosteroid irrigation for chronic rhinosinusitis. Ann Allergy Asthma Immunol 2023; 130:46-57. [PMID: 36116748 DOI: 10.1016/j.anai.2022.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To analyze published reports on the efficacy and safety of CSI in CRS and evaluate the clinical implications of current gaps in evidence. Corticosteroid irrigation (CSI) is commonly used for management of chronic rhinosinusitis (CRS) with nasal polyps; however, such use is not approved by the US Food and Drug Administration (FDA). DATA SOURCES Publications were obtained through PubMed searches through January 2022. STUDY SELECTION Searches were conducted using 2 terms: "chronic rhinosinusitis" or "nasal polyps" as the first term and "corticosteroid irrigation," "steroid nasal lavage," or "sinus rinse" as the second term. We reviewed relevant, peer-reviewed literature (19 original research [9 controlled, 10 uncontrolled trials], 7 reviews, and 1 meta-analysis) reporting safety and efficacy of CSI in patients with CRS. RESULTS Studies were difficult to compare because they used a variety of solution volumes (60 mL to 125 mL per nostril), corticosteroid agents (budesonide, betamethasone, mometasone, or fluticasone), corticosteroid doses, preparation protocols (by compounding pharmacy or by patient), and administration (frequency, time of day, body positioning). It is difficult to determine which parameters might substantially influence clinical effects because studies were generally small, showed marginal benefits, and rarely assessed safety. To date, no studies evaluating CSI have shown statistically significant differences in a type-I error-controlled primary end point over any comparator, possibly owing to small sample sizes. CONCLUSION Designing more robust clinical trials may help determine whether CSI is a valid treatment option. Until more evidence supporting CSI use exists, health care professionals should strongly consider choosing FDA-approved therapies for the treatment of CRS.
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Affiliation(s)
- Jonathan A Bernstein
- Division of Immunology-Allergy Section, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Andrew A White
- Division of Allergy, Asthma and Immunology, Scripps Clinic, La Jolla, California
| | - Joseph K Han
- Eastern Virginia Medical School, Norfolk, Virginia
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - David Elkayam
- Bellingham Asthma, Allergy and Immunology Clinic, Bellingham, Washington
| | - Fuad M Baroody
- Department of Surgery (Otolaryngology-Head and Neck Surgery) and Pediatrics, University of Chicago Medicine and the Comer Children's Hospital, Chicago, Illinois
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Shamil E, Hopkins C. Unified Airway Disease. Otolaryngol Clin North Am 2022; 56:157-168. [DOI: 10.1016/j.otc.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kothiwala M, Samdani S, Grover M, Gurjar V. Efficacy of Topical High Volume Budesonide Nasal Irrigation in Post FESS Patients of Chronic Rhinosinusitis With or Without Nasal Polyposis. Indian J Otolaryngol Head Neck Surg 2022; 74:1399-1407. [PMID: 36452810 PMCID: PMC9702420 DOI: 10.1007/s12070-021-02509-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022] Open
Abstract
Chronic rhinosinusitis (CRS) is a chronic inflammatory process of nasal mucosa and paranasal sinuses, lasting more than 12 weeks, without complete resolution of symptoms. CRS is treated medically, followed by Endoscopic sinus surgery (ESS) if necessary, and supplemented by post-operative topical treatment with highly variable clinical outcomes. However, till date there is no consensus on the composition and duration of maximal medical treatment. Despite proven role of topical steroids, the mode of delivery, dose and duration of topical intranasal corticosteroids still remains debatable. Studies found that high volume sinonasal irrigation (> 50 ml) using budesonide is most efficient method but still there is not sufficient data to prove this and results are variable with multiple modifiable factors therefore, this study has been conducted. (1) To determine the difference in mean decrease in Lund-Kennedy endoscopic scores and SNOT-22 scores among post ESS patients with high volume budesonide nasal irrigation nasal cavity and control nasal cavity of chronic rhinosinusitis patients. (2) To determine safety by measuring serum cortisol levels and intra ocular pressure. This is hospital based interventional, randomised, double blind, control trial study. A total of 66 patients of CRS with previous failed medical therapy were included. Same patients nasal cavities were divided into control and case nasal cavities, to avoid demographic bias. All subjects had a baseline SNOT-22 scores (Sino Nasal Outcome Test scores), Lund Kennedy endoscopy score, NCCT PNS score. All patients were undergone ESS procedure. After nasal pack removal, nasal cavities were randomly assigned 1:1 to receive normal saline irrigation (control group) or 1 mg of budesonide irrigation (case group) for transnasal irrigation twice daily for 12 weeks. A total of 66 patients with 132 nasal cavities were included in the study. Out of which 16 were female and 50 were male with mean age 33 year and mean duration of symptoms was 38.19 months. Mean duration of follow up was for 3 months. Mean decrement in SNOT-22 score in control nasal cavity from 52.54(16.309) to 30.06 (18.16) and in endoscopic score from 6.53 (1.33) to 3.93 (1.6) which is statically significant (p value < 0.05) in both scores. Mean decrement in SNOT-22 score in case nasal cavity from 53.73 (15.75) to 21.15 (13.52) and in endoscopic score from 6.74 (1.8) to 2.77 (1.4) which is statically significant (p value < 0.05) in both scores. Decrement in SNOT-22 scores and endoscopy scores in case nasal cavity in comparision to control nasal cavity were compared by student 't' test and found to be statically significant (p value equals to 0.0001). In subjective outcomes 57.57% shows total improvement in control nasal cavities while 72.73% case nasal cavities shows total improvement. Our study shows high volume budesonide irrigation is safe and superior over normal saline irrigation and results were statistically comparable. Still further studies with larger sample size and longer duration of irrigation needed.Based on available evidence, high volume budesonide irrigation is statically safe and superior over normal saline irrigation.
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Affiliation(s)
- Mamta Kothiwala
- Department of ENT and Head and Neck Surgery, SMS Medical College and Hospital, Dr Kothiwala Neurosurgery and ENT Clinic, B-48, Shyam colony (near rammandir sitabadi), Tonk road, 302019 Jaipur, Rajasthan India
| | - Sunil Samdani
- Department of ENT and Head and Neck Surgery, SMS Medical College and Hospital, Dr Kothiwala Neurosurgery and ENT Clinic, B-48, Shyam colony (near rammandir sitabadi), Tonk road, 302019 Jaipur, Rajasthan India
| | - Mohnish Grover
- Department of ENT and Head and Neck Surgery, SMS Medical College and Hospital, Dr Kothiwala Neurosurgery and ENT Clinic, B-48, Shyam colony (near rammandir sitabadi), Tonk road, 302019 Jaipur, Rajasthan India
| | - Vishram Gurjar
- Department of ENT and Head and Neck Surgery, SMS Medical College and Hospital, Dr Kothiwala Neurosurgery and ENT Clinic, B-48, Shyam colony (near rammandir sitabadi), Tonk road, 302019 Jaipur, Rajasthan India
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Jung SM, Kwak JH, Kim MK, Tae K, Cho SH, Jeong JH. The Long-Term Effects of Budesonide Nasal Irrigation in Chronic Rhinosinusitis with Asthma. J Clin Med 2022; 11:2690. [PMID: 35628816 PMCID: PMC9144201 DOI: 10.3390/jcm11102690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 02/01/2023] Open
Abstract
Chronic rhinosinusitis with nasal polyps (CRSwNP) in asthmatic patients has a high recurrence rate even after surgery. For this reason, oral steroids are frequently used, but their long-term use may cause side effects. The purpose of this study is to investigate the long-term effects of budesonide nasal irrigation (BNI) in CRSwNP and asthma. An analysis of 33 patients with CRSwNP and well-controlled asthma, who performed BNI for more than 12 months, was performed. We compared oral steroid and antibiotic dosages as well as nasal endoscopy scores before, and every six months after, BNI. The six-month dosages of oral steroids and antibiotics prescribed were significantly decreased at all time points after BNI compared to before BNI. When the dosages were compared at the time point immediately preceding six months, oral steroid intake decreased significantly until 12 months, and antibiotic intake decreased until 6 months. Furthermore, the endoscopic score decreased significantly until 12 months. The nasal symptom questionnaire score also significantly improved after BNI. Therefore, BNI is considered an effective treatment method that can improve subjective symptoms and objective intranasal findings while reducing oral steroid and antibiotic doses after long-term use in patients with CRSwNP accompanied by asthma.
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Affiliation(s)
| | | | | | | | | | - Jin Hyeok Jeong
- Department of Otolaryngology-Head & Neck Surgery, Hanyang University College of Medicine, Seoul 04763, Korea; (S.M.J.); (J.H.K.); (M.K.K.); (K.T.); (S.H.C.)
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Park DY, Choi JH, Kim DK, Jung YG, Mun SJ, Min HJ, Park SK, Shin JM, Yang HC, Hong SN, Mo JH. Clinical Practice Guideline: Nasal Irrigation for Chronic Rhinosinusitis in Adults. Clin Exp Otorhinolaryngol 2022; 15:5-23. [PMID: 35158420 PMCID: PMC8901942 DOI: 10.21053/ceo.2021.00654] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/17/2021] [Indexed: 11/22/2022] Open
Abstract
The Korean Society of Otorhinolaryngology-Head and Neck Surgery and Korean Rhinologic Society appointed a guideline development group (GDG) to establish a clinical practice guideline, and the GDG developed a guideline for nasal irrigation for adult patients with chronic rhinosinusitis (CRS). The guideline focuses on knowledge gaps, practice variations, and clinical concerns associated with nasal irrigation. Nasal irrigation has been recommended as the first-line treatment for CRS in various guidelines, and its clinical effectiveness has been demonstrated through a number of studies with robust evidence. However, no guidelines have presented a consistent nasal irrigation method. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. The committee developed 11 evidence-based recommendations. This guideline focuses on the evidence-based quality improvement opportunities deemed the most important by the GDG. Moreover, the guideline addresses whether nasal lavage helps treat CRS, what type of rinsing solution should be used, and the effectiveness of using additional medications to increase the therapeutic effect.
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Affiliation(s)
- Do-Yang Park
- Department of Otolaryngology, Ajou University School of Medicine, Suwon, Korea
| | - Ji Ho Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Dong-Kyu Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Yong Gi Jung
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sue Jean Mun
- Department of Otorhinolaryngology-Head and Neck Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyun Jin Min
- Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Soo Kyoung Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jae-Min Shin
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University College of Medicine, Seoul, Korea
| | - Hyung Chae Yang
- Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Seung-No Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Ji-Hun Mo
- Department of Otorhinolaryngology-Head and Neck Surgery, Dankook University College of Medicine, Cheonan, Korea
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12
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Papagiannopoulos P, Brown HJ, Kim YJ, Houser TK, Ganti A, Raad RA, Kuan EC, Losavio P, Batra PS, Tajudeen BA. Improved sinonasal symptom and endoscopy sinus scores with dose-escalated intranasal mometasone irrigation in patients with refractory chronic rhinosinusitis. Int Forum Allergy Rhinol 2021; 12:955-957. [PMID: 34894112 DOI: 10.1002/alr.22940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 10/27/2021] [Accepted: 12/08/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Peter Papagiannopoulos
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL
| | - Hannah J Brown
- Rush Medical College, Rush University Medical Center, Chicago, IL
| | - Young Jae Kim
- Rush Medical College, Rush University Medical Center, Chicago, IL
| | - Thomas K Houser
- Rush Medical College, Rush University Medical Center, Chicago, IL
| | - Ashwin Ganti
- Rush Medical College, Rush University Medical Center, Chicago, IL
| | - Richard A Raad
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL
| | - Edward C Kuan
- Department of Otolaryngology - Head and Neck Surgery, University of California Irvine, Orange County, CA
| | - Phillip Losavio
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL
| | - Pete S Batra
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL
| | - Bobby A Tajudeen
- Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL
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13
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Talat R, Gengler I, Phillips KM, Caradonna DS, Gray ST, Sedaghat AR. Chronic Rhinosinusitis Outcomes of Patients With Aspirin-Exacerbated Respiratory Disease Treated With Budesonide Irrigations: A Case Series. Ann Otol Rhinol Laryngol 2021; 131:1130-1136. [PMID: 34775833 DOI: 10.1177/00034894211054948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pathophysiology-targeting treatments exist for aspirin-exacerbated respiratory disease (AERD) through aspirin desensitization and biologics, such as dupilumab. With increasing attention paid to these treatments, which may be associated with significant side effects and/or cost, there is little description of chronic rhinosinusitis with nasal polyps (CRSwNP) response to treatment with intranasal corticosteroids and saline irrigations in AERD. OBJECTIVE To determine the effect of intranasal budesonide irrigations for the treatment of CRSwNP in AERD. METHODS This is an observational study of 14 AERD patients presenting to a rhinology clinic for CRS who were treated with twice daily high volume, low pressure irrigations with 240 mL of saline to which a 0.5 mg/2 mL respule of budesonide was added. All participants completed a 22-item Sinonasal Outcome Test (SNOT-22) at enrollment and at follow up 1 to 6 months later. Polyp scores were also calculated at each time point. RESULTS SNOT-22 scores ranged from 26 to 98 (median: 40.5) at enrollment and 3 to 85 (median: 38.5) at follow-up. Polyp scores ranged from 2 to 6 (median: 4) at enrollment at 0 to 6 (median: 2) at follow-up. Over the treatment period, change in SNOT-22 score ranged from -38 to 16 (median: -18) and change in polyp score ranged from -2 to 0 (median: -0.5). Approximately 57% of participants experienced at least 1 minimal clinically important difference in SNOT-22 score and 21% of participants had a SNOT-22 score <20 at follow-up. CONCLUSION Medical management with intranasal corticosteroids and saline irrigations alone leads to significant improvement in sinonasal symptomatology in a subset of AERD.
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Affiliation(s)
- Rehab Talat
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Isabelle Gengler
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Katie M Phillips
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David S Caradonna
- Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.,Division of Otolaryngology, Boston, MA, USA
| | - Stacey T Gray
- Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Ahmad R Sedaghat
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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14
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Borish L, Baroody FM, Kim MS, Lieberman JA, Peters A, Stevens WW, Bernstein JA. Yardstick for the medical management of chronic rhinosinusitis. Ann Allergy Asthma Immunol 2021; 128:118-128. [PMID: 34687874 DOI: 10.1016/j.anai.2021.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 02/07/2023]
Abstract
Chronic rhinosinusitis (CRS) is an inflammatory condition of the paranasal sinuses defined by classic symptoms, imaging findings, or endoscopic findings. There are a growing number of emerging pharmacologic therapies being evaluated to treat patients with CRS, some of which have gained indication status in the United States. There have not been updated treatment guidelines published in the United States however since 2014. This document is meant to serve as an updated expert consensus document for the pharmacologic management of patients with CRS. We review available data focusing on prospective clinical trials on oral and intranasal corticosteroids, nasal irrigation, biologics, antibiotics, and allergy immunotherapy for CRS both with and without nasal polyposis, including specific therapies for aspirin-exacerbated respiratory disease-associated CRS and allergic fungal CRS. There are multiple options to treat CRS, and clinicians should be knowledgeable on the efficacy and risks of these available therapies. Allergists-immunologists now have various therapies available to treat patients with CRS.
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Affiliation(s)
- Larry Borish
- Department of Medicine, Asthma and Allergic Disease Center, The University of Virginia, Charlottesville, Virginia
| | - Fuad M Baroody
- Department of Surgery (Otolaryngology-Head and Neck Surgery) and Pediatrics, The University of Chicago Medicine and the Comer Children's Hospital, Chicago, Illinois
| | - Margaret S Kim
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jay A Lieberman
- Division of Pulmonology, Allergy, & Immunology, Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Anju Peters
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Whitney W Stevens
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jonathan A Bernstein
- Division of Immunology-Allergy Section, Department of Internal Medicine, The University of Cincinnati College of Medicine, Cincinnati, Ohio.
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15
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Brown HJ, Batra PS, Eggerstedt M, Ganti A, Papagiannopoulos P, Tajudeen BA. The possibility of short-term hypothalamic-pituitary-adrenal axis suppression with high-volume, high-dose nasal mometasone irrigation in postsurgical patients with chronic rhinosinusitis. Int Forum Allergy Rhinol 2021; 12:249-256. [PMID: 34569177 DOI: 10.1002/alr.22894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 08/07/2021] [Accepted: 08/10/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Medically refractory chronic rhinosinusitis (CRS) is often treated with functional endoscopic sinus surgery (FESS) and high-volume steroid nasal irrigation. While budesonide is the most common steroid irrigation for this indication, mometasone has a superior pharmacokinetic profile, which may allow dose escalation. The safety and efficacy of mometasone at higher concentrations than previously used in treating CRS have not been explored. METHODS Patients were recruited from a tertiary level clinic between June 2018 and December 2019. Inclusion criteria included adults (>18 years); CRS diagnosis; previous FESS; pre-treatment morning cortisol within normal range; minimum of twice daily high-volume sinonasal mometasone irrigations (total dose of 4 mg) for 12 weeks; and post-treatment morning cortisol measured within 2 weeks following the study period. Patients with potential for endogenous or exogenous disruption of the HPA axis were excluded. RESULTS 14 patients were enrolled in this prospective cohort study. In all but one patient, pre- and post-treatment morning cortisol levels were not significantly different and were within normal limits (6.7-25.4 μg/dL). Following an uninterrupted 12-week treatment course, no evidence of HPA axis suppression was found (P = 0.915). The single patient who was found to have a low (1.3 μg/dL) post-treatment morning serum cortisol level reportedly received an intraarticular steroid shot several days prior to the blood draw. She remained asymptomatic and her rechecked serum cortisol was within normal limits at 12.3 μg/dL. CONCLUSIONS High-volume 2 mg twice daily sinonasal mometasone irrigations did not cause HPA axis suppression in a representative sample of patients with refractory CRS post-FESS with normal baseline cortisol levels.
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Affiliation(s)
- Hannah J Brown
- Rush Medical College, Rush University Medical Center, Chicago, Illinois, USA
| | - Pete S Batra
- Rush Sinus Program, Department of Otorhinolaryngology - Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael Eggerstedt
- Rush Sinus Program, Department of Otorhinolaryngology - Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Ashwin Ganti
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Peter Papagiannopoulos
- Rush Sinus Program, Department of Otorhinolaryngology - Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Bobby A Tajudeen
- Rush Sinus Program, Department of Otorhinolaryngology - Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA
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16
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Sampieri G, Namavarian A, Lee JJW, Hamour AF, Lee JM. Hypothalamic-pituitary-adrenal axis suppression and intranasal corticosteroid use: A systematic review and meta-analysis. Int Forum Allergy Rhinol 2021; 12:11-27. [PMID: 34260153 DOI: 10.1002/alr.22863] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/23/2021] [Accepted: 06/21/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Intranasal corticosteroids (INCS) are used in the management of sinonasal conditions. Use of exogenous steroids can be associated with hypothalamic-pituitary-adrenal axis dysfunction and adrenal insufficiency (AI). We aimed to estimate the rate of AI after INCS use in a meta-analysis, stratified by steroid type and treatment duration. METHODS Ovid Medline, Embase Classic, PubMed, Web of Science, and CINAHL databases were searched following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies investigating INCS use and AI. AI was defined as morning serum cortisol <550 nmol/L and <80 nmol/L with and without adrenocorticotropic hormone stimulation. INCS were classified as first (beclomethasone dipropionate, triamcinolone acetonide, beclomethasone, budesonide, dexamethasone) and second (ciclesonide, mometasone furoate, and fluticasone propionate) generation. Duration of treatment was classified as short (<1 month), medium (1-12 months), and long-term (>12 months) time periods. RESULTS This search identified 3668 articles. A total of 39 studies (1678 patients) were included in the final analysis. The pooled percentage of AI for routinely utilized first- and second-generation INCS was 0.70% (95% confidence interval [CI], 0.29-1.12%). Stratified by type, AI was observed in 0.78% (95% CI, 0.25-1.30%) of first-generation and 0.58% (95% CI, -0.1% to 1.26%) of second-generation steroids. AI was seen in 0.48% (95% CI, -0.01% to 0.96%) of short-term, 1.13% (95% CI, 0.2-2.1%) of medium-term, and 1.67% (95% CI, 0.37-2.9%) of long-term use of INCS. CONCLUSION Overall, the use of INCS carries a low risk for AI. Although modest, this risk may differ depending on the length of duration and type of INCS used. Informing patients of these risks is of importance for the treatment of chronic sinonasal conditions.
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Affiliation(s)
- Gianluca Sampieri
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - John J W Lee
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Amr F Hamour
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - John M Lee
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada.,Department of Otolaryngology-Head and Neck Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
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17
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Ranford D, Hopkins C. Safety review of current systemic treatments for severe chronic rhinosinusitis with nasal polyps and future directions. Expert Opin Drug Saf 2021; 20:1177-1189. [PMID: 33957840 DOI: 10.1080/14740338.2021.1926981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Chronic rhinosinusitis is a common condition characterized by inflammation of the nasal and sinus linings, rhinorrhea, nasal blockage, facial pain, and loss of sense of smell for longer than 12 weeks. CRS can occur with or without nasal polyps.Areas covered: First-line treatment in chronic rhinosinusitis with nasal polyps is long-term intranasal corticosteroids, which have few adverse events associated with their use, as second-generation intranasal corticosteroids having a bioavailability of <0.5%. Systemic corticosteroids are used when intranasal steroids fail to achieve symptom control. However, the repeated use of oral corticosteroids is associated with numerous adverse events and the benefit from a course of oral corticosteroids is lost within three to six months.Expert opinion: Antibiotics are commonly prescribed in nasal polyposis although there is also very little evidence for their use outside of acute infection. Macrolide antibiotics are also associated with a transient increase in the risk of arrhythmias. Biologics offer a steroid-sparing alternative to the treatment of severe nasal polyposis. They have shown to be relatively well tolerated in studies to date; however, studies suggest that there is no disease modifying effect and that any benefit is lost within weeks of finishing treatment.
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Affiliation(s)
- David Ranford
- ENT Department, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Claire Hopkins
- ENT Department, Guy's and St Thomas NHS Foundation Trust, London, UK
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18
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Fowler J, Rotenberg BW, Sowerby LJ. The subtle nuances of intranasal corticosteroids. J Otolaryngol Head Neck Surg 2021; 50:18. [PMID: 33731223 PMCID: PMC7968222 DOI: 10.1186/s40463-020-00480-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 11/16/2020] [Indexed: 01/31/2024] Open
Abstract
Background In the specialty of Otolaryngology – Head and Neck Surgery, intranasal corticosteroids are the mainstay treatment for inflammatory processes within the nasal cavity. All too often, physician prescribing patterns are based on previous training, personal experience, and interactions with industry. The purpose of this commentary is to review the nuances of each intranasal corticosteroid. Commentary There are nine intranasal corticosteroids approved for use in Canada. Each are discussed in detail, including their indication, bioavailability, effects on intranasal environment, and factors around patient adherence. Off-label use of budesonide irrigations is also discussed and cost information is presented in reference format for all available intranasal corticosteroids. Conclusion Although the efficacy of each intranasal corticosteroid has been shown to be similar, prescribing should be tailored based on bioavailability, intranasal environment, and factors that impact patient adherence such as dosing, cost and tolerability. Graphical abstract ![]()
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Affiliation(s)
- James Fowler
- Department of Otolaryngology - Head and Neck Surgery, Western University, 3St. Joseph's Hospital, 268 Grosvenor Street, London, ON, N6A 4V2, Canada
| | - Brian W Rotenberg
- Department of Otolaryngology - Head and Neck Surgery, Western University, 3St. Joseph's Hospital, 268 Grosvenor Street, London, ON, N6A 4V2, Canada
| | - Leigh J Sowerby
- Department of Otolaryngology - Head and Neck Surgery, Western University, 3St. Joseph's Hospital, 268 Grosvenor Street, London, ON, N6A 4V2, Canada.
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19
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Orlandi RR, Kingdom TT, Smith TL, Bleier B, DeConde A, Luong AU, Poetker DM, Soler Z, Welch KC, Wise SK, Adappa N, Alt JA, Anselmo-Lima WT, Bachert C, Baroody FM, Batra PS, Bernal-Sprekelsen M, Beswick D, Bhattacharyya N, Chandra RK, Chang EH, Chiu A, Chowdhury N, Citardi MJ, Cohen NA, Conley DB, DelGaudio J, Desrosiers M, Douglas R, Eloy JA, Fokkens WJ, Gray ST, Gudis DA, Hamilos DL, Han JK, Harvey R, Hellings P, Holbrook EH, Hopkins C, Hwang P, Javer AR, Jiang RS, Kennedy D, Kern R, Laidlaw T, Lal D, Lane A, Lee HM, Lee JT, Levy JM, Lin SY, Lund V, McMains KC, Metson R, Mullol J, Naclerio R, Oakley G, Otori N, Palmer JN, Parikh SR, Passali D, Patel Z, Peters A, Philpott C, Psaltis AJ, Ramakrishnan VR, Ramanathan M, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Sedaghat AR, Senior BA, Sindwani R, Smith K, Snidvongs K, Stewart M, Suh JD, Tan BK, Turner JH, van Drunen CM, Voegels R, Wang DY, Woodworth BA, Wormald PJ, Wright ED, Yan C, Zhang L, Zhou B. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol 2021; 11:213-739. [PMID: 33236525 DOI: 10.1002/alr.22741] [Citation(s) in RCA: 385] [Impact Index Per Article: 128.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
I. EXECUTIVE SUMMARY BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. METHODS ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. RESULTS ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. CONCLUSION This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.
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Affiliation(s)
| | | | | | | | | | - Amber U Luong
- University of Texas Medical School at Houston, Houston, TX
| | | | - Zachary Soler
- Medical University of South Carolina, Charleston, SC
| | - Kevin C Welch
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Claus Bachert
- Ghent University, Ghent, Belgium.,Karolinska Institute, Stockholm, Sweden.,Sun Yatsen University, Gangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David A Gudis
- Columbia University Irving Medical Center, New York, NY
| | - Daniel L Hamilos
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Richard Harvey
- University of New South Wales and Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | | | - Amin R Javer
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital, UCLH, London, UK
| | - Kevin C McMains
- Uniformed Services University of Health Sciences, San Antonio, TX
| | | | - Joaquim Mullol
- IDIBAPS Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Alkis J Psaltis
- University of Adelaide, Adelaide, South Australia, Australia
| | | | | | | | - Luke Rudmik
- University of Calgary, Calgary, Alberta, Canada
| | - Raymond Sacks
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - De Yun Wang
- National University of Singapore, Singapore, Singapore
| | | | | | | | - Carol Yan
- University of California San Diego, La Jolla, CA
| | - Luo Zhang
- Capital Medical University, Beijing, China
| | - Bing Zhou
- Capital Medical University, Beijing, China
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20
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Jiramongkolchai P, Patel S, Schneider JS. Use of Off-Label Nasal Steroid Irrigations in Long-Term Management of Chronic Rhinosinusitis. EAR, NOSE & THROAT JOURNAL 2021; 100:329-334. [PMID: 33683979 DOI: 10.1177/0145561321998521] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE Chronic rhinosinusitis (CRS) is an inflammatory disease of the paranasal sinuses and mucosa. Topical nasal corticosteroids are a mainstay treatment for CRS by reducing sinonasal inflammation and improving mucociliary clearance. However, topical corticosteroids have limited paranasal distribution, and patient response to treatment has been variable in randomized controlled trials (RCT). Thus, there is significant interest in evaluating the efficacy of nasal steroids delivered by nasal irrigation in order to improve penetration and absorption of topical steroids into the sinonasal mucosa. In this review, we discuss the use of off-label nasal steroid irrigations in the management of CRS. METHODS A review of clinical trials evaluating the use of nasal steroid irrigations for CRS in the PubMed electronic database was performed. RESULTS Of the 12 clinical studies identified, 10 evaluated budesonide irrigations while the remaining 2 focused on mometasone. The overwhelming majority of studies for both budesonide and mometasone supported the use of nasal irrigations with corticosteroids over nasal corticosteroid sprays alone. However, the heterogeneity in study design, patient cohort, and volume of steroid irrigation limit the interpretations of these studies. CONCLUSIONS Nasal irrigation with corticosteroids is beneficial and safe for the treatment of CRS. Future RCTs controlling for type of surgical intervention, CRS pheno- and endo-type, as well as dosing and duration of nasal corticosteroid irrigations are warranted.
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Affiliation(s)
- Pawina Jiramongkolchai
- Department of Otolaryngology-Head and Neck Surgery, 12275Washington University School of Medicine in St. Louis, MO, USA
| | | | - John S Schneider
- Department of Otolaryngology-Head and Neck Surgery, 12275Washington University School of Medicine in St. Louis, MO, USA
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21
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Macias-Valle L, Psaltis AJ. A Scholarly Review of the Safety and Efficacy of Intranasal Corticosteroids Preparations in the Treatment of Chronic Rhinosinusitis. EAR, NOSE & THROAT JOURNAL 2020; 100:295-301. [PMID: 33084428 DOI: 10.1177/0145561320967727] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The purpose of this scholarly review is to present an update of the efficacy, safety, and distribution of intranasal corticosteroids (INCS) in the context of treatment for chronic rhinosinusitis (CRS). MATERIALS AND METHODS A literature review from 1999 to 2020 of MEDLINE, PubMed, and EMBASE databases was performed, using a comprehensive search strategy. Studies reporting on efficacy, safety, and distribution of all INCS formulations, both Food and Drug Administration (FDA) and non-FDA approved, were reviewed. RESULTS AND CONCLUSIONS High-level evidence publications and position papers support the role of INCS in medical treatment for CRS. Significant improvement in disease-specific and general quality of life measures is observed with all formulations of INCS. Overall, the use of both FDA and published non-FDA INCS appears to be safe. Several novel distribution devices might improve penetration to specific areas within the sinuses.
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Affiliation(s)
- Luis Macias-Valle
- Department of Otolaryngology Head and Neck Surgery, Hospital Español de México, 103472Universidad La Salle. México City, México
| | - Alkis J Psaltis
- Department of Otolaryngology Head and Neck Surgery, 1066University of Adelaide, Adelaide, Australia and Central Adelaide Local Health Network, South Australia
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Donaldson AM, Choby G, Kim DH, Marks LA, Lal D. Intranasal Corticosteroid Therapy: Systematic Review and Meta-analysis of Reported Safety and Adverse Effects in Adults. Otolaryngol Head Neck Surg 2020; 163:1097-1108. [DOI: 10.1177/0194599820931455] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives To address concerns related to the safety profile of both Food and Drug Administration (FDA)–approved and non–FDA-approved intranasal corticosteroid (INCS) use in the adult population. Data Source Systematic review of MEDLINE, PubMed, and EMBASE databases using a comprehensive search strategy including all INCS formulations and adverse events. The study design was developed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional sources were identified from study references of relevant articles. Review Methods A structured literature search was conducted. Each study was graded for level of evidence using the Oxford Centre for Evidence-Based Medicine. Extracted data included population size, study design, drug (dosage, route, and frequency), presence of hypothalamus pituitary axis suppression, ocular symptoms, and treatment-related adverse events. Results A total of 60 studies met inclusion criteria. The studies included use of INCS as metered nasal sprays, drops, injections, aerosols, and irrigations. There were no persistent abnormalities in cortisol level or intraocular pressure change. Meta-analysis of epistaxis showed a significantly increased risk in the FDA-approved treatment group in comparison with control (risk ratio 1.56; 95% confidence interval, 1.13-2.14; P = .007). Conclusions Overall, it appears that the use of both FDA and published non-FDA application of INCS are safe in the adult population. Meta-analysis demonstrated an increased risk of epistaxis in patients using INCS compared with placebo. Otherwise, there was no significant difference between in adults in the treatment group and placebo group. As an important caveat, the interpretation of safety of nonstandard INCS is restricted to delivery methods and dosages published in the literature.
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Affiliation(s)
- Angela M. Donaldson
- Department of Otolaryngology Head and Neck Surgery, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Garret Choby
- Department of Otolaryngology Head and Neck Surgery, Mayo Clinic in Rochester, Rochester, New York, USA
| | - Daniel H. Kim
- Department of Pediatrics, University of California Irvine, Irvine, California, USA
| | - Lisa A. Marks
- Department of Neurological Surgery, Mayo Clinic in Arizona, Phoenix, Arizona, USA
| | - Devyani Lal
- Department of Otolaryngology Head & Neck Surgery, Mayo Clinic in Arizona, Phoenix, Arizona, USA
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Ryu G, Cho YS, Hong SD, Kim HY, Chung SK, Dhong HJ. The Effect of Triamcinolone-Soaked Gelfoam in Patients with Polypoid Mucosal Change after Endoscopic Sinus Surgery. JOURNAL OF RHINOLOGY 2020. [DOI: 10.18787/jr.2019.00288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background and Objectives: Chronic rhinosinusitis with nasal polyps (CRSwNP) recurs frequently after endoscopic sinus surgery (ESS). The aim of study was to evaluate the efficacy of triamcinolone-soaked absorbable gelatin foam (gelfoam) as a treatment for recurred polypoid changes after ESS.Subjects and Method: A total of 35 patients and 57 nasal cavities was retrospectively reviewed. All patients underwent triamcinolone- infused gelfoam packing for 1 week under nasal endoscopic guidance. Endoscopic scores were evaluated at 1 week, 1 month, and 3 months. We analyzed clinical characteristics between success and failure groups.Results: Endoscopic scores were significantly improved after triamcinolone-soaked gelfoam packing, and the effects were maintained at 3-month follow-up (1.85±0.61 vs. 0.82±0.77, p<0.001). Duration between surgery and gelfoam packing was shorter in the success group compared to the failure group (8.2±6.9 vs. 13.7±8.4 weeks, p=0.033). Serum eosinophil cationic protein and tissue eosinophil counts were significantly higher in the failure group (p=0.025 and p=0.010, respectively).Conclusion: Triamcinolone-soaked gelfoam packing is an effective and safe method for managing recurrent polypoid change in patients with CRSwNP after ESS. Early intervention contributed to a successful result, and eosinophilic inflammation was associated with poor outcomes.
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Liu Z, Chen J, Cheng L, Li H, Liu S, Lou H, Shi J, Sun Y, Wang D, Wang C, Wang X, Wei Y, Wen W, Yang P, Yang Q, Zhang G, Zhang Y, Zhao C, Zhu D, Zhu L, Chen F, Dong Y, Fu Q, Li J, Li Y, Liu C, Liu F, Lu M, Meng Y, Sha J, She W, Shi L, Wang K, Xue J, Yang L, Yin M, Zhang L, Zheng M, Zhou B, Zhang L. Chinese Society of Allergy and Chinese Society of Otorhinolaryngology-Head and Neck Surgery Guideline for Chronic Rhinosinusitis. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2020; 12:176-237. [PMID: 32009319 PMCID: PMC6997287 DOI: 10.4168/aair.2020.12.2.176] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 11/05/2019] [Accepted: 11/13/2019] [Indexed: 02/05/2023]
Abstract
The current document is based on a consensus reached by a panel of experts from the Chinese Society of Allergy and the Chinese Society of Otorhinolaryngology-Head and Neck Surgery, Rhinology Group. Chronic rhinosinusitis (CRS) affects approximately 8% of Chinese adults. The inflammatory and remodeling mechanisms of CRS in the Chinese population differ from those observed in the populations of European descent. Recently, precision medicine has been used to treat inflammation by targeting key biomarkers that are involved in the process. However, there are no CRS guidelines or a consensus available from China that can be shared with the international academia. The guidelines presented in this paper cover the epidemiology, economic burden, genetics and epigenetics, mechanisms, phenotypes and endotypes, diagnosis and differential diagnosis, management, and the current status of CRS in China. These guidelines-with a focus on China-will improve the abilities of clinical and medical staff during the treatment of CRS. Additionally, they will help international agencies in improving the verification of CRS endotypes, mapping of eosinophilic shifts, the identification of suitable biomarkers for endotyping, and predicting responses to therapies. In conclusion, these guidelines will help select therapies, such as pharmacotherapy, surgical approaches and innovative biotherapeutics, which are tailored to each of the individual CRS endotypes.
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Affiliation(s)
- Zheng Liu
- Department of Otolaryngology Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jianjun Chen
- Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lei Cheng
- Department of Otorhinolaryngology, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
- International Centre for Allergy Research, Nanjing Medical University, Nanjing, China
| | - Huabin Li
- Department of Otolaryngology, Head and Neck Surgery, Affiliated Eye, Ear, Nose and Throat Hospital, Fudan University, Shanghai, China
| | - Shixi Liu
- Department of Otolaryngology, West China Hospital, Sichuan University, Chengdu, China
| | - Hongfei Lou
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | - Jianbo Shi
- Otorhinolaryngology Hospital, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ying Sun
- Department of Immunology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Dehui Wang
- Department of Otolaryngology, Head and Neck Surgery, Affiliated Eye, Ear, Nose and Throat Hospital, Fudan University, Shanghai, China
| | - Chengshuo Wang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | - Xiangdong Wang
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | - Yongxiang Wei
- Department of Otolaryngology Head and Neck Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Weiping Wen
- Otorhinolaryngology Hospital, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Otorhinolaryngology Hospital, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Pingchang Yang
- Research Center of Allergy & Immunology, Shenzhen University School of Medicine, Shenzhen, China
| | - Qintai Yang
- Department of Otolaryngology Head and Neck Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Gehua Zhang
- Department of Otolaryngology Head and Neck Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yuan Zhang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
- Department of Allergy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Changqing Zhao
- Department of Otolaryngology Head and Neck Surgery, The Second Hospital, Shanxi Medical University, Taiyuan, China
| | - Dongdong Zhu
- Department of Otolaryngology Head and Neck Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Li Zhu
- Department of Otolaryngology Head and Neck Surgery, Peking University Third Hospital, Beijing, China
| | - Fenghong Chen
- Otorhinolaryngology Hospital, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yi Dong
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | - Qingling Fu
- Otorhinolaryngology Hospital, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jingyun Li
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | - Yanqing Li
- Department of Otolaryngology, Head and Neck Surgery, Affiliated Eye, Ear, Nose and Throat Hospital, Fudan University, Shanghai, China
| | - Chengyao Liu
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Feng Liu
- Department of Otolaryngology, West China Hospital, Sichuan University, Chengdu, China
| | - Meiping Lu
- Department of Otorhinolaryngology, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Yifan Meng
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | - Jichao Sha
- Department of Otolaryngology Head and Neck Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Wenyu She
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
- Department of Allergy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Lili Shi
- Department of Otolaryngology Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kuiji Wang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | - Jinmei Xue
- Department of Otolaryngology Head and Neck Surgery, The Second Hospital, Shanxi Medical University, Taiyuan, China
| | - Luoying Yang
- Department of Otolaryngology Head and Neck Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Min Yin
- Department of Otorhinolaryngology, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
- International Centre for Allergy Research, Nanjing Medical University, Nanjing, China
| | - Lichuan Zhang
- Department of Otolaryngology Head and Neck Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ming Zheng
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | - Bing Zhou
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
| | - Luo Zhang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
- Department of Allergy, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
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Latest developments on topical therapies in chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg 2020; 28:25-30. [DOI: 10.1097/moo.0000000000000598] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Tyler MA, Luong AU. Current Concepts in the Management of Allergic Fungal Rhinosinusitis. Immunol Allergy Clin North Am 2020; 40:345-359. [PMID: 32278456 DOI: 10.1016/j.iac.2019.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Allergic fungal rhinosinusitis (AFRS) represents a subtype of chronic rhinosinusitis with nasal polyposis that exhibits a unique, often striking clinical presentation. Since its initial description more than a quarter century ago, a more sophisticated understanding of the pathophysiology of AFRS has been achieved and significant advancements in improving clinical outcomes made. This review focuses on the latest developments involving the pathophysiology and clinical management of this fascinating disease.
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Affiliation(s)
- Matthew A Tyler
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota Medical School, 516 Delaware Street Southeast, # 8A, Minneapolis, MN 55455, USA
| | - Amber U Luong
- Department of Otorhinolaryngology-Head & Neck Surgery, McGovern Medical School at the University of Texas Health Science Center, Texas Sinus Institute, 6431 Fannin Street, MSB 5.036, Houston, TX 77030, USA; Center for Immunology and Autoimmune Diseases, Institute of Molecular Medicine, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA.
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Psaltis AJ, Vyskocil E. What are the challenges in choosing pharmacotherapy for rhinosinusitis? Expert Opin Pharmacother 2020; 21:427-433. [DOI: 10.1080/14656566.2020.1717467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Alkis J Psaltis
- Department of Otorhinolaryngology, Head and Neck Surgery, The Queen Elizabeth Hospital, Adelaide, Australia
- Department of Surgery, University of Adelaide, Adelaide, Australia
| | - Erich Vyskocil
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, Vienna, Austria
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Abstract
As the understanding of the primary cause of chronic rhinosinusitis has shifted away from infection toward inflammation, topical corticosteroid sprays and saline irrigations have become mainstays of treatment. Topical corticosteroid irrigations are recommended particularly in the postoperative setting, but further research on their effect and possible hypothalamic-pituitary-adrenal axis suppression is needed. The popularity of topical antibiotics has subsequently waned with their use reserved for recalcitrant cases. Further research is needed on the effect of topical antifungals in allergic fungal rhinosinusitis. Topical alternative therapies that target biofilms have gained increasing recognition, and investigations on topical probiotics are on the horizon.
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Affiliation(s)
- Victoria S Lee
- Department of Otolaryngology-Head and Neck Surgery, University of Illinois at Chicago, 1855 West Taylor Street, MC 648, Room 3.87, Chicago, IL 60611, USA.
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Grayson JW, Harvey RJ. Topical corticosteroid irrigations in chronic rhinosinusitis. Int Forum Allergy Rhinol 2020; 9:S9-S15. [PMID: 31087637 DOI: 10.1002/alr.22331] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 02/18/2019] [Accepted: 02/24/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Chronic rhinosinusitis (CRS) has previously been thought to occur secondary to infectious or obstructive etiologies. However, in recent years, primary CRS has been more discretely defined as diffuse airway inflammation, similar to asthma. Adequate medical and surgical therapy are needed to control the inflammation. Our purpose in this study was to evaluate the efficacy and safety of topical corticosteroid treatment. METHODS A focused literature review was conducted and we identified 11 original articles from the years 2013-2018 evaluating safety or efficacy of topical corticosteroid irrigations. RESULTS Eleven articles were identified. One study found significant benefit between corticosteroid irrigations versus corticosteroid sprays. Two studies found significant benefit between corticosteroid irrigations compared to saline irrigations while two did not. One study found significant improvement in certain patient populations when using corticosteroid irrigations compared to no irrigation. Five studies found no significant increase in risk of adverse side effects with the use of topical corticosteroids. CONCLUSION Many factors are associated with efficacious and adequate treatment of primary CRS. The pathology must be correctly diagnosed and be inflammatory in nature. The treatment paradigm should include wide and complete endoscopic sinus surgery for the adequate delivery of topical therapy. Topical therapy should be delivered in large-volume, low-pressure devices with adequate dosing. Although there is some systemic absorption, multiple studies have demonstrated that long-term, daily use of topical corticosteroids does not increase intraocular pressure, suppress the hypothalamic-pituitary-adrenal axis, or increase the risk of subcapsular cataracts. Therefore, topical corticosteroid irrigations should be considered a part of first-line medical treatment in postsurgical CRS patients.
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Affiliation(s)
- Jessica W Grayson
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, New South Wales, Australia
| | - Richard J Harvey
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, New South Wales, Australia.,Department of Otolaryngology, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
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Husain Q, Banks C, Bleier BS. Use of off-label steroid irrigations in chronic rhinosinusitis: a survey of the American Rhinologic Society. Int Forum Allergy Rhinol 2020; 10:575-576. [PMID: 31944584 DOI: 10.1002/alr.22519] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/04/2019] [Accepted: 12/10/2019] [Indexed: 01/30/2023]
Affiliation(s)
- Qasim Husain
- Department of Otolaryngology-Head & Neck Surgery, Hackensack Meridian School of Medicine at Seton Hall University, Coastal Ear, Nose, and Throat, Holmdel, NJ
| | - Catherine Banks
- Department of Otolaryngology-Head & Neck Surgery, Prince of Wales Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Benjamin S Bleier
- Department of Otolaryngology-Head & Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA
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Kuan EC, Kovacs AJ, Workman AD, Bosso JV, Adappa ND. Efficacy of fluticasone exhalation delivery system in the management of chronic rhinosinusitis: what is the evidence? Int Forum Allergy Rhinol 2020; 9:S16-S21. [PMID: 31087635 DOI: 10.1002/alr.22340] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/09/2019] [Accepted: 03/22/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Intranasal steroids have become part of the mainstay in the long-term management of chronic rhinosinusitis. A long-standing problem remains in efficient and easy-to-use delivery of topical corticosteroids to the nasal mucosa. Currently available means of intranasal steroid delivery include sprays, which are generally limited to treating the anterior nasal cavity, and rinses, which are not FDA-approved for this indication. The exhalation delivery system is a novel method of delivering fluticasone to the deeper areas within the nasal cavities, including the posterior nasal cavity and middle and superior meatuses. METHODS Comprehensive literature review. RESULTS Recent large scale studies have suggested its efficacy and safety in the use of patients with both chronic sinusitis with polyposis and without polyps. Specifically, studies have demonstrated decreased Sinonasal Outcome Test scores of 20 points following treatment, as well as improvement of polyp grade by 1 or more point in more than 60% of patients. Furthermore, among patients with nasal polyps, there was approximately 60-70% decreased indication for surgery following EDS-FLU use. CONCLUSION EDS-FLU is an important adjunct therapy for sinonasal inflammatory disease.
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Affiliation(s)
- Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Alexander J Kovacs
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Alan D Workman
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA
| | - John V Bosso
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA
| | - Nithin D Adappa
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA
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Grammatopoulou V, Praveena CV, Sunkaraneni VS. Optimising Medical Management in CRS. CURRENT OTORHINOLARYNGOLOGY REPORTS 2019. [DOI: 10.1007/s40136-019-00232-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Toskala E. Editorial. Int Forum Allergy Rhinol 2018; 7:439-440. [PMID: 28493305 DOI: 10.1002/alr.21947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Mullings WP, Al-Salman R, Javer AR. Managing Allergic Fungal Rhinosinusitis. CURRENT OTORHINOLARYNGOLOGY REPORTS 2018. [DOI: 10.1007/s40136-018-0206-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
Nasal obstruction is a common, and potentially debilitating, problem. It is caused by a combination of structural factors and/or mucosal swelling/inflammation. The medical treatment of nasal obstruction is aimed at decreasing mucosal inflammation and edema and is generally guided by the underlying cause. Several different drug classes are commonly used in the treatment of nasal obstruction, each with different indications, and pros and cons to their use. This article discusses the most commonly used therapies for nasal obstruction. Current evidence on the efficacy and side effect profile of each therapy is reviewed.
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Affiliation(s)
- Daniel R Cox
- Department of Otolaryngology-Head and Neck Surgery, Emory University, 550 Peachtree Street, MOT 11th Floor, Atlanta, GA 30308, USA
| | - Sarah K Wise
- Department of Otolaryngology-Head and Neck Surgery, Emory University, 550 Peachtree Street, MOT 11th Floor, Atlanta, GA 30308, USA.
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Kohanski MA, Toskala E, Kennedy DW. Evolution in the surgical management of chronic rhinosinusitis: Current indications and pitfalls. J Allergy Clin Immunol 2018; 141:1561-1569. [DOI: 10.1016/j.jaci.2018.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/20/2018] [Accepted: 03/26/2018] [Indexed: 11/16/2022]
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Yoon HY, Lee HS, Kim IH, Hwang SH. Post-operative corticosteroid irrigation for chronic rhinosinusitis after endoscopic sinus surgery: A meta-analysis. Clin Otolaryngol 2017; 43:525-532. [PMID: 29054113 DOI: 10.1111/coa.13015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recently, topical steroid therapy delivery using high-volume sinonasal irrigations has been used more frequently, following endoscopic sinus surgery (ESS), to improve drug delivery into the paranasal sinuses. OBJECTIVE The goal of this study was to perform a systematic review with meta-analysis of the efficacy of steroid nasal irrigation on post-operative management of Chronic rhinosinusitis (CRS) following ESS. METHODS Five databases (PubMed, SCOPUS, Embase, Web of Science, and the Cochrane database) from inception to March 2017 were independently reviewed by two researchers. Studies that scored CRS endoscopic findings and CRS-related quality of life (QOL) post-operatively before and after steroid nasal irrigation and that compared the effects of steroid nasal irrigation (treatment groups) with saline alone irrigation (control group) were included in the analysis. RESULTS Twelve studies (n = 360) met inclusion criteria. Steroid nasal irrigation significantly reduced the endoscopic score compared with pre-treatment values and also improved QOL. Adverse effects following steroid nasal irrigation such as increased intraocular pressure (IOP) and hypothalamus-pituitary-adrenal (HPA) axis disturbance were not significant. However, compared with saline alone irrigation, the additional effects of steroid irrigation were not significant in the view of the endoscopic score and disease-specific QOL. CONCLUSION Although steroid nasal irrigation would not induce adverse effects related to systemic steroid absorption, the beneficial effects of additional steroids in saline irrigation were ambiguous in regard to endoscopic score and CRS-related QOL improvement compared with saline alone irrigation. However, further clinical trials with robust research methodologies should be conducted to confirm the results of this study.
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Affiliation(s)
- H Y Yoon
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - H S Lee
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - I H Kim
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - S H Hwang
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Cai Y, Gudis DA. Is topical high-volume budesonide sinus irrigation safe? Laryngoscope 2017; 128:781-782. [DOI: 10.1002/lary.26880] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2017] [Indexed: 01/30/2023]
Affiliation(s)
- Yi Cai
- Department of Otolaryngology-Head and Neck Surgery; University of California, San Francisco; San Francisco California
| | - David A. Gudis
- Department of Otolaryngology-Head and Neck Surgery; Columbia University Medical Center; New York New York U.S.A
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Hauser LJ, Turner JH, Chandra RK. Trends in the Use of Stents and Drug-Eluting Stents in Sinus Surgery. Otolaryngol Clin North Am 2017; 50:565-571. [DOI: 10.1016/j.otc.2017.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Manji J, Singh G, Okpaleke C, Dadgostar A, Al-Asousi F, Amanian A, Macias-Valle L, Finkelstein A, Tacey M, Thamboo A, Javer A. Safety of long-term intranasal budesonide delivered via the mucosal atomization device for chronic rhinosinusitis. Int Forum Allergy Rhinol 2017; 7:488-493. [PMID: 28151588 DOI: 10.1002/alr.21910] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 11/23/2016] [Accepted: 12/13/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND Although short-term use (≤2 months) of atomized topical nasal steroids has been shown to be safe and effective, the long-term safety has yet to be demonstrated. The aim of this study was to determine the impact of long-term topical budesonide treatment via the mucosal atomization device (MAD) on the hypothalamic-pituitary-adrenal axis (HPAA) and intraocular pressure (IOP). METHODS A cross-sectional study of patients with chronic rhinosinusitis (CRS), with or without nasal polyposis, managed with daily nasal budesonide via MAD was conducted at a tertiary rhinology center. Patients using systemic steroids within 3 months of assessment were excluded. HPAA impact was assessed using the cosyntropin stimulation test for adrenal function and a survey of relevant symptomatology. Patients also underwent tonometry to assess for elevated IOP potentially related to corticosteroid use. RESULTS A total of 100 CRS patients were recruited with a mean budesonide treatment duration of 23.5 months (range, 6-37 months). Stimulated cortisol response was diminished in 3 patients (3%). No patients with adrenal suppression had relevant symptomatology. IOP was elevated in 6 patients (6%). CONCLUSION These findings suggest that there is a risk of adrenal suppression and raised IOP associated with the long-term use of topical nasal budesonide via MAD. Otolaryngologists should consider periodic surveillance for these adverse events in this patient cohort.
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Affiliation(s)
- Jamil Manji
- St. Paul's Sinus Centre, Vancouver, British Columbia, Canada.,Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Gurkaran Singh
- St. Paul's Sinus Centre, Vancouver, British Columbia, Canada
| | | | - Anali Dadgostar
- St. Paul's Sinus Centre, Vancouver, British Columbia, Canada
| | - Fahad Al-Asousi
- St. Paul's Sinus Centre, Vancouver, British Columbia, Canada
| | - Ameen Amanian
- St. Paul's Sinus Centre, Vancouver, British Columbia, Canada
| | - Luis Macias-Valle
- Hospital Español de México, Facultad Mexicana de Medicina Universidad La Salle Mexico City, Mexico
| | - Andres Finkelstein
- Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Chile
| | - Mark Tacey
- Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Thamboo
- St. Paul's Sinus Centre, Vancouver, British Columbia, Canada
| | - Amin Javer
- St. Paul's Sinus Centre, Vancouver, British Columbia, Canada
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Varshney R, Lee JT. Current trends in topical therapies for chronic rhinosinusitis: update and literature review. Expert Opin Drug Deliv 2016; 14:257-271. [PMID: 27500891 DOI: 10.1080/17425247.2016.1214563] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Chronic rhinosinusitis (CRS) affects millions of patients worldwide. The disease is multifactorial with influences including anatomic factors, immunological disturbances, and altered sinonasal microbiome. Although oral medications are effective in controlling some symptoms, they are associated with side effects and long-term use is not ideal. Thus, topical therapies have emerged as an alternative delivery method for localized, high-concentration medication with less side effects. Areas covered: This is a review of the various topical therapies available or under investigation for the management of CRS. Common medications such as saline, steroids, and antimicrobials will be discussed. Furthermore, additives including manuka honey, xylitol, surfactant, N-chlorotaurine, Dead Sea salt, and sodium hyaluronate will be addressed. Innovations in topical therapies, such as drug-eluting biomaterials and photodynamic therapy, will also be reviewed. Expert opinion: Although topical therapies provide a high dose of active substance at the site of disease, their efficacy in CRS is not clear. Topical saline and intranasal steroids appear to consistently demonstrate therapeutic benefits. However, other topical medications require further investigation to determine long-term clinical efficacy and safety. A better understanding of their effects on the sinonasal mucociliary system is needed before they become the standard of care in CRS.
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Affiliation(s)
- Rickul Varshney
- a Orange County Sinus Institute , Southern California Permanente Medical Group , Irvine , CA , USA
| | - Jivianne T Lee
- a Orange County Sinus Institute , Southern California Permanente Medical Group , Irvine , CA , USA.,b Department of Head & Neck Surgery , David Geffen School of Medicine at UCLA , Los Angeles , CA , USA
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Wormald PJ. Editorial IFAR February 2016. Int Forum Allergy Rhinol 2016; 6:226-7. [PMID: 26954902 DOI: 10.1002/alr.21764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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