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Böscke R. [Difficult-to-treat chronic rhinosinusitis-when the standard treatment is not effective and biologics are not available]. HNO 2024; 72:231-241. [PMID: 38472346 DOI: 10.1007/s00106-024-01443-w] [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] [Accepted: 02/06/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND In recent years, significant improvements have been made in the treatment options for uncontrolled chronic rhinosinusitis (CRS) refractory to standard medical and surgical therapy. This is the result of a better understanding of the pathophysiology and the resulting development of biologicals for CRS with nasal polyps (CRSwNP). However, biologics are not (yet) available for all patients in Europe. OBJECTIVE Based on the session "Difficult-to-treat CRS, when biologics are not available" at the 29th Congress of the European Rhinologic Society (ERS) 2023 in Sofia, Bulgaria, the treatment options for uncontrolled CRS with the exclusion of biologics will be discussed. MATERIALS AND METHODS The content of the presentations "Is there a place for antibiotics?" "Indications for revision surgery," "Novel systemic treatment options," "Novel local treatment options," and "Phototherapy for nasal polyps" are outlined and supported by a review of the literature. RESULTS Various treatment options are available for managing uncontrolled CRS, even if biologic treatments are unavailable. Treatment options for type‑2 (T2) CRS include steroid rinses, repeated short-term oral steroids, steroid-eluting stents, and extended sinus surgery. In the case of nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (NERD), acetylsalicylic acid (ASA) desensitization can be considered. Non-T2 endotypes or CRS without nasal polyps (CRSsNP) may benefit from several weeks of macrolides and xylitol rinses. CONCLUSION To accurately assess the efficacy of second-line therapies for treatment of difficult-to-treat CRS within an endotype-specific framework, additional controlled clinical trials are needed that take into account the heterogeneity of CRS endotypes.
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Affiliation(s)
- Robert Böscke
- Universitätsklinik für Hals-Nasen-Ohren-Heilkunde, Evangelisches Krankenhaus Oldenburg, Medizinischer Campus der Carl-von-Ossietzky Universität Oldenburg, Steinweg 13-17, 26122, Oldenburg, Deutschland.
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Brar T, Brown A, Miglani A, Lal D, Marino MJ. Outcomes of Frontal Sinus Stenting With Steroid Impregnated Microsponge Versus Steroid-Eluting Implant. Am J Rhinol Allergy 2023; 37:679-685. [PMID: 37408359 DOI: 10.1177/19458924231186901] [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] [Indexed: 07/07/2023]
Abstract
BACKGROUND Mometasone-eluting poly-L-lactide-coglycolide (MPLG) is available commercially for frontal sinus ostium (FSO) stenting. An alternative chitosan polymer-based drug delivery microsponge is also available at a lower cost per unit. OBJECTIVE To compare the outcomes of MPLG stents versus triamcinolone-impregnated chitosan polymer (TICP) microsponge in frontal sinus surgery. METHODS Patients who underwent endoscopic sinus surgery from December 2018 to February 2022 were reviewed to identify those with the intraoperative placement of TICP microsponge or MPLG stent in the FSO. FSO patency was evaluated by endoscopy at follow-up. Twenty-two-item sinonasal outcome test (SNOT-22) was also recorded, and complications were noted. RESULTS A total of 68 subjects and 96 FSOs were treated. TICP was first used in August 2021 and MPLG in December 2018. MPLG placement in a Draf 3 cavity was excluded since TICP had not been used during Draf 3 procedure. Both cohorts (TICP 20 subjects, 35 FSOs; MPLG 26 subjects, 39 FSOs) had similar clinical characteristics. At a mean total follow-up of 249.2 days for TICP and 490.4 days for MPLG, FSO patency was 82.9% and 87.1%, respectively (P = .265). At an equivalent follow-up of 130.6 days in TICP and 154.0 days in MPLG, patency was 94.3% and 89.7%, respectively (P = .475). Both groups showed significant reductions in SNOT-22 (P < .001). MPLG demonstrated crusting within the FSO at 1 month (none in TICP). CONCLUSION FSO patency for both stents was similar, although TICP had significantly lower costs per unit. Additional comparative trials may be helpful for guiding clinicians on the appropriate clinical situations for the use of these devices.
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Affiliation(s)
- Tripti Brar
- Division of Rhinology, Department of Otolaryngology, Mayo Clinic in Arizona, Scottsdale, AZ, USA
| | - Adam Brown
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | - Amar Miglani
- Division of Rhinology, Department of Otolaryngology, Mayo Clinic in Arizona, Scottsdale, AZ, USA
| | - Devyani Lal
- Division of Rhinology, Department of Otolaryngology, Mayo Clinic in Arizona, Scottsdale, AZ, USA
| | - Michael J Marino
- Division of Rhinology, Department of Otolaryngology, Mayo Clinic in Arizona, Scottsdale, AZ, USA
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Rimmer J, Cervin A, Wrobel A, Gartung A, Brayton L, Shao J, Belanger V. Impact of long-acting implantable LYR-210 corticosteroid matrices on quality of life of patients with chronic rhinosinusitis in the LANTERN study. Int Forum Allergy Rhinol 2023; 13:1821-1824. [PMID: 36752990 DOI: 10.1002/alr.23139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/24/2022] [Accepted: 02/06/2022] [Indexed: 02/09/2023]
Affiliation(s)
- Joanne Rimmer
- Monash Health, St Vincent's Hospital Melbourne, and Department of Surgery, Monash University, Melbourne, Australia
| | - Anders Cervin
- Royal Brisbane & Women's Hospital Campus, University of Queensland Centre for Clinical Research, Herston, Queensland, Australia
| | | | | | | | - James Shao
- Lyra Therapeutics, Inc., Watertown, Massachusetts, USA
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Chua AJ, Francesco VD, Huang D, D'Souza A, Bleier BS, Amiji MM. Nanotechnology-enabled topical delivery of therapeutics in chronic rhinosinusitis. Nanomedicine (Lond) 2023; 18:1399-1415. [PMID: 37800470 DOI: 10.2217/nnm-2023-0072] [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: 10/07/2023] Open
Abstract
Chronic rhinosinusitis (CRS) is a chronic inflammatory disease of the paranasal sinuses which represents a significant health burden due to its widespread prevalence and impact on patients' quality of life. As the molecular pathways driving and sustaining inflammation in CRS become better elucidated, the diversity of treatment options is likely to widen significantly. Nanotechnology offers several tools to enhance the effectiveness of topical therapies, which has been limited by factors such as poor drug retention, mucosal permeation and adhesion, removal by epithelial efflux pumps and the inability to effectively penetrate biofilms. In this review, we highlight the successful application of nanomedicine in the field of CRS therapeutics, discuss current limitations and propose opportunities for future work.
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Affiliation(s)
- Andy J Chua
- Department of Pharmaceutical Sciences, School of Pharmacy & Pharmaceutical Sciences, Northeastern University, 360 Huntington Avenue, Boston, 140 The Fenway Building, MA 02115, USA
- Department of Otolaryngology, Massachusetts Eye & Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA
- Department of Otorhinolaryngology - Head & Neck Surgery, Sengkang General Hospital, 110 Sengkang E Way, 544886, Singapore
| | - Valentina Di Francesco
- Department of Pharmaceutical Sciences, School of Pharmacy & Pharmaceutical Sciences, Northeastern University, 360 Huntington Avenue, Boston, 140 The Fenway Building, MA 02115, USA
| | - Di Huang
- Department of Pharmaceutical Sciences, School of Pharmacy & Pharmaceutical Sciences, Northeastern University, 360 Huntington Avenue, Boston, 140 The Fenway Building, MA 02115, USA
- Department of Otolaryngology, Massachusetts Eye & Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA
| | - Anisha D'Souza
- Department of Pharmaceutical Sciences, School of Pharmacy & Pharmaceutical Sciences, Northeastern University, 360 Huntington Avenue, Boston, 140 The Fenway Building, MA 02115, USA
- Department of Otolaryngology, Massachusetts Eye & Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA
| | - Benjamin S Bleier
- Department of Otolaryngology, Massachusetts Eye & Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA
| | - Mansoor M Amiji
- Department of Pharmaceutical Sciences, School of Pharmacy & Pharmaceutical Sciences, Northeastern University, 360 Huntington Avenue, Boston, 140 The Fenway Building, MA 02115, USA
- Department of Chemical Engineering, College of Engineering, Northeastern University, 360 Huntington Avenue, 140 The Fenway Building, Boston, MA 02115, USA
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Gershnabel Milk D, Lam KK, Han JK. Corticosteroid-eluting implants for the management of chronic rhinosinusitis with or without nasal polyps. Expert Rev Clin Immunol 2023; 19:831-836. [PMID: 36996022 DOI: 10.1080/1744666x.2023.2198211] [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: 01/28/2023] [Accepted: 03/29/2023] [Indexed: 03/31/2023]
Abstract
INTRODUCTION Topical corticosteroid therapies are the most popular prescribed medications for patients with chronic rhinosinusitis (CRS). While topical corticosteroids effectively reduce the inflammatory burden associated with CRS, their distribution inside the nasal cavity is limited and primarily dependent on their delivery device. Corticosteroid-eluting implants serve as relatively novel technology, allowing targeted, sustained release of a high concentration of corticosteroids directly onto the sinus mucosa. Three types of corticosteroid-eluting implants can be characterized: 1. intraoperatively inserted corticosteroid-eluting sinus implants, 2. postoperatively inserted, office-based corticosteroid-eluting sinus implants, and 3. office-based corticosteroid-eluting implants for naïve paranasal sinuses. AREAS COVERED The review summarizes the different steroid-eluting sinus implants, their indications for use in CRS patients, and the existing evidence regarding their clinical efficacy. We also highlight potential areas for improvement and development. EXPERT OPINION Corticosteroid-eluting sinus implants highlight an evolving field that is constantly investigating and adding new treatment options to the market. Presently, corticosteroid-eluting implants for CRS are most commonly applied intraoperatively and postoperatively with endoscopic sinus surgery, providing significant improvements in mucosal healing and reducing the amount of surgical failures. Future development around corticosteroid-eluting implants should focus on strategies to reduce the amount of crusting around the implants.
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Affiliation(s)
- Dafna Gershnabel Milk
- Divisions of Rhinology, Endoscopic Skull Base Surgery, Department of Otolaryngology - Head Neck Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Kent K Lam
- Divisions of Rhinology, Endoscopic Skull Base Surgery, Department of Otolaryngology - Head Neck Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Joseph K Han
- Divisions of Rhinology, Endoscopic Skull Base Surgery, Department of Otolaryngology - Head Neck Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
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Naclerio R, Mullol J, Stevens WW. A Decade of Clinical Advances in Chronic Rhinosinusitis: 2012-2022. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:43-50. [PMID: 36610759 DOI: 10.1016/j.jaip.2022.10.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/21/2022] [Accepted: 10/21/2022] [Indexed: 01/07/2023]
Abstract
The field of chronic rhinosinusitis (CRS) is constantly evolving. In the past 10 years, key advancements in basic and translational research as well as clinical studies have improved our understanding and management of CRS. Notably, treatment options have expanded to include novel therapeutic drugs, devices, and surgical techniques. Assessments of patient symptoms and their impact on quality of life have become more standardized. Progress has also been made in both determining the true prevalence of CRS and recognizing comorbidities that can impact CRS severity. Practice guidelines have also shifted from expert opinion to more data-driven analyses. This review highlights major clinical advancements made in the field of CRS over the past 10 years as well as identifies current gaps in knowledge that can form the basis for new areas of study over the next decade.
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Affiliation(s)
- Robert Naclerio
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Md
| | - Joaquim Mullol
- Rhinology Unit and Smell Clinic, Department of Otorhinolaryngology, Hospital Clinic Barcelona, University of Barcelona; Clinical and Experimental Respiratory Immunoallergy, Institute of Biomedical Investigations 'August Pi i Sunyer' (IDIBAPS) Centre for Biomedical Investigations in Respiratory Diseases (CIBERES), Institute of Health Carlos III, Barcelona, Catalonia, Spain
| | - Whitney W Stevens
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill.
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Ow RA, Shotts S, Kakarlapudi V, McIntyre J, Naclerio RM, You C, Pappas A, Brayton L, Kuang Y, Shao J. Pharmacokinetic Evidence of Steady and Sustained Drug Release from Long-Acting Implantable Corticosteroid Matrices for Chronic Rhinosinusitis. Am J Rhinol Allergy 2022; 36:733-740. [PMID: 35708181 PMCID: PMC9549255 DOI: 10.1177/19458924221107200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background The efficacy of topical corticosteroids is limited in chronic rhinosinusitis
(CRS) due to rapid clearance from the nasal cavity and insufficient drug
delivery to inflamed sinonasal passages. LYR-210 is an implantable
corticosteroid matrix designed to provide up to 24 weeks of treatment to
patients with CRS by locally delivering mometasone furoate (MF) to the
sinonasal mucosa. In a randomized, controlled, dose-ranging LANTERN study,
LYR-210 (7500 µg) achieved clinically relevant improvement in CRS cardinal
symptom composite scores, the 22-item Sinonasal Outcome Test (SNOT-22),
ethmoid opacification, and the need for rescue treatment at 24 weeks. Objective As the plasma MF concentrations of LYR-210 (2500 µg) and LYR-210 (7500 µg)
were evaluated at weeks 4, 12, and 24 in the LANTERN study (data on file at
Lyra Therapeutics, Inc.), this study aims to characterize the
pharmacokinetic profiles of both doses of LYR-210 at earlier timepoints
post-placement in patients with CRS. Methods Twenty-four surgically naïve adult patients with CRS were enrolled in an
open-label, multicenter study and underwent in-office bilateral
administration of LYR-210 (2500 µg) (n = 12 patients) or
LYR-210 (7500 µg) (n = 12 patients) into the middle meatus.
Plasma MF concentrations were determined pre-placement and 1-h
post-placement (day 1), and on days 2, 3, 7, 14, 21, 28, 42, and 56 by
liquid chromatography-tandem mass spectrometry. Results Both LYR-210 doses were well-tolerated with no serious adverse events.
Systemic MF levels were dose-dependent and lower than reported values of
other respiratory MF products. Plasma MF concentrations showed steady drug
release from LYR-210 (2500 µg) and LYR-210 (7500 µg) that persisted through
day 56. Conclusion LYR-210 achieved dose-dependent, continuous local MF delivery at a steady
rate with low systemic exposure for months.
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Affiliation(s)
- Randall A Ow
- Sacramento Ear, Nose, and Throat, Roseville, California
| | | | | | | | | | | | | | | | - Yina Kuang
- Lyra Therapeutics, Inc., Watertown, Massachusetts
| | - James Shao
- Lyra Therapeutics, Inc., Watertown, Massachusetts
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