What is the role of long-term macrolide therapy in the treatment of recalcitrant chronic rhinosinusitis?

The effects of erythromycin towards the treatment of persistent rhinosinusitis after functional endoscopic sinus surgery: A randomized, active comparator-controlled study

BACKGROUND

Long-term, low-dose macrolide treatment has been in recent use to treat chronic rhinosinusitis. In this study, we investigated the effect of long-term, low-dose erythromycin on patients who had persistent rhinosinusitis after functional endoscopic sinus surgery (FESS).

METHODS

Patients with persistent rhinosinusitis for 3 months after FESS were recruited and randomly assigned to two groups. Patients in the erythromycin group took erythromycin (250 mg twice a day) for 12 weeks, while those in the intranasal steroid group were administered with mometasone furoate nasal spray for 12 weeks. Both before and after treatment, sino-nasal symptoms were assessed via questionnaires. Patients also received an endoscopic examination, acoustic rhinometry, smell test, and saccharine transit test. A bacterial culture was obtained from the middle meatus.

RESULTS

Seventy-two patients completed the study, with 35 in the erythromycin group and 37 in the intranasal steroid group. Endoscopic scores decreased significantly after treatment in both groups. Erythromycin improved the smell threshold and saccharine transit time better than the intranasal steroid. In contrast, the intranasal steroid increased the second minimal cross-sectional area of the nasal cavity at a level greater than erythromycin had.

CONCLUSION

Our study showed that long-term, low-dose erythromycin treatment improved the endoscopic score, smell threshold, and saccharine transit time in patients with persistent rhinosinusitis after FESS.

Topical Therapies for Refractory Chronic Rhinosinusitis

Topical therapy has become an important tool in the otolaryngologist's armamentarium for refractory chronic rhinosinusitis (CRS). Daily high-volume sinonasal saline irrigation and standard metered-dose topical nasal steroid therapy are supported by the most evidence. Nonstandard topical sinonasal steroid therapies are a potential option for refractory CRS. Current evidence recommends against the use of topical antifungal therapy and topical antibiotic therapy delivered using spray and nebulized techniques in routine cases of CRS. Stents are a new modality with preliminary data showing they are an option when traditional treatment has failed. Further research with long-term effects and outcomes studies for refractory CRS are needed.

Bactericidal antibiotics promote reactive oxygen species formation and inflammation in human sinonasal epithelial cells

BACKGROUND

Bactericidal antibiotics have been shown to stimulate reactive oxygen species (ROS) formation in mammalian cells through mitochondrial dysfunction. This results in oxidative tissue damage that may have negative consequences for long-term antibiotic use. Antibiotics are widely and heavily used in the treatment of acute and chronic sinusitis; however, the relationship between antibiotics and ROS formation in sinonasal epithelial cells (SNECs) has not yet been demonstrated.

METHODS

Human SNECs were collected from patients during endoscopic sinus surgery and grown in culture at the air-liquid interface. Differentiated SNECs were stimulated with the bactericidal antibiotics amoxicillin and levofloxacin and the bacteriostatic antibiotic clarithromycin for 24 hours. ROS were quantified via fluorescence. Cell death was quantified by lactate dehydrogenase (LDH) secretion. Expression of inflammatory markers such as tumor necrosis factor α (TNF-α) and nuclear factor erythroid 2-related factor 2 (Nrf2)-mediated antioxidant genes were measured by real-time polymerase chain reaction (RT-PCR).

RESULTS

Cultured SNECs treated with the bactericidal antibiotics amoxicillin and levofloxacin resulted in a significant increase in production of ROS (p < 0.05) and secretion of LDH (p < 0.05). The increase in ROS formation correlated with an increase in expression of Nrf2-mediated antioxidant genes as well as the expression and production of proinflammatory cytokine TNF-α, and interleukin 1 β (IL-1β) (p < 0.05). SNECs treated with clarithromycin did not demonstrate statistically significant increases in ROS or proinflammatory cytokine production.

CONCLUSION

In this study, we show that treatment of cultured human SNECs with bactericidal antibiotics leads to formation of ROS with an associated increase in inflammatory and antioxidant gene expression and cell death. This suggests that long-term or inappropriate antibiotic use in the treatment of sinusitis may result in oxidative tissue damage to the sinonasal epithelium. Future studies will explore the clinical implications of such damage to the sinonasal epithelium.

What is the proper role of oral antibiotics in the treatment of patients with chronic sinusitis?

PURPOSE OF REVIEW

Chronic rhinosinusitis is a common illness for which systemic antibiotics are frequently prescribed, although high-level evidence for this practice is largely lacking. We review the available literature addressing the proper role of oral antibiotics in the treatment of chronic rhinosinusitis.

RECENT FINDINGS

Chronic rhinosinusitis is an incompletely understood disease process for which the role of antibiotics remains difficult to define despite its historical prominence. There is no high-level evidence to support the use of oral antibiotics in chronic rhinosinusitis. Placebo-controlled studies of macrolide antibiotics indicate either no effect or limited degrees of improvement. Recent literature has identified that sinusitis refractory to medical therapy may represent an odontogenic source, and this should be addressed by dental surgery rather than by additional antibiotics.

SUMMARY

Oral antibiotics can be prescribed most confidently for the management of chronic rhinosinusitis when purulent exacerbations of disease are detected endoscopically and antibiotic choices are directed by culture. Long-term macrolide antibiotic therapy, acting through immunomodulatory pathways, may be of benefit in chronic rhinosinusitis patients with low immmunoglobulin E levels. Odontogenic sources of sinusitis are best detected by a computed tomography scan and treated through dental surgery. There is no high-level experimental evidence to support the use of oral antibiotics in the management of chronic rhinosinusitis. The challenge continues to be the inability to perform double-blinded studies, as both patients and physicians are generally unwilling to participate in chronic sinusitis treatment studies with a placebo arm, given the deep-seated belief of oral antibiotic efficacy in treatment.

Topical therapies in the management of chronic rhinosinusitis: an evidence-based review with recommendations

BACKGROUND

Topical therapies have become an integral component in the management plan for chronic rhinosinusitis (CRS). Several topical therapy strategies have been evaluated, but a formal comprehensive evaluation of the evidence has never been performed. The purpose of this article is to provide an evidence-based approach for the utilization of topical therapies in the management of CRS.

METHODS

A systematic review of the literature was performed and the guidelines for development of an evidence-based review with recommendations were followed. Study inclusion criteria were: adult population >18 years old; chronic rhinosinusitis (CRS) based on published diagnostic criteria; and clearly defined primary clinical end-point. We focused on reporting higher-quality studies (level 2b or higher), but reported on lower-level studies if the topic contained insufficient evidence. We excluded drug-eluting spacer and stent therapy from this review.

RESULTS

This review identified and evaluated the literature on 5 topical therapy strategies for CRS: saline irrigation, topical steroid, topical antibiotic, topical antifungal, and topical alternatives (surfactant, manuka honey, and xylitol irrigations).

CONCLUSION

Based on the available evidence, sinonasal saline irrigation and standard topical nasal steroid therapy are recommended in the topical treatment of CRS. Nonstandard (off-label) topical sinonasal steroid therapies can be an option for managing CRS. The evidence recommends against the use of topical antifungal therapy and topical antibiotic therapy delivered using nebulized and spray techniques in routine cases of CRS. There is insufficient clinical research to provide recommendations for alternative therapies or topical antibiotic therapy delivered using other delivery methods (eg, irrigations).

Efficacy of Chinese Herbal Medicine Compared with a Macrolide in the Treatment of Chronic Rhinosinusitis without Nasal Polyps

Background

This study was designed to examine the efficacy of Chinese herbal medicine (CHM) in the treatment of chronic rhinosinusitis (CRS) without nasal polyps.

Methods

Patients with CRS without nasal polyps were enrolled in the study. Before treatment, they were evaluated by the Taiwanese version of the 20-item Sino-Nasal Outcome Test (TWSNOT-20), nasal endoscopy, saccharin test, and bacterial culture. Then, they were randomized to take CHM (Tsang-Erh-San extract granules and Houttuynia extract powder) or erythromycin for 8 weeks. After treatment, they were evaluated again by the TWSNOT-20, nasal endoscopy, saccharin test, and bacterial culture.

Results

Fifty-three patients completed the study with 26 in the CHM group and 27 in the erythromycin group. In both the CHM and the erythromycin groups, TWSNOT-20 scores significantly decreased after treatment, but the decrease was not significantly different between the two groups. However, the saccharin transit times were shortened in more patients in the CHM group than in patients in the erythromycin group.

Conclusion

Our results showed CHM had an efficacy similar to that of macrolides in the treatment of CRS without nasal polyps. However, a placebo effect remained possible in both treatment groups.

Modified endoscopic medial maxillectomy for recalcitrant chronic maxillary sinusitis

BACKGROUND

Modified endoscopic medial maxillectomy (MEMM) is an accepted alternative treatment for benign sinonasal neoplasms. Its use as definitive treatment for inflammatory disease of the maxillary sinus has yet to be adequately explored. We evaluate the efficacy of MEMM for chronic maxillary sinusitis and attempt to identify factors that predispose patients for failure.

METHODS

A retrospective chart review of 46 patients who underwent a total of 61 medial maxillectomies for recurrent chronic maxillary sinusitis from 2003 to 2010 was performed. Data was collected regarding patient demographics, prior therapies, and exudative cultures.

RESULTS

Complete resolution of disease was achieved in 37 of 46 patients (80%). Four patients required additional topical medical management prior to resolution of their inflammatory disease. When the culture was negative, resolution of disease was seen in 90% of patient. However if P. aeruginosa was cultured, the rate of disease resolution dropped to 75%. Similarly if S. aureus was culture, only 56% of patient demonstrated complete disease resolution. Of patients who had previous Caldwell-Luc procedures, 73% were successfully salvaged. No revision surgeries were required. The mean follow-up time was 35 months.

CONCLUSION

MEMM is an effective and acceptable alternative treatment for chronic maxillary sinusitis refractory to standard medical treatment and endoscopic surgical treatment. Cultures positive for P. aeruginosa and S. aureus may be associated with worse outcomes.

Controversies in the treatment of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) including nasal polyps is a chronic inflammatory disease involving the mucosa of the nose and one or more paranasal sinuses. Despite differing hypotheses, the cause remains poorly understood. The key issue is the maintaining of ostial patency. CRS with nasal polyps is considered to be a subgroup of CRS. Major symptoms are nasal congestion or blockage, loss of smell, rhinorrhea, post-nasal drip, and facial pain or pressure. CRS is associated with lower airway disease such asthma, chronic obstructive pulmonary disease and bronchiectasis. In CRS with and without nasal polyps, medical treatment, including nasal and oral corticosteroids, is the first therapeutic option. The treatment of CRS still remains an unmet need. Corticosteroids are the mainstay of treatment and are the most effective drugs for treating airway inflammatory diseases such as asthma, allergic rhinitis and CRS. Endoscopic sinus surgery is only recommended when medical treatment fails. After surgery, medical treatment, including nasal and oral corticosteroids, is recommended.