Maximal medical therapy for chronic rhinosinusitis

Advancements in acoustic drug delivery for paranasal sinuses: A comprehensive review

Chronic rhinosinusitis (CRS) impacts patients' quality of life and healthcare costs. Traditional methods of drug delivery, such as nasal sprays and irrigation, have limited effectiveness. Acoustic Drug Delivery (ADD) using a nebulizer offers targeted delivery of drug to the sinuses, which may improve the treatment of CRS. This review examines the influence of aerosol particle characteristics, aero-acoustic parameters, inlet flow conditions, and acoustic waves on sinus drug delivery. Key findings reveal that smaller particles improve the ADD efficiency, whereas larger sizes or increased density impair it. The oscillation amplitude of the air plug in the ostium is crucial for the ADD efficiency. Introducing acoustic waves at the NC-sinus system's resonance frequency improves aerosol deposition within sinuses. Future research should address advanced models, optimizing particle characteristics, investigating novel acoustic waveforms, incorporating patient-specific anatomy, and evaluating long-term safety and efficacy. Tackling these challenges, ADD could offer more effective and targeted treatments for sinus-related conditions such as CRS.

Comparison Between Effectiveness of Topical Mometasone Furoate Nasal Spray Versus Topical Fluticasone Furoate Nasal Spray in the Treatment of Chronic Rhinosinusitis: A One Year Hospital Based Study

To compare the effectiveness between topical mometasone furoate nasal spray versus topical fluticasone furoate nasal spray in the treatment of chronic rhinosinusitis. Randomized control trial was conducted involving 70 patients. One group received topical mometasone furoate nasal spray and the other group received fluticasone furoate nasal spray for 3 weeks. All patients were prescribed oral ciprofloxacin for 3 weeks and were subjectively evaluated using the Lund and Mackay staging system and objectively using nasal endoscopy by the Lund and Kennedy scoring system. There was no inter group significance but all patients improved significantly after the administration of either of the steroid sprays. Following administration of steroid nasal sprays, there was clinically significant improvement in the symptoms and signs of chronic rhinosinusitis, but there was no statistical significance between the two study groups. Thus, steroid nasal sprays significantly improve the symptoms and resolution of signs of chronic rhinosinusitis. The choice of drug still remains uncertain to the clinician. However, long term studies with more sample size is needed to arrive at sound conclusions.

Is there a role for antibiotics in the treatment of chronic rhinosinusitis?

Rhinosinusitis is one of the most common reasons for adult outpatient antibiotic prescriptions, though there is little clinical evidence to support this practice, especially for chronic rhinosinusitis. Despite considerable research, the etiology of chronic rhinosinusitis, including the pathogenic role of microbes, remains poorly understood. Rigorous studies of the efficacy of antibiotic treatment of chronic sinusitis are surprisingly few in number and the results are somewhat conflicting. This review article will review the rationales for and against the treatment of chronic rhinosinusitis with antibiotics, based on current evidence and understanding of pathophysiology, and will also summarize the current guidelines.

Prevalence and clinical presentation of sinusitis in pediatric age group in Aseer, Saudi Arabia

Background:

Paediatric rhinosinusitis is mostly different than that in adults. More frequently, children presented with cough, bad breath, crankiness, low energy, and swelling around the eyes, besides a thick yellow-green nasal or post-nasal discharge. About 5- 13% of childhood viral upper respiratory tract infections may advance to acute rhinosinusitis, with some of them developing a chronic condition.

Aim:

To assess prevalence and clinical presentation of sinusitis in the paediatric age group in Aseer, Saudi Arabia.

Methodology:

A retrospective record-based study was conducted in Abha Maternity and Children Hospital in Abha city, Saudi Arabia between January 2015 and January 2018. All medical records during the study period for children whose from to 15 years old attended the hospital and diagnosed as having sinusitis were included.

Results:

The study included 100 children with complete files whose ages ranged from less than 1 year to up to 13 years old with a mean age of 5.3 4.2 years. Nearly 51% of the children aged 4 years or less and male were 53 (53%). Past history for chronic rhinosinusitis (CRS) was positive among 30 children. Regarding clinical presentations of rhinosinusitis (RS) as reported by the children caregivers, fever was the most reported complaint (50%) followed by red eye (44%), ringing nose (42%), cough (41%) and headache (36%). Mucous culture was positive among 58 cases. The most isolated pathogens were streptococcus pneumoniae (45.6%), Haemophilis influenza (24.6%).

Conclusions:

In conclusion, the study revealed that CRS is a common disease in children at different ages, especially, maxillary and frontal sinuses. In most of the cases, medical treatment is highly appreciated; though, surgical intervention may be needed in a small percentage.

Chronic rhinosinusitis with nasal polyps management in the age of biologics

Background: Chronic rhinosinusitis is one of the most common medical conditions seen in the U.S. population. Chronic rhinosinusitis with nasal polyps (CRSwNP) in adults has predominately a type 2 inflammatory endotype that usually is treated with medical management that consists of inhaled corticosteroids, saline solution irrigation, oral corticosteroid bursts, and, at times, leukotriene antagonists and antibiotics. If medical management fails, then surgical intervention is usually recommended. Various biologics that target type 2 inflammation are now available, which have been or will be approved for use in these patients. Objective: To determine where biologics that affect the type 2 pathway fit into the algorithm of treatment for CRSwNP. Methods: A review of the literature on standard-of-care measures and surgical interventions in CRSwNP and an analysis of recent studies on the efficacy and safety of biologics in this condition. Results: Standard of care with medication and surgical interventions fail in some patients with CRSwNP. Biologics that affect the type 2 inflammatory pathway led to a decrease in nasal polyp size, improved nasal congestion, and improved quality of life both in patients who had surgery and those who had not had surgery for CRSwNP. Also, they showed efficacy and safety in patients whether or not they had comorbid asthma. These agents do not cure the patient with CRSwNP, and will be required chronically for control. Conclusion: Shared decision-making should be used in determining the use of certain medications, surgical management, and biologics in patients with CRSwNP. In patients for whom surgery has already failed and in patients with moderate-to-severe CRSwNP who have other type 2 comorbidities, e.g., asthma, a trial of biologics is a rational course.

Oral Corticosteroid Regimens in the Management of Chronic Rhinosinusitis

BACKGROUND

Oral corticosteroids are often used in the medical management of chronic rhinosinusitis (CRS) with and without polyps. The purpose of our study is to review the literature for studies reporting the dosage of oral corticosteroids as part of the appropriate medical management prior to, immediately before, and after surgical intervention.

METHODS

We reviewed the literature for oral corticosteroid regimens given to patients with CRS from March 2012 to September 2018. Studies that did not disclose the exact doses of the regimen were excluded from our analysis.

RESULTS

Our search resulted in 7 articles with 4 studies of Level of Evidence (LOE) 1b, 2 studies with LOE III, and 1 study with LOE IV. The daily doses varied from 15 mg to 1 mg/kg, and with total doses ranging from 150 to 352 mg. In addition, several studies gave the same regimen to both subtypes of CRS. There was no mention of side effects in most of the studies.

CONCLUSION

There is a wide variation in the steroid doses given to patients with CRS and prospective or randomized controlled trials are needed to provide better improved evidence.

Chinese Society of Allergy and Chinese Society of Otorhinolaryngology-Head and Neck Surgery Guideline for Chronic Rhinosinusitis

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.

Appropriateness Criteria for Surgery in the Management of Adult Recurrent Acute Rhinosinusitis

OBJECTIVES/HYPOTHESIS

Endoscopic sinus surgery (ESS) is frequently performed for recurrent acute rhinosinusitis (RARS). Appropriate indications for surgery among patients with RARS have not yet been rigorously determined. The objective of this study was to define appropriateness criteria for ESS in the management of adult RARS.

STUDY DESIGN

Application of RAND-UCLA appropriateness methodology.

METHODS

A panel of nine multidisciplinary experts in RARS was formed to evaluate RARS scenarios generated from current evidence. The panel completed two rounds of a modified Delphi-ranking process and a teleconference.

RESULTS

A total of 32 clinical scenarios were ranked in each round. For adult patients with RARS, ESS can appropriately be offered as a treatment option when patients experience ≥ four annual episodes, and there is confirmation of at least one episode via computed tomography or nasal endoscopy, and the patient and clinician jointly participate in shared decision making, and the patient has either failed a trial of topical nasal steroids or experienced RARS-related productivity loss.

CONCLUSIONS

This study has defined appropriateness criteria for ESS as a management option for adult patients with RARS. These criteria are intended to represent a minimum threshold for which ESS should be considered in the treatment of RARS and do not suggest that all patients who meet these criteria should undergo surgery. These criteria may serve as a baseline set of indications for ESS in patients with RARS.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:37-44, 2019.

Effect on Quality Of Life of Patients Before and After Functional Endoscopic Sinus Surgery

Rhinosinusitis is defined as an inflammatory process involving the mucosa of the nose and one or more of the paranasal sinuses. Rhinosinusitis is not associated with increased mortality, but may have an impact on the quality of life (QOL). Current study is aimed at investigating the role of FESS in the enhancement of QOL of the patients with rhinosinusitis. Several instruments have been designed to assess the QOL, among which Glasgow Benefit Inventory (GBI) questionnaire, has been used in this study. This cross sectional study of duration of 1 year and 6 months was conducted on 30 patients between the age group 18-60 years in the Department of Otorhinolaryngology at Safdarjung Hospital in New Delhi. Our results showed that FESS was associated with improved QOL in patients with Chronic Sinusitis. Observations were made on the basis of the GBI questionnaire which is designed to measure outcomes of the surgical procedures in form of 4 different scores. Mean total score before surgery was (-) 65.28 ± 7.39 and after surgery was 21.22 ± 11.24. Mean general Subscale Score before surgery was (-) 60.56 ± 9.14 and after surgery was 25.28 ± 13.40. Mean Social Support Score before surgery was (-) 79.44 ± 14.31 and after surgery was 17.78 ± 16.34. Mean Physical Health score before surgery was (-) 70.00 ± 10.17 and after surgery 10.00 ± 14.25. A statistically significant improvement was observed in all the four scores before and after surgery. The present study demonstrates that radical surgery has led to improvement in the QOL of chronic rhinosinusitis.

American Rhinologic Society Member Survey on “Maximal Medical Therapy” for Chronic Rhinosinusitis

Background

“Maximal medical therapy” is the standard of care for chronic rhinosinusitis (CRS) treatment before the recommendation for surgery. However, this therapy is not consistent. Therefore, as a first step in determining the role of the disparate “maximal medical” treatments for CRS, American Rhinologic Society (ARS) members were surveyed.

Methods

A survey was mailed to all nonresident members of the ARS (n = 723). Focusing on the time period before surgical intervention is first considered for CRS patients, the survey assessed types of therapies, frequency of use, details on antibiotic and steroid usage, use of computed tomography (CT), and demographic data of respondents. All responses were anonymous.

Results

Three hundred eight surveys were returned (43%). A majority of respondents used oral antibiotics and nasal steroids “almost always (>90%).” Oral antibiotics, oral steroids, nasal steroids, saline irrigation, and allergy testing were most commonly used at least “usually (50–90%).” The median antibiotic length was 3.1–4 weeks. The mean peak prednisone dose was 51.7 mg when oral steroids were used. Therapies that were rarely or never used by the majority included oral antifungals, antifungal spray, antibiotic spray, antibiotic nebulizer, steroid nebulizer, and i.v. antibiotics.

Conclusion

Oral antibiotics (median, 3.1–4 weeks) and nasal steroids are used >90% of the time by a majority of ARS members for maximal medical treatment of CRS.

Economics of Chronic Rhinosinusitis

PURPOSE OF REVIEW

The objective of this article is to provide an updated review of the economic burden of chronic rhinosinusitis (CRS) and discuss how both medical and surgical interventions impact direct and indirect costs related to CRS. By understanding the economics of CRS, clinicians may improve the patient-centeredness of their care and help distinguish between low and high value interventions.

RECENT FINDINGS

Direct costs related to CRS are primarily driven by outpatient physician visits, prescription medical therapy, and endoscopic sinus surgery (ESS). CRS produces large indirect costs and these costs often vary based on the severity of the patients CRS-specific QoL impairment. The overall direct cost related to CRS is estimated to range between $10 and $13 billion per year in the USA. The overall indirect cost related to CRS-related losses in work productivity is estimated to be in excess of $20 billion per year. In the appropriate patients with refractory CRS, ESS provides significant reductions in both direct and indirect costs; however, continued medical therapy alone may be a high value intervention in select patients who have lower severity in their baseline QoL and work productivity.

Defining appropriateness criteria for endoscopic sinus surgery during management of uncomplicated adult chronic rhinosinusitis: a RAND/UCLA appropriateness study

BACKGROUND

Appropriate indications for endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) are currently poorly defined. The lack of clear surgical indications for ESS likely contributes to the large geographic variation in surgical rates and contributes to reduced quality of care. The objective of this study was to define appropriateness criteria for ESS during management of adult patients with uncomplicated CRS.

METHODS

The RAND/UCLA appropriateness methodology was performed. An international, multidisciplinary panel of 10 experts in CRS was formed and completed 2 rounds of a modified Delphi ranking process along with a face-to-face meeting.

RESULTS

A total of 624 clinical scenarios were ranked, 312 scenarios each for CRS with and CRS without nasal polyps. For adult patients with uncomplicated CRS with nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus a short-course of systemic corticosteroid with a post-treatment total SNOT-22 score ≥ 20. For adult patients with uncomplicated CRS without nasal polyps, ESS can be appropriately offered when the CT Lund-Mackay score is ≥ 1 and there has been a minimum trial of a topical intranasal corticosteroid plus either a short-course of a broad spectrum/culture-directed systemic antibiotic or the use of a prolonged course of systemic low-dose anti-inflammatory antibiotic with a post-treatment total SNOT-22 score ≥ 20.

CONCLUSION

This study has developed and reported of list of appropriateness criteria to offer ESS as a treatment "option" during management of uncomplicated adult CRS. The extent or technique of ESS was not addressed in this study and will depend on surgeon and patient factors. Furthermore, these criteria are the minimal threshold to make ESS a treatment "option" and do not imply that all patients meeting these criteria require surgery. The decision to perform ESS should be made after an informed patient makes a preference-sensitive decision to proceed with surgery. Applying these appropriateness criteria for ESS may optimize patient selection, reduce the incidence of unwarranted surgery, and assist clinicians in providing high-quality, patient-centered care to patients with CRS.

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.

When are we operating for chronic rhinosinusitis? A systematic review of maximal medical therapy protocols prior to endoscopic sinus surgery

BACKGROUND

Endoscopic sinus surgery (ESS) is considered a therapeutic option after failure of maximal medical therapy (MMT) for chronic rhinosinusitis (CRS). There is currently no consensus on the definition of MMT. The objective of this systematic review is to describe the various MMT criteria employed prior to considering ESS.

METHODS

A systematic review was performed using the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were adults with CRS based on guideline diagnostic criteria, enrolled to undergo ESS, and study publication within the last 5 years (January 1, 2009, to December 30, 2014). Studies were excluded if the study population included non-CRS indications for ESS. Primary outcome was the MMT criteria employed prior to considering a patient a candidate for ESS. A subgroup analysis was performed based on polyp status.

RESULTS

Of 387 reviewed studies, 21% reported MMT criteria. When reported, criteria included topical nasal corticosteroids (91% of studies) for a mean of 8 ± 8 weeks, oral antibiotics (89%) for 23 ± 8 days, systemic corticosteroids (61%) for 18 ± 12 days, saline irrigations (39%), oral antihistamines (11%), oral mucolytics (10%), and topical/oral decongestants (10%).

CONCLUSION

A minority of studies report MMT criteria used as the indication for ESS. When reported, the majority included an 8-week course of topical intranasal corticosteroids and 3-week course of oral antibiotics. Use of systemic corticosteroids did not differ based on polyp status. Because of variation in current MMT criteria, there is a need to develop standardized indications for ESS that will work to improve the appropriateness of care for patients with.

Effects of Fluticasone Furoate on Clinical and Immunological Outcomes (IL-17) for Patients With Nasal Polyposis Naive to Steroid Treatment

Objectives:

We investigated the effect of topical steroids on clinical outcomes and related immune response of chronic rhinosinusitis with nasal polyp (CRSwNP) patients and in eradicating some polyps. We want to explore a new potential mechanism linked to Th-17 cells.

Methods:

Prospective, double-blind, placebo-controlled studies with 24 allergic and nonallergic patients were randomized to either placebo or fluticasone furoate for 12 weeks. Assessment of clinical response, endoscopic score with biopsies of the inferior turbinate, and polyps before and after treatment were performed. Biopsies were stained for T-cells, eosinophils, neutrophils, and IL-17A/F.

Results:

Steroid treatment improved the mean symptoms scores from 7.12 to 4.02 ( P < .01) and the polyp score from 5.13 to 3.31 ( P < .05), but the comparison with placebo was not statistically significant in nonallergics due to insufficient study power. Steroid treatment decreased eosinophil counts on allergics but not neutrophils or T-cells. The IL-17A/F expression was higher in nonallergics with high neutrophil counts and was inclined by steroids. Compared to baselines, IL-17 cells were significantly less in allergic individuals and were not observed in allergics and with high neutrophil counts.

Conclusion:

Topical steroids were more effective on certain nasal polyp phenotypes. Identification of polyp phenotype might be essential to ensure a better therapeutic response to intranasal corticosteroids.

Topical therapy with high-volume budesonide nasal irrigations in difficult-to-treat chronic rhinosinusitis

INTRODUCTION

Chronic rhinosinusitis (CRS) is termed difficult-to-treat when patients do not reach acceptable level of control despite adequate surgery, intranasal corticosteroid treatment and up to 2 short courses of systemic antibiotics or corticosteroids in the preceding year. Recently, high-volume corticosteroid nasal irrigations have been recommended for CRS treatment.

OBJECTIVE

To assess high-volume budesonide nasal irrigations for difficult-to-treat CRS.

METHODS

Prospective uncontrolled intervention trial. Participants were assessed before- and 3 months after nasal irrigation with 1mg of budesonide in 500 mL of saline solution daily for 2 days. Subjective (satisfactory clinical improvement) and objective (SNOT-22 questionnaire and Lund-Kennedy endoscopic scores) assessments were performed.

RESULTS

Sixteen patients were included, and 13 (81.3%) described satisfactory clinical improvement. SNOT-22 mean scores (50.2-29.6; p=0.006) and Lund-Kennedy mean scores (8.8-5.1; p=0.01) improved significantly. Individually, 75% of patients improved SNOT-22 scores, and 75% improved Lund-Kennedy scores after high volume budesonide nasal irrigations.

CONCLUSION

High-volume corticosteroid nasal irrigations are a good option in difficult-to-treat CRS control of disease, reaching 81.3% success control and significant improvement of SNOT-22 and Lund-Kennedy scores.

Sinonasal epithelial cell response to Staphylococcus aureus burden in chronic rhinosinusitis

IMPORTANCE

Chronic rhinosinusitis (CRS) is an inflammatory disorder of the nose and paranasal sinuses. Staphylococcus aureus is increasingly linked with CRS exacerbations. Little is known about how bacteria activate inflammatory pathways that contribute to CRS.

OBJECTIVE

To develop an in vitro coculture system to explore how infection with S aureus stimulates innate immune responses of sinonasal epithelial cells (SNECs).

DESIGN, SETTING, AND PARTICIPANTS

Sinonasal epithelial cells were collected from 13 patients during endoscopic sinus surgery and grown in culture at the air-liquid interface from July 2014 through December 2014.

INTERVENTIONS

Differentiated SNECs from control individuals, patients with CRS with nasal polyps (CRSwNPs), and patients with CRS without nasal polyps (CRSsNPs) were infected with S aureus at 3 different concentrations for 24 hours.

MAIN OUTCOMES AND MEASURES

Growth of S aureus and viability of SNECs were measured. Expression of inflammatory markers and innate immune genes was measured by reverse transcription-polymerase chain reaction. Basal secretion of interleukin 8 was determined by enzyme-linked immunosorbent assay.

RESULTS

Cultured SNECs from patients with CRSsNPs demonstrated a significant increase (P < .05) in expression of interleukin 8 (23-fold to 82-fold) and tumor necrosis factor (11-fold to 61-fold) at all the tested concentrations of S aureus. Control or CRSwNP SNECs demonstrated a significant increase (P < .05) in expression of interleukin 8 (47-fold and 50-fold, respectively) and tumor necrosis factor (106-fold and 58-fold, respectively) at the higher inoculum of S aureus. Basal secretion of inflammatory markers correlated with expression changes. No significant changes in expression were observed for the helper T cell, subtype 2, inflammatory mediators tested.

CONCLUSIONS AND RELEVANCE

In this study, we developed a model to study early innate immune-mediated changes in SNECs cocultured at an air-liquid interface with bacteria. We also demonstrated that bacterial burden can be detected by SNECs in the absence of adaptive immune-mediated responses. The CRSsNP SNECs are more sensitive to S aureus burden than control or CRSwNP SNECs. Future studies will further develop this infection model and explore the SNEC innate immune response to bacteria.

Cost efficient workup and management of patients with chronic rhinosinusitis - challenges and unmet needs

Chronic rhinosinusitis (CRS) is a common disease, estimated to occur in 12-16% of the United States population. This prevalence creates a significant health burden with an estimated 15 million ambulatory visits for the condition annually. Consequently, practice guidelines have been designed to assist both the primary care provider and specialist in establishing a CRS diagnosis and prescribing effective treatment for CRS. The guidelines for CRS diagnosis have evolved since the United States Rhinosinusitis Task Force first published its symptom-based guidelines in 1997. Contemporary practice guidelines still require 12 weeks of appropriate symptoms, but now include corroboration of objective sinonasal inflammation demonstrated on physical exam, imaging, or endoscopy to arrive at a CRS diagnosis. While these diagnostic criteria are seemingly straightforward and are regarded as the gold standard for the diagnosis, the appropriate timing of imaging and endoscopy remain unspecified and continue to present challenges for both primary care and specialty providers. These considerations have to be measured by the direct and indirect costs of the diagnostic workup including office visits, CT scanning, endoscopy, as well as the potential for overuse of treatment modalities such as antibiotics and steroid medications. The goal of this review is to update the primary care provider and otolaryngologist on current evidence regarding the diagnosis and treatment of chronic rhinosinusitis, including the costs and timing of endoscopy and imaging.

In-office use of a steroid-eluting implant for maintenance of frontal ostial patency after revision sinus surgery

Achieving long-term, successful outcomes with endoscopic sinus surgery (ESS) can be challenging in patients with recalcitrant chronic rhinosinusitis (CRS). Local complications, including scar formation and ostial stenosis, can lead to recurrent blockage and subsequent relapse. The frontal sinus is particularly vulnerable to surgical failure given its narrow outflow and inaccessibility to topical therapies. The advent of steroid-eluting sinus implants has enhanced ESS outcomes, with significant reductions in synechiae, inflammation, and secondary postoperative interventions when placed in the ethmoid cavity. However, use of this technology in the frontal sinus has yet to be described. The purpose of this report is to present two cases, in which in-office frontal placement of a mometasone furoate (MF)-eluting implant facilitated maintenance of ostial patency after revision ESS. The clinical presentation, in-office intervention, and treatment outcomes were examined. Two patients (male, 63 and 68 years of age) with a history of multiple ESS presented with recurrent unilateral frontal headache refractory to medical therapy. Nasal endoscopy/imaging revealed frontal sinus outflow obstruction. Both declined revision ESS under general anesthesia and underwent endoscopic frontal sinustomy/ostial dilation in the clinic. A MF-eluting implant was placed in the frontal sinus at the end of the procedure, with preservation of ostial patency upon last follow-up at 3 and 11 months, respectively. In-office placement of a MF-eluting implant successfully maintained frontal ostial patency in patients with a history of multiple ESS. Additional randomized trials are necessary to determine statistical significance, cost-effectiveness analysis, and long-term efficacy of frontal sinus implantation.

Complementary and integrative treatments: rhinosinusitis

Rhinosinusitis is characterized by inflammation of the mucosa involving the paranasal sinuses and the nasal cavity and is one of the most common health care problems, with significant impairment of quality of life. There is a growing amount of interest in the use of complementary and integrative medicine for the treatment of rhinosinusitis. This article focuses on an integrative approach to rhinosinusitis.

Maximal medical therapy for chronic rhinosinusitis: a survey of otolaryngology consultants in the United Kingdom

BACKGROUND

The management of chronic rhinosinusitis is based on a trial of "maximal medical therapy" before surgery is considered. Ear-Nose-Throat (ENT) UK consultant members were surveyed to determine the role and variability of UK-wide practices.

METHODS

A survey was posted to all ENT UK consultant members (n = 603). This assessed the frequency of prescription, duration, and type of oral antibiotics, steroids, and antihistamines for chronic rhinosinusitis.

RESULTS

A total of 158 questionnaires (26.3%) were returned. Of these, 61% were primarily rhinologists. The use of decongestants, antifungals, and immunotherapy was generally limited. Oral antibiotics were often used, with clarithromycin of <5 weeks duration being the preferred choice. Sixty-one percent of consultants always prescribe a steroid spray, most commonly mometasone furoate (75%).

CONCLUSION

Although most respondents use triple therapy of oral antibiotics, steroid nasal spray, and saline douching to some extent, "maximal medical therapy" for chronic rhinosinusitis seems to vary greatly among consultants and frequently does not reflect recent guidelines.

Concurrent rhinoplasty and endoscopic sinus surgery: a review of the pros and cons and a template for success

Historically concurrent FESS/rhinoplasty was avoided due to concerns of increased risk of complication. Recent studies have shown that FESS/rhinoplasty can be performed simultaneously with good outcomes and no significant increase in complications. A thorough and effective approach to the patient with sinonasal obstruction requires attention to aesthetic, functional, and inflammatory issues. Medical treatment is an important adjuvant to surgery in order to optimize outcomes by improving patient symptoms long-term. Surgery for these patients should be performed in a careful, stepwise approach to address the nasal septum, inferior turbinates, paranasal sinuses, and external nasal structures.

Efficacy of medical therapy in treatment of chronic rhinosinusitis

Uncomplicated chronic rhinosinusitis (CRS) is generally treated with medical therapy initially and surgery is contemplated only after medical therapy has failed. However, there is considerable variation in the medical treatment regimens used and studies defining their efficacy are few. The aim of this study was to determine the proportion of patients treated medically who responded sufficiently well so that surgery was not required. Subgroup analysis to identify clinical features that predicted a favorable response to medical therapy was also performed. Eighty patients referred to the Otorhinolaryngology Clinic at North Shore Hospital were treated with a standardized medical therapy protocol (oral prednisone for 3 weeks, oral antibiotics and ongoing saline lavage and intranasal budesonide spray). Symptom scores were collected before and after medical therapy. Clinical features such as presence of polyps, asthma, and aspirin hypersensitivity were recorded. Failure of medical therapy was defined as the persistence of significant CRS symptoms, and those patients who failed medical therapy were offered surgery. Follow-up data were available for 72 (90%) patients. Of this group, 52.5%, (95% CI, 42.7%, 62.2%) failed to respond adequately to medical therapy and were offered surgery. The remaining patients (37.5%) were successfully treated with medical therapy and did not require surgery at the time of follow-up. The premedical therapy symptom scores were significantly higher than the postmedical therapy symptom scores (p < 0.01). The symptom scores of those patients postmedical therapy who proceeded to have surgery were significantly higher than the group who responded well to maximum medical therapy (MMT) and did not require surgery (p < 0.0001). There were no significant differences in the proportion of patients with asthma, aspirin sensitivity, or polyps between the groups failing or not failing MMT. In approximately one-third of patients with CRS, medical therapy improved symptoms sufficiently so that surgical therapy was avoided. Patients with more severe symptoms tended not to respond as well as those with less severe symptoms. Long-term follow-up is required for the group of responders to determine how many will eventually relapse.

Quality of life in patients with chronic rhinosinusitis

Health-related quality of life (HRQoL) is a domain of quality-of-life assessment that is influenced by the individual's perception of his or her health status. Measurement of HRQoL can enable physicians to understand how an illness interferes with a patient's day-to-day life, improve patient-physician communication, and optimize clinical outcomes. Chronic rhinosinusitis (CRS) is one of the most common chronic diseases, affecting 14-16% of the adult US population. In addition to significant health care costs, CRS has been shown to substantially reduce HRQoL. In this review article, we discuss the definition and interpretation of HRQoL data and describe several validated rhinosinusitis HRQoL instruments. Additionally, we review how CRS functions to lower HRQoL and the effect of medical and surgical intervention on improving HRQoL status. By understanding the relationship between CRS and associated chronic conditions, clinicians can target their evaluation to problems that will maximize clinical success.

The Effects of Serum and Urinary Cortisol Levels of Topical Intranasal Irrigations with Budesonide Added to Saline in Patients with Recurrent Polyposis after Endoscopic Sinus Surgery

Background

The delivery of topical intranasal corticosteroid sprays has traditionally been the primary method of treating recurrent nasal polyposis. An emerging treatment for polyposis is budesonide nasal irrigations. Delivered at concentrations nearly 100 times greater than found in prescription nasal sprays, there have been little studies on the effects of budesonide irrigation on the adrenal axis. Therefore, we investigated whether irrigation with budesonide solution was associated with any increase in serum cortisol and 24-hour urinary cortisol levels.

Methods

Patients who previously had undergone endoscopic sinus surgery and were not taking prednisone for 3 months were prospectively enrolled in this study. Patients irrigated twice daily with 0.5 mg/2 mL of budesonide mixed with 240 mL of saline solution. Serum cortisol and 24-hour urinary cortisol were collected before drug administration and 6 weeks after continuous use.

Results

Ten patients completed this study. The average serum cortisol and 24-hour urinary cortisol before drug administration were 9.8 ± 5.4 μg/dL and 28.1 ± 15.1 μg/24 hours, respectively. After 6-week follow-up, the average serum cortisol and 24-hour urinary cortisol were 12.8 ± 3.5 μg/dL and 16.5 ± 5.6 μg/24 hours, respectively. Normal ranges for serum cortisol and 24-hour urinary cortisol are 5–25 μg/dL and 4–50 μg/24 hours, respectively. Conclusions: Irrigation with budesonide, 0.5 mg/2 mL, in 250 mL of saline solution does not result in decreases of serum cortisol and 24-hour urinary cortisol levels. Based on this, we feel irrigation with budesonide solution is safe to perform in patients as an alternative to traditional aerosolized steroid sprays or systemic corticosteroids.

Efficacy of targeted medical therapy in chronic rhinosinusitis, and predictors of failure

BACKGROUND

No standardized medical therapy for chronic rhinosinusitis (CRS) is universally accepted. Success of medical therapy is reportedly 50% to 88%, but studies differ in inclusion criteria, medications, duration of therapy, and defining "success." The objectives of this study were to determine efficacy of a standardized targeted medical therapy (TMT) regimen in CRS and to analyze factors associated with failure of therapy.

METHODS

Retrospective analysis of prospectively collected data was performed. CRS was diagnosed based on CRS Taskforce guidelines. TMT was defined as a minimum 4-week treatment with oral antibiotics, oral steroids, topical nasal steroids, topical nasal decongestant rotation, and saline nasal douching. "Failure" was defined as relapse/persistence of signs/symptoms or need for surgery. One hundred forty-five patients that received TMT, with a minimum 2-month follow-up, were identified. The results of therapy were reviewed to determine efficacy and analyze factors associated with failure.

RESULTS

Seventy-four patients (51.03%) were successfully treated. Failures included 26 patients (17.8%) with only partial improvement and 45 (31.03%) who underwent surgery. Only history of facial pressure/pain (p = 0.049), presence of mucosal inflammation (p = 0.013), and higher endoscopic severity grade (p = 0.011) were associated with failure of TMT.

CONCLUSIONS

TMT was unequivocally successful in 51% of patients. Failures included 31% who underwent surgery and 18% with partial benefit. Surgery was avoided in 69%. Facial pressure/pain, mucosal inflammation, and higher endoscopic severity grade were associated with failure of medical therapy.

Effects of intranasal steroid spray in bacterial culture of chronic rhinosinusitis

BACKGROUND

We attempted to determine whether use of a topical intranasal corticosteroid (INCS) preoperatively had an effect on bacterial culture and antibiotic sensitivity in chronic rhinosinusitis with nasal polyposis.

METHODS

In a prospective study, patients that were diagnosed with rhinosinusitis with nasal polyposis received INCS for one month before functional endoscopic sinus surgery. Bacterial culture testing, obtained under telescope from a source near the middle meatus, was performed before and after INCS. Antibiotic sensitivity was also performed.

RESULTS

One hundred fifty-six patients were enrolled in the prospective study, and 115 patients completed the procedures. The male-to-female ratio was 83:32 and the age range was 14 approximately 76 years (46.7 +/- 2.1). The positive culture rates were 80.9% and 79.1% pre-INCS treatment and post-INCS treatment, respectively. There was no significant difference between pretreatment and posttreatment samples in bacterial culture rate. The single bacterial culture rates were 66.7% and 65.9% pre-INCS treatment and post-INCS treatment, respectively. The drug sensitivities to oxacillin and cephaxolin showed no significant difference in coagulase negative Staphylococcus and Staphylococcus aureus.

CONCLUSION

INCS did not influence the rate of bacterial culture or antibiotic sensitivity in patients with chronic rhinosinusitis with nasal polyps.

Radiographic resolution of chronic rhinosinusitis without polyposis after 6 weeks vs 3 weeks of oral antibiotics

BACKGROUND

Maximal medical therapy is poorly defined in chronic sinusitis treatment.

OBJECTIVE

To objectively evaluate the radiographic response of chronic rhinosinusitis without polyposis after 3 and 6 weeks of oral antibiotics.

METHODS

Thirty-five patients with confirmed chronic sinusitis without polyposis (disease apparent on initial computed tomography [CT] with appropriate symptom duration) were prescribed 6 weeks of antibiotics. When possible, culture-directed antibiotics were used; otherwise clindamycin was used empirically. A CT was performed after 3 and 6 weeks of therapy. CTs were then graded by the Lund-Mackay system. Demographic data were reviewed.

RESULTS

Of the 35 patients, 16 underwent all 3 CT scans and completed all 6 weeks of antibiotics. Three patients completed only 3 weeks of antibiotics, and 16 did not undergo the interval 3-week CT. Six patients (38%) had statistically significant improvement in their CT scans between weeks 3 and 6. In this subset of patients who improved, 37% of their overall radiographic improvement occurred in the 3- to 6-week treatment interval. No prognostic variables predicted which patients would radiographically improve after 3 weeks of antibiotics.

CONCLUSION

Some patients achieve radiographic improvement and disease resolution after the completion of a 3-week course of antibiotics. Therefore, maximal medical therapy for chronic sinusitis may consist of longer than 3 weeks of therapy to ensure maximal benefit.