Quantification of Budesonide Retained in the Sinonasal Cavity After High-Volume Saline Irrigation in Post-Operative Chronic Rhinosinusitis

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.

Olfaction and Quality of Life in Patients with Eosinophilic CRS Undergoing Endoscopic Sinus Surgery

Introduction  Chronic rhinosinusitis (CRS) is a common inflammatory disease. This high prevalence leads to high direct and indirect public health costs, which include medical visits, laboratory tests and imaging, pharmacotherapy, hospitalizations, and surgical treatment. Furthermore, CRS has a substantial impact on patient quality of life, affecting productivity and being a common cause of absence from work CRS-associated olfactory dysfunction is highly prevalent, the actual effectiveness of surgical intervention remains inconsistent. Although there are studies evaluating the postoperative course of patients with eosinophilic Chronic rhinosinusitis (eCRS) treated with high-volume budesonide irrigation, there is little objective information regarding the impact of this intervention on olfactory status and quality of life. Objective  To conduct a pre- and postoperative analysis of olfaction and quality of life in patients with eCRS treated with surgical intervention followed by high-volume budesonide nasal irrigation. Methods  Prospective, descriptive, uncontrolled study of patients with eCRS. All patients underwent pre- and postoperative nasal endoscopy, SNOT-22 questionnaire, and the University of Pennsylvania Smell Identification Text (UPSIT), always by the same previously trained examiner. The SNOT-22 questionnaire and the UPSIT were readministered to all patients at 3 months, 6 months, and 1 year postoperatively, and scores compared with those obtained preoperatively. Results  Twenty patients were included in the study, 13 males and 7 females, between the ages of 23 and 65; 8 patients had comorbid asthma. Quantitative evaluation using the UPSIT test showed a significant improvement in olfaction 3 months after surgery, which remained 6 months and 1 year after surgery (p = 0.0063). There was no significant association between eosinophil concentrations in polypoid tissue and postoperative SNOT-22 and UPSIT results. Patients with tissue eosinophils >50 had a lower preoperative UPSIT score. As early as 3 months postoperatively, a significant improvement in quality of life was already noticeable, as represented by a decrease in SNOT-22 values, which persisted through the 1-year postoperative follow-up evaluation (p = 0.0005). Quantitative evaluation using the UPSIT test showed a significant improvement in olfaction 3 months after surgery, which remained 6 months and 1 year after surgery (p = 0.0063). Conclusion  Surgery effectively controlled eCRS in patients who adhered to high-volume budesonide nasal irrigation postoperatively. There were significant improvements in quality of life and olfaction, which persisted at least up to one year postoperatively.

Incidence of hypocortisolism with long-term budesonide irrigation for chronic rhinosinusitis

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.

Postoperative mometasone irrigations improve quality of life in skull base tumor patients

Objectives

The use of topical corticosteroids to manage postoperative sinonasal symptoms after endoscopic skull base surgery (ESBS) has not been well studied. We quantified long-term impact of postoperative steroid irrigations (SIs) on quality of life of patients after ESBS.

Methods

Retrospective review of patients at the University of Pennsylvania undergoing ESBS from 2010 to 2019. Data on patient demographics and postoperative treatment with nasal saline irrigation twice daily with and without dissolved steroids (mometasone or budesonide) was collected. Preoperative, and 1-, 3-, 6-, 12-, 18-, and 24-month postoperative Sino-Nasal Outcome Test (SNOT-22) scores were assessed.

Results

A total of 727 patients were assessed (53.4% males), with 479 patients in the no SI group and 248 patients in the SI group. Preoperative SNOT-22 scores did not differ significantly (P = 0.19). 1-, 3-, 6-, 12-, 18-, and 24-month post-op SNOT-22 scores did not significantly differ between groups. However, mometasone irrigations resulted in significantly lower postoperative 2-year SNOT-22 scores compared to budesonide (P < 0.01) and saline (P = 0.03).

Conclusions

Though corticosteroid irrigations are routine in managing inflammatory sinus disease, their role in postoperative management after ESBS for tumors is unclear. Our findings suggest that mometasone irrigation may be effective at improving postoperative quality of life in patients after ESBS.

Nasal sprays: commonly used medications that are often misunderstood

Sinonasal inflammatory disease is very common and all clinicians who care for these patients should understand the topical treatment options available. This article reviews the utility and application of steroidal, saline, decongestant, antihistamine and anticholinergic preparations for the treatment of sinonasal disease, with a particular focus on evidence-based guidelines for use in both specialist and non-specialist healthcare settings.

The Role of Corticosteroid Nasal Irrigations in the Management of Chronic Rhinosinusitis: A State-of-the-Art Systematic Review

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.

Review of evidence supporting the use of nasal corticosteroid irrigation for chronic rhinosinusitis

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.

Efficacy of Topical High Volume Budesonide Nasal Irrigation in Post FESS Patients of Chronic Rhinosinusitis With or Without Nasal Polyposis

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.

Chinese expert recommendation on transnasal corticosteroid nebulization for the treatment of chronic rhinosinusitis 2021

Corticosteroids are efficacious in treating chronic rhinosinusitis (CRS), but concerns on the potential side effects remain, especially for long-term usage of systemic corticosteroids. Accumulated evidence shows that transnasal nebulization may be a reasonable solution in balancing both efficacy and safety. However, no consensus or guideline has been formulated on the use of steroid transnasal nebulization in treating CRS. The consensus is achieved through literature review and exchange of Chinese experts in Group of Otorhinolaryngology and Ophthalmology, Chinese Society of Allergy (CSA). This document covers the development, equipment, pharmacological mechanism, and evidence-based efficacy and safety, as well as the special concern of the application of steroid transnasal nebulization during the coronavirus disease (COVID-19) pandemic. The expert consensus clarifies the application of steroid transnasal nebulization in treating CRS and common comorbidities during the perioperative and postoperative periods.

Hypothalamic-pituitary-adrenal axis suppression and intranasal corticosteroid use: A systematic review and meta-analysis

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.

The subtle nuances of intranasal corticosteroids

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

International consensus statement on allergy and rhinology: rhinosinusitis 2021

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.

Use of Off-Label Nasal Steroid Irrigations in Long-Term Management of Chronic Rhinosinusitis

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.

Efficacy of corticosteroid solution administration via Mygind's position for the management of chronic rhinosinusitis with nasal polyps

OBJECTIVE

To investigate whether direct steroid application via Mygind's position improved objective and subjective measures of chronic rhinosinusitis with nasal polyposis (CRSwNP).

METHODS

A retrospective chart review was performed on patients seen by the senior author in a Rhinology Clinic of a tertiary academic center over a 2 year period. Patients whose only change in medical regimen was initiation of corticosteroid administration via Mygind's position were included for this analysis. The main subjective and objective outcome measures were Sino-nasal Outcome Test-22 (SNOT-22) and endoscopy scores, respectively. Patient scores before and after the change in treatment were compared and analyzed using Student's t test and Wilcoxon signed-rank test.

RESULTS

Twenty-two patients were identified for inclusion. There was a statistically significant decrease in overall nasal endoscopy scores for both the right (P = .001) and left (P = .001) sides. A statistically significant and clinically meaningful decrease in total SNOT-22 scores (12.7 points, P = .008) was also seen. Intolerance to the regimen was observed in 5/48 patients reviewed for inclusion (10.4%), with issues including neck pain, burning, pressure, and thrush.

CONCLUSION

The direct application of topical corticosteroids, specifically via Mygind's position, may improve both objective exam findings and clinical symptomatology in patients with CRSwNP compared to indirect application. Intolerance to the regimen can be observed.

LEVEL OF EVIDENCE

4-Case series (with or without comparison).

The Effectiveness of Budesonide Nasal Irrigation After Endoscopic Sinus Surgery in Chronic Allergic Rhinosinusitis with Polyps

Nasal polyposis is one of the most common chronic upper airway diseases. Management of allergic rhinosinusitis with polyps is to control the disease process and the local immune response of the nasal mucosa. This is achieved by surgical removal of polypoid mucosa of all sinuses by functional endoscopic sinus surgery (FESS) followed by suppression of local immune response by using steroids. Budesonide nasal douching was introduced recently for postoperative management of patients with allergic rhinosinusitis. The therapeutic effectiveness and safety of this procedure are becoming accepted by many physicians. Evaluation of the efficacy of budesonide nasal irrigation in the postoperative management of chronic allergic rhinosinusitis with polyps. A total of 60 postoperative chronic allergic rhinosinusitis with polyps patients were randomly divided into two groups. Both groups received routine post-FESS medication as per the institute protocol. One group of patients received budesonide nasal douching in addition to regular care. Both groups were evaluated endoscopically at 1, 2, 6 and 10 weeks after surgery. Pre and postoperative quality of life change, the patient complaints, need for revision surgery were evaluated. Endoscopic Lund-Kennedy scoring (objective measurement) and Sino-Nasal Outcome Test-22 (subjective analysis) were used to compare the two postoperative groups. The average preoperative Sino-Nasal Outcome Test 22 score was 52.2. It was reduced to an average of 29.4 in patients who used the standard postoperative regimen and to 15.8 postoperatively in patients who had budesonide added to their douching solutions. The average endoscopy score was 2.2 for patients who did receive budesonide as compared to 2.9 for patients who did not receive budesonide nasal douching. Budesonide nasal douching can offer a safe and effective tool in managing local inflammatory response in allergic rhinosinusitis. It leads to a significantly better quality of life and has an adequate response on nasal mucosa-leading to less mucosal oedema and lower incidence of polypoidal changes postoperatively.

Intranasal Corticosteroid Therapy: Systematic Review and Meta-analysis of Reported Safety and Adverse Effects in Adults

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.

Topical Irrigations for Chronic Rhinosinusitis

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.

Efficacy and safety of steroid-impregnated implants following sinus surgery: A meta-analysis

OBJECTIVES

The purpose of this meta-analysis was to discuss the efficacy and safety of bioabsorbable steroid-impregnated implants following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) patients.

METHODS

PubMed, Cochrane, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials were comprehensively searched for studies comparing the experimental group (bioabsorbable steroid-impregnated implants) with the control group (bioabsorbable nonsteroid-impregnated implants). Lund-Kennedy scores, Perioperative Sinus Endoscopy (POSE) scores, polyp change, significant adhesion, middle turbinate lateralization, and adverse events were extracted from the final eligible studies. RevMan 5.3 software was used to analyze the data.

RESULTS

Eight randomized controlled trials were included in our analysis. The experimental group showed no significant differences from the control group in Lund-Kennedy scores (weighted mean difference (WMD) -0.40; 95% confidence interval [confidence interval (CI)] -1.05 to -0.62; P = 0.23). The experimental group had lower POSE scores compared with the control group, and there was a significant difference (WMD -1.88; 95% CI -2.32 to -1.43, P < 0.00001). The pooled results also demonstrated significant differences in polyp change, significant adhesion, and middle turbinate lateralization between the two groups. In addition, there was no significant difference with respect to adverse events between the two groups (odds ratio (OR) 0.38; 95% CI: 0.07 to 2.03; P = 0.26).

CONCLUSION

Bioabsorbable steroid-impregnated implants following ESS are effective in improving the endoscopic appearance of the healing process, and the safety profile appears to be favorable for the treatment of CRS patients.

LEVEL OF EVIDENCE

1A Laryngoscope, 2019.

Efficacy of Dexamethasone Versus Fluticasone Nasal Sprays in Postoperative Patients With Chronic Rhinosinusitis With Nasal Polyps

Background

Topical nasal steroids are commonly prescribed to patients with chronic rhinosinusitis with nasal polyposis (CRSwNP) following endoscopic sinus surgery (ESS). They are found to be effective in improving symptoms and quality of life as well as reducing the incidence of nasal polyps recurrence.

Objective

We sought to determine whether a higher concentration of topical nasal steroid spray is more effective than the standard nasal steroid spray in controlling symptoms and preventing recurrence of polyps in patients with CRSwNP who underwent ESS.

Method

A double-blind randomized controlled trial was performed on patients with CRSwNP after ESS. Patients were randomized into 2 treatment groups: one received topical nasal dexamethasone 0.032% and the other, fluticasone proprionate. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Lund-Kennedy nasal endoscopy scores were measured at the initiation of topical nasal steroid treatment and then at approximately 4-, 8-, and 12-week intervals.

Results

Thirty-nine patients were enrolled in the study. Eighteen patients continued using the medications prescribed to them for the duration of the study. There were 8 patients in the dexamethasone group and 10 patients in the fluticasone group. Both groups saw significant improvements in postoperative SNOT-22 and Lund-Kenney scores over time. There was no significant difference in improvement between the groups.

Conclusion

There is no significant increased benefit in using a higher dose nasal steroid spray compared to the standard dose nasal steroid spray after ESS.

Chronic Rhinosinusitis in Cystic Fibrosis: Diagnosis and Medical Management

Chronic rhinosinusitis (CRS) is nearly ubiquitous in patients with cystic fibrosis (CF). CF CRS is a challenging entity to define, diagnose, and treat, as patients often have severe refractory sinus disease in addition to complex medical comorbidities. The purpose of this article is to review the literature on the medical management of CF CRS and determine how to best identify, diagnose, and manage CF CRS. Ultimately, the treatment of these patients requires a multi-disciplinary approach involving the pulmonologist and otolaryngologist.

Budesonide nasal irrigation improved Lund-Kennedy endoscopic score of chronic rhinosinusitis patients after endoscopic sinus surgery

PURPOSE

Budesonide improves the prognosis of chronic rhinosinusitis (CRS). However, few reports have examined whether its use for nasal irrigation, compared to normal saline, improves the prognosis of patients after endoscopic sinus surgery (ESS). We compared the effects of nasal irrigation with budesonide and normal saline in CRS patients after ESS.

METHODS

Sixty CRS patients who had undergone ESS were randomly divided into an experimental group (30 patients), which used budesonide nasal irrigation, and a control group (30 patients), which used normal saline nasal irrigation. All patients received regular follow-up evaluations and were assessed via questionnaires, including the Lund-Kennedy endoscopic score (LKES), the symptom visual analog scale (VAS), the 22-item Sino-Nasal Outcome Test (SNOT-22), the Short-Form 36-Item Questionnaire (SF-36), the Self-Rating Anxiety Scale (SAS), the Self-Rating Depression Scale (SDS) and a side effects scale.

RESULTS

Scores of polyposis, mucosal edema, secretions and total score of LKES; VAS scores of nasal blockage, hyposmia and rhinorrhea; and SNOT-22 results in both groups were significantly improved 3 months after ESS. Scores of polyposis, mucosal edema, secretions and scarring and total score of LKES in experimental group were significantly better than in control group 3 months after ESS. No significant differences were observed in SF-36, SAS or SDS before or 3 months after ESS within or between the two groups. The side effects of the two groups were not significantly different.

CONCLUSIONS

Nasal irrigation improved the prognosis of CRS patients after ESS. Budesonide nasal irrigation had a better effect than normal saline nasal irrigation.

Comparison of Corticosteroids by 3 Approaches to the Treatment of Chronic Rhinosinusitis With Nasal Polyps

Purpose

Corticosteroids are regarded as the mainstay of medical treatment of eosinophilic chronic rhinosinusitis with nasal polyps (ECRSwNP). To date, a head-to-head comparison of the efficacy and safety of glucocorticoid preparations administered via different routes for the treatment of chronic rhinosinusitis with nasal polyps has not been reported. To compare the efficacy and safety of steroids administered via the oral, intranasal spray and transnasal nebulization routes in the management of ECRSwNP over a short course.

Methods

Overall, 91 patients with ECRSwNP were recruited prospectively and randomized to receive either oral methylprednisolone, budesonide inhalation suspension (BIS) via transnasal nebulization, or budesonide nasal spray (BNS) for 2 weeks. Nasal symptoms and polyp sizes were assessed before and after the treatment. Similarly, nasal polyp samples were evaluated for immunological and tissue remodeling markers. Serum cortisol levels were assessed as a safety outcome.

Results

Oral methylprednisolone and BIS decreased symptoms and polyp sizes to a significantly greater extent from baseline (P < 0.05) than BNS. Similarly, BIS and oral methylprednisolone significantly reduced eosinophils, T helper 2 cells, eosinophil cationic protein, interleukin (IL)-5, and expression of matrix metalloproteinases 2 and 9, and significantly increased type 1 regulatory T cells, IL-10, transforming growth factor-β, and tissue inhibitor of metalloproteinases 1 and 2 in nasal polyps to a greater extent than BNS. Post-treatment serum cortisol levels were significantly decreased by oral methylprednisolone compared to BIS or BNS, which did not significantly alter the cortisol levels.

Conclusions

A short course of BIS transnasal nebulization is more efficacious compared to BNS in the management of ECRSwNP and is safer than oral methylprednisolone with respect to hypothalamic-pituitary-adrenal axis function.

Effects of mometasone furoate-impregnated biodegradable nasal dressing on endoscopic appearance in healing process following endoscopic sinus surgery: a randomized, double-blind, placebo-controlled study

BACKGROUND

Postoperative care is an important factor affecting the outcome of endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS). The aim of this study was to test the effect of mometasone furoate (MF)-soaked biodegradable nasal dressings (BNDs) on endoscopic appearance in CRS patients with nasal polyps (CRSwNP) after ESS.

METHODS

This study was a prospective, randomized, double-blinded, placebo-controlled study. A total of 64 CRSwNP patients with bilateral ESS were enrolled and randomly given 4 mL or 8 mL of MF-soaked BNDs (NasoPore) in 1 nasal cavity and the same amount of normal saline-soaked BNDs in the contralateral side. The BNDs were removed on the 7th or 14th postoperative day. Perioperative sinus endoscopy (POSE) and Lund-Kennedy scores were collected, on the 7th or 14th postoperative days and at 1, 2, and 3 postoperative months.

RESULTS

The POSE and Lund-Kennedy scores showed that in the 4-mL, 1-week group, no significant differences between the sides treated with MF-soaked BNDs and the normal saline-soaked control were observed at any postoperative visits. In the 4-mL, 2-week group, significant differences were found at the 2-week and 1-month postoperative visits but not at the 2-month and 3-month visits. In the 8-mL, 1-week group, significant differences were found at the 1-week, 1-month, and 2-month postoperative visits but not at the 3-month visit. In the 8-mL, 2-week group, significant differences were found at all postoperative visits.

CONCLUSION

This study reveals that MF-impregnated BNDs improve the endoscopic appearance in the healing process of CRSwNP after ESS.

Risks and management of long-term corticosteroid use in chronic rhinosinusitis

PURPOSE OF REVIEW

The purpose of this review is to provide an update on the use and risks of long-term corticosteroids in the management of chronic rhinosinusitis (CRS).

RECENT FINDINGS

Long-term use of systemic corticosteroids is not indicated in the management of CRS due to the associated side effects and potential complications. Therefore, recent research has focused on the safety and efficacy of topical corticosteroid, particularly second-generation corticosteroids, and their modes of administration. Second-generation corticosteroids are more potent and have less systemic bioavailability than their first-generation counterparts. However, caution must be taken with concomitant use of more than two types of corticosteroids (topical, systemic, inhaled etc.) and also with their dosage and frequency of administration to avoid adrenal suppression, growth suppression in children, elevated intraocular pressure or epistaxis. Research is ongoing into therapies that may reduce corticosteroid resistance which has been demonstrated in some nasal polyps.

SUMMARY

Corticosteroids play an essential role in the management of CRS; however, use must be tailored to the patient-specific disease and requires ongoing review and regular reevaluation by their physician.

Outcomes of Endoscopic Dacryocystorhinostomy in Secondary Acquired Nasolacrimal Duct Obstruction: A Case-Control Study

INTRODUCTION

Secondary acquired nasolacrimal duct obstruction (SANDO), where the obstruction is caused by a known process, is becoming more commonly treated by endoscopic dacryocystorhinostomy (endoDCR). This study evaluates outcomes of endoDCR for cases of SANDO in comparison to endoDCR outcomes treating primary acquired nasolacrimal duct obstruction (PANDO).

METHODS

All patients undergoing endoDCR from 2006 to 2015 at a tertiary referral center were reviewed for etiology of nasolacrimal duct obstruction (NLDO) and success of procedure. Inclusion criteria were preoperative determination of NLDO via probing and irrigation, greater than 60-day follow up with assessment of duct patency via probing and irrigation after silicone tube removal, and postoperative survey for recurrent epiphora. Exclusion criteria were cases treating partial NLDO, patients undergoing concurrent conjunctivodacryocystorhinostomy, and patients lost to follow up or with incomplete records. Preanalysis stratification was performed for the following preexisting conditions: PANDO, granulomatosis with polyangiitis, sarcoidosis, midfacial radiotherapy, radioactive iodine therapy, severe prolonged sinusitis, prior failed DCR, and midface trauma. The primary outcome was postoperative anatomical patency of the nasolacrimal system with resolution of epiphora. Fisher-Freeman-Halton exact tests were performed comparing each SANDO group to the PANDO group with statistical significance set at p < 0.05.

RESULTS

Fifty-nine cases of NLDO underwent endoDCR in this series, 21 of which had a diagnosis consistent with SANDO. All patients treated with the aggressive perioperative management protocol the authors describe achieved anatomical patency. Patients with history of radioactive iodine therapy and radiotherapy had statistically worse outcomes compared with patients with PANDO, p = 0.011, p = 0.045, respectively. Stratified groups with increased intranasal sinus inflammation trended toward worse outcomes, but were not statistically different.

CONCLUSIONS

EndoDCR is a viable approach for the treatment of SANDO. In patients with history of radiotherapy or radioactive iodine therapy, however, endoDCR demonstrated decreased success rates as compared with patients with PANDO. Modifications of operative and postoperative management based on underlying etiology of NLDO may improve outcomes of endoDCR in SANDO cases. The authors describe an aggressive protocol for perioperative management of patients with pathologic nasal inflammation undergoing endoDCR.

Post-operative corticosteroid irrigation for chronic rhinosinusitis after endoscopic sinus surgery: A meta-analysis

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.

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

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Effect of nebulized budesonide on decreasing the recurrence of allergic fungal rhinosinusitis

OBJECTIVE

The aim of this study was to evaluate the clinical efficacy and the effects on decreasing the recurrence of AFRS (allergic fungal rhinosinusitis) of a budesonide inhalation suspension delivered via transnasal nebulization to patients following endoscopic sinus surgery.

SUBJECTS AND METHODS

Thirty-five patients were recruited into this study. Final diagnoses were reached using Bent and Kuhn's criteria. The eligible patients were randomly divided into two groups: the budesonide transnasal nebulization group (group A) and the topical nasal steroids group (group B). Nasal symptoms, Lund-Mackay scores, and Kupferberg grades were evaluated before surgery, after surgery and during the follow-up to assess the effects of these two approaches.

RESULTS

A total of 30 patients with AFRS who were eligible were included in the study. Four of the 15 patients in group B (26.67%) developed recurrent disease, whereas no patients in group A developed recurrent disease. This difference was statistically significant (p=0.032).

CONCLUSION

Nebulized budesonide is an effective and safe treatment for patients with AFRS following endoscopic sinus surgery, as evidenced by the reduced recurrence rate observed in the budesonide transnasal nebulization group relative to the topical nasal steroids group.

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.

Medical and Surgical Advancements in the Management of Cystic Fibrosis Chronic Rhinosinusitis

PURPOSE OF REVIEW

The purpose of this review is to provide otolaryngologists with the most up-to-date advancements in both the medical and surgical management of CF-related sinus disease.

RECENT FINDINGS

Recent studies have supported more aggressive CRS management, often with a combination of both medical and surgical therapies. Comprehensive treatment strategies have been shown to reduce hospital admissions secondary to pulmonary exacerbations in addition to improving CRS symptoms. Still, current management strategies are lacking in both high-level evidence and standardized guidelines.

SUMMARY

The unified airway model describes the bi-directional relationship between the upper and lower airways as a single functional unit and suggests that CRS may play a pivotal role in both the development and progression of lower airway disease. Current strategies for CF CRS focus primarily on amelioration of symptoms with antibiotics, nasal saline and/or topical medicated irrigations, and surgery. However, there are no definitive management guidelines and there remains a persistent need for additional studies. Nevertheless, otolaryngologists have a significant role in the overall management of CF, which requires a multi-disciplinary approach and a combination of both surgical and medical interventions for optimal outcomes of airway disease. Here we present a review of currently available literature and summarize medical and surgical therapies best suited for the management of CF-related sinus disease.

Endoscopic dacryocystorhinostomy following head and neck radiation therapy

This article determines the efficacy of endoscopic dacryocystorhinostomy (endoDCR) in patients who have undergone adjuvant external beam radiation therapy (XRT) following head and neck cancer resection. A retrospective chart review was performed on all patients who underwent endoDCR between 2006 and 2014 at a tertiary referral center. Cases were reviewed and selected for the following inclusion criteria: history of adjuvant sinonasal XRT following head and neck cancer resection, preoperative probing and irrigation demonstrating nasolacrimal duct obstruction (NLDO), postoperative probing and irrigation following silicone tube extubation. Exclusion criteria included active dacryocystitis, postoperative follow-up of less than 4 months, presence of epiphora prior to XRT, lack of probing/irrigation at preoperative or postoperative visit, and lid malposition including ectropion, facial palsy, and/or poor tear pump. Six patients (7 eyes) met the selection criteria. EndoDCR was performed at a mean time of 30 months following last radiation treatment (range, 3-71 months). Mitomycin C was used in 4/7 cases. Silicone tube removal occurred between 3-8 months postoperatively. Five out of 6 patients had postoperative sinonasal debridement and nasal saline/corticosteroid irrigation. Five out of 6 patients (83%) had both resolution of epiphora and anatomic patency confirmed by probing and irrigation. Our experience suggests that endoDCR procedures can be effective in patients with NLDO following prior sinonasal XRT for head and neck neoplasms. Postoperative management with sinonasal debridement and combined saline/corticosteroid nasal irrigation may help to improve surgical success in patients with increased post-radiotherapy mucosal inflammation.

Current trends in topical therapies for chronic rhinosinusitis: update and literature review

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.

The Effectiveness of Budesonide Nasal Irrigation After Endoscopic Sinus Surgery in Chronic Rhinosinusitis With Asthma

Objectives

Budesonide nasal irrigation was introduced recently for postoperative management of patients with chronic rhinosinusitis. The safety and therapeutic effectiveness of this procedure is becoming accepted by many physicians. The objective of this study was to evaluate the efficacy of postoperative steroid irrigation in patients with chronic rhinosinusitis and asthma.

Methods

This prospective study involved 12 chronic rhinosinusitis patients with nasal polyps and asthma who received oral steroid treatment for recurring or worsening disease. The 22-item Sinonasal Outcomes Test (SNOT-22) and Lund-Kennedy endoscopy scores were checked before nasal budesonide irrigation, and 1, 2, 4, and 6 months after irrigation. We also calculated the total amount of oral steroids and inhaled steroids in the 6 months before irrigation and the 6 months after it.

Results

The mean SNOT-22 score improved from 30.8±14.4 before irrigation to 14.2±8.7 after 6 months of irrigation (P=0.030). The endoscopy score also improved from 7.4±4.7 before irrigation to 2.2±2.7 after 6 months (P<0.001). The total amount of oral steroid was decreased from 397.8±97.6 mg over the 6 months before irrigation to 72.7±99.7 mg over the 6 months after irrigation (P<0.001).

Conclusion

Nasal irrigation with budesonide is an effective postoperative treatment for chronic rhinosinusitis with asthma, which recurs frequently, reducing the oral steroid intake.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Orbital Complications Associated with the Treatment of Chronic Rhinosinusitis

Orbital injuries from endoscopic sinus surgery are rare but potentially catastrophic. The most feared complications from sinus surgery include blindness and diplopia. Recent publications note that the rate of orbital complications has decreased when compared with the past, reflecting the use of endoscopes, better technology, and improved training. The sinus surgeon must have mastery over the procedure she or he plans to undertake and be aware of the specific potential for orbital injury given the patient's anatomy and disease. The sinus surgeon must also have expert knowledge of the appropriate and immediate medical and surgical management of orbital complications.

Management of the upper airway in cystic fibrosis

PURPOSE OF REVIEW

Upper airway disease engenders significant morbidity for patients with cystic fibrosis and is increasingly recognized as having a much greater role in pulmonary outcomes and quality of life than originally believed. Widespread disparate therapeutic strategies for cystic fibrosis chronic rhinosinusitis underscore the absence of a standardized treatment paradigm. This review outlines the most recent evidence-based trends in the management of upper airway disease in cystic fibrosis.

RECENT FINDINGS

The unified airway theory proposes that the sinuses are a focus of initial bacterial colonization which seeds the lower airway and may play a large role in maintaining lung infections. Mounting evidence suggests more aggressive treatment of the sinuses may confer significant improvement in pulmonary disease and quality of life outcomes in cystic fibrosis patients. However, there is a lack of high-level evidence regarding medical and surgical management of cystic fibrosis chronic rhinosinusitis that makes generalizations difficult.

SUMMARY

Well designed clinical trials with long-term follow-up concerning medical and surgical interventions for cystic fibrosis sinus disease are required to establish standardized treatment protocols, but increased interest in the sinuses as a bacterial reservoir for pulmonary infections has generated considerable attention.

Safety, feasibility, and efficacy of placement of steroid-eluting bioabsorbable sinus implants in the office setting: a prospective case series

BACKGROUND

The outcomes of endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) can be compromised by postoperative inflammation, recurrent polyposis, middle turbinate lateralization, and synechiae, often requiring subsequent interventions. A bioabsorbable steroid-eluting sinus implant placed in the operating room following ESS has been proven safe and effective in 2 randomized controlled trials and a subsequent meta-analysis, for its ability to preserve sinus patency, and reduce medical and surgical interventions. This trial sought to evaluate the safety, feasibility, and outcomes of implants placed in the office after achieving hemostasis.

METHODS

Twenty patients with CRS underwent ESS including bilateral ethmoidectomy. A steroid-eluting bioabsorbable implant was deployed into each ethmoid cavity in the office within 7 days after ESS. Endoscopic appearance of the ethmoid cavities was evaluated at 1 week, 2 weeks, and 4 weeks postoperatively by the operating surgeon and an independent blinded evaluator. Procedural tolerance was assessed at week 2 using a patient preference questionnaire. The 20-item Sino-Nasal Outcome Test (SNOT-20) questionnaire was completed at baseline, week 2, and week 4.

RESULTS

In-office placement of steroid-eluting bioabsorbable implants was well tolerated, with 90% of patients very satisfied with the overall experience, and 80% very satisfied with the recovery process. At 1 month, there were no significant adhesions or frank polyposis, and middle turbinate lateralization was only 5%. Compared to baseline, ethmoid sinus inflammation was significantly reduced (p = 0.03), and the mean SNOT-20 score was significantly improved (p < 0.001).

CONCLUSION

In-office placement of steroid-eluting bioabsorbable implants after achieving hemostasis was well tolerated and might improve local drug diffusion and surgical outcomes.