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Heiland LD, Marrero-Gonzalez AR, Nguyen SA, Farmer HG, Rathi VK, Soler ZM, Schlosser RJ. Surgical management of headache and facial pain/pressure in chronic rhinosinusitis: A systematic review and meta-analysis. Int Forum Allergy Rhinol 2024; 14:1465-1476. [PMID: 38739100 DOI: 10.1002/alr.23359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/10/2024] [Accepted: 04/22/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Headache and facial pain are common symptoms of chronic rhinosinusitis (CRS). However, given the numerous etiologies that can cause these symptoms, the impact of sinus surgery is not well characterized. METHODS A systematic review was performed by searching the literature from inception through June 6, 2023. English-language articles reporting outcomes for facial pain/pressure or headache following endoscopic sinus surgery were selected for inclusion. Meta-analyses were performed using random and fixed effect models on continuous measures (mean), mean difference (Δ), and proportions (%). RESULTS A total of 26 articles reporting on 2839 patients were selected for inclusion. The mean patient age was 44.0 ± 3.9 (range 16.0-84.0), with an average symptom duration of 5.3 ± 2.8 years. Among these patients, 56.5% (95% confidence interval [CI]: 52.3-60.6) were male and 77.0% (95% CI: 56.6-92.3) had nasal polyposis (NP). Patients with and without NP reported substantial reductions in both 22-item sino-nasal outcome test facial pain/pressure (with NP: -1.4 [95% CI: -1.6 to -1.2; relative reduction 59.1%]; without NP: -1.5 [95% CI: -1.9 to -1.1; relative reduction 60.9%]) and visual analogue scale (VAS) headache (with NP: -2.5 [95% CI: -2.8 to -2.1; relative reduction 67.2%]; without NP: -2.8 [95% CI: -4.7 to -1.0; relative reduction 42.7%]). Symptom reductions were greater in the without NP versus with NP group; VAS facial pain/pressure: Δ0.4 (95% CI: 0.2-0.6; p = 0.0006) and VAS headache: Δ0.4 (95% CI: 0.1-0.7; p = 0.02). CONCLUSIONS Our findings suggest that CRS patients, regardless of polyp status, benefit from significant reductions in facial pain/pressure and headache following surgical therapy.
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Affiliation(s)
- Luke D Heiland
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, USA
- Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Alejandro R Marrero-Gonzalez
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Hannah G Farmer
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Vinay K Rathi
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Zachary M Soler
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Rodney J Schlosser
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri, USA
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den Heijer MC, Joustra GE, Vermeulen KM, Korsten-Meijer AGW, Feijen RA. Sinonasal inverted papilloma and predictors of health-related quality of life after endonasal endoscopic surgery: A prospective cohort study. Clin Otolaryngol 2024; 49:453-461. [PMID: 38613400 DOI: 10.1111/coa.14158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 02/06/2024] [Accepted: 03/17/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVES Existing knowledge on health-related quality of life (HRQoL) after surgical removal of sinonasal inverted papilloma (IP) is limited. Moreover, predictors for a better or worse post-operative HRQoL outcome are not known. Our aim was to assess HRQoL in all three health domains (physical, psychological, and social), track its post-operative trajectory, investigate if pre-operative observations could predict distinct post-operative HRQoL outcomes, and evaluate whether physicians' interventions could contribute to improved post-operative HRQoL. DESIGN Prospective cohort study. SETTING Tertiary referral hospital. PARTICIPANTS Seventy-four patients who underwent surgery for an IP were included. They were asked to fill in the Endonasal Endoscopic Sinus and Skull-Base Surgery Questionnaire (EES-Q) pre-operatively, and then 2 weeks, 3 months, and 1 year post-operatively. MAIN OUTCOME MEASURES Linear mixed models analyses were performed to evaluate the overall post-operative HRQoL and the separate health domains, as well as the impact of specific variables (sex, age, American Society of Anaesthesiologists [ASA] classification, smoker, Krouse staging, pre-operative EES-Q score, type of surgery, and post-operative antibiotics) on HRQoL improvement. RESULTS The total EES-Q score (p < .001) as well as the physical (p < .001), psychological (p = .049), and the social (p = .002) domains significantly improved post-operatively. ASA classification (p = .049), pre-operative EES-Q score (p < .001) and post-operative antibiotics (p = .036) were significant variables. CONCLUSIONS Overall HRQoL, as well as each of the three health domains, improved significantly. A higher ASA score, a higher pre-operative EES-Q score, and the administration of post-operative antibiotics were significant predictors for better HRQoL recovery post-operatively. Further research is necessary to confirm these results.
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Affiliation(s)
- Marc C den Heijer
- Department of Otorhinolaryngology - Head and Neck Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Graduate School of Medical Sciences, University of Groningen, Groningen, The Netherlands
| | - Gonneke E Joustra
- Department of Otorhinolaryngology - Head and Neck Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Graduate School of Medical Sciences, University of Groningen, Groningen, The Netherlands
| | - Karin M Vermeulen
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Astrid G W Korsten-Meijer
- Department of Otorhinolaryngology - Head and Neck Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert A Feijen
- Department of Otorhinolaryngology - Head and Neck Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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M Yusoff NNF, Ahmad S, Wan Abdul Rahman WF, Mohamud R, C Boer J, Plebanski M, Abdullah B, Chen X, Tengku Din TADAA. CD4+ Foxp3+ Regulatory T-cells in Modulating Inflammatory Microenvironment in Chronic Rhinosinusitis with Nasal Polyps: Progress and Future Prospect. Cytokine 2024; 178:156557. [PMID: 38452440 DOI: 10.1016/j.cyto.2024.156557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/26/2024] [Accepted: 02/20/2024] [Indexed: 03/09/2024]
Abstract
Chronic rhinosinusitis with nasal polyps (CRSwNP) is a subtype of chronic rhinosinusitis (CRS) characterized by the presence of nasal polyps (NP) in the paranasal mucosa. Despite the complex etiology, NP is believed to result from chronic inflammation. The long-term aftermath of the type 2 response is responsible for symptoms seen in NP patients, i.e. rhinorrhea, hyposmia, and nasal obstruction. Immune cellular tolerogenic mechanisms, particularly CD4 + Foxp3 + regulatory T cells (Tregs), are crucial to curtail inflammatory responses. Current evidence suggests impaired Treg activity is the main reason underlying the compromise of self-tolerance, contributing to the onset of CRSwNP. There is compelling evidence that tumor necrosis factor 2 (TNFR2) is preferentially expressed by Tregs, and TNFR2 is able to identify the most potent suppressive subset of Tregs. Tumor necrosis factor (TNF)-TNFR2 interaction plays a decisive role in the activation and expansion of Tregs. This review summarizes current understanding of Tregs biology, focusing on the discussion of the recent advances in the study of TNF-TNFR2 axis in the upregulation of Treg function as a negative feedback mechanism in the control of chronic inflammation. The role of dysregulation of Tregs in the immunopathogenesis of CRSwNP will be analyzed. The future perspective on the harnessing Tregs-mediated self-tolerant mechanism in the management of CRSwNP will be introduced.
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Affiliation(s)
- Nur Najwa Farahin M Yusoff
- Department of Chemical Pathology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Suhana Ahmad
- Department of Immunology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | | | - Rohimah Mohamud
- Department of Immunology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Jennifer C Boer
- Translational Immunology and Nanotechnology Unit, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria 3083, Australia
| | - Magdalena Plebanski
- Translational Immunology and Nanotechnology Unit, School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria 3083, Australia
| | - Baharudin Abdullah
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia.
| | - Xin Chen
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau SAR, China
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Chen H, Zhou B, Huang Q, Li C, Wu Y, Huang Z, Li Y, Qu J, Xiao N, Wang M. Efficacy and Safety of Long-Term Low-Dose Clarithromycin in Patients With Refractory Chronic Sinusitis After Endoscopic Sinus Surgery: A Prospective Clinical Trial. EAR, NOSE & THROAT JOURNAL 2024; 103:NP31-NP39. [PMID: 34315239 DOI: 10.1177/01455613211032020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To observe the efficacy and safety of postoperative long-term low-dose oral administration of clarithromycin in patients with refractory chronic rhinosinusitis (RCRS), to explore the characteristics of postoperative microbiota in the nasal cavity in patients with RCRS, and to compare the differences and changes in microbiota in the nasal cavity before and after medication. METHODS This was a prospective, self-controlled study. Eighteen patients with RCRS who had persistent symptoms after endoscopic sinus surgery and standard therapy with normal immunoglobulin E and eosinophil level were included. Low dose (250 mg, once daily) clarithromycin was orally administrated for 12 weeks. Symptom severity and endoscopic findings were evaluated before, after 4 weeks, and 12 weeks of treatment, and nasal cavity microbiota was analyzed simultaneously. RESULTS A total of 18 patients with RCRS were enrolled and 17 patients completed the study. Four weeks after oral administration of clarithromycin, significant improvement was observed in subjective symptoms including nasal congestion, rhinorrhea, postnasal drip, and general discomfort, as well as endoscopic findings including general surgical cavity condition, rhinedema, and rhinorrhea (P < .05). After continuous treatment to the 12th week, symptoms showed significant improvement compared with baseline, and endoscopic score showed significant improvement compared with both baseline and 4 weeks after treatment. Analysis of middle nasal meatus flora revealed a significant decrease of Streptococcus pneumoniae after 12 weeks of clarithromycin treatment (P < .05), while the richness, composition, and diversity were similar before and after treatment. Patients enrolled experienced no adverse drug reaction or allergic reaction, nor clinical significant liver function impairment observed. CONCLUSION Postoperative low-dose long-term oral administration of clarithromycin in patients with RCRS can improve the clinical symptoms and facilitate the mucosal epithelialization, with good tolerance and safety. The efficacy of clarithromycin in patients with RCRS may be related to its regulatory effect on nasal cavity microbiota.
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Affiliation(s)
- Han Chen
- Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otorhinolaryngology Head and Neck Surgery (Capital Medical University), Ministry of Education, Beijing, China
| | - Bing Zhou
- Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otorhinolaryngology Head and Neck Surgery (Capital Medical University), Ministry of Education, Beijing, China
| | - Qian Huang
- Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otorhinolaryngology Head and Neck Surgery (Capital Medical University), Ministry of Education, Beijing, China
| | - Cheng Li
- Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otorhinolaryngology Head and Neck Surgery (Capital Medical University), Ministry of Education, Beijing, China
| | - Yubin Wu
- Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otorhinolaryngology Head and Neck Surgery (Capital Medical University), Ministry of Education, Beijing, China
| | - Zhenxiao Huang
- Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otorhinolaryngology Head and Neck Surgery (Capital Medical University), Ministry of Education, Beijing, China
| | - Yunxia Li
- Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otorhinolaryngology Head and Neck Surgery (Capital Medical University), Ministry of Education, Beijing, China
| | - Jing Qu
- Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otorhinolaryngology Head and Neck Surgery (Capital Medical University), Ministry of Education, Beijing, China
| | - Nianci Xiao
- Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otorhinolaryngology Head and Neck Surgery (Capital Medical University), Ministry of Education, Beijing, China
| | - Mingjie Wang
- Department of Otorhinolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Key Laboratory of Otorhinolaryngology Head and Neck Surgery (Capital Medical University), Ministry of Education, Beijing, China
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Shu F, Li CX, Zhang F, Peng M, Shi L, Li L, Xiong J, Mu Z, Wang Y, Mao D. Systematic Review and Meta-analysis: Macrolide in the Treatment of Chronic Rhinosinusitis After Endoscopic Sinus Surgery. Otolaryngol Head Neck Surg 2023; 169:1424-1435. [PMID: 37548067 DOI: 10.1002/ohn.461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/06/2023] [Accepted: 07/11/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVES To evaluate the efficacy and safety of macrolide antibiotics therapy in patients with chronic rhinosinusitis (CRS) receiving endoscopic sinus surgery. DATA SOURCES PubMed, Web of Science, Embase, and Cochrane Library. REVIEW METHODS The electronic databases were comprehensively searched on June 2, 2022, for randomized controlled trials on macrolide antibiotics in the treatment of patients undergoing CRS endoscopic surgery. The primary outcome measures were the sinonasal outcome test (SNOT) score and the visual analog scale (VAS) score. The secondary outcome measures were the nasal endoscopy score (NES), the sinus computed tomography score, and adverse events. RESULTS A total of 8 studies were included, involving 606 patients who used macrolide for a long time. Meta-analysis showed that no significant difference was observed in SNOT (standardized mean difference [SMD] = -0.13; 95% confidence interval [CI]: -0.38 to 0.13, I2 = 0%) and VAS (SMD = -0.10; 95% CI, -0.88 to 0.68, I2 = 81%) between the macrolide and placebo groups. However, macrolide outperformed the placebo in improving NES (SMD = -0.32; 95% CI, -0.62 to -0.03, I2 = 21%). The use of macrolide did not increase the incidence of adverse events. CONCLUSION Long-term use of macrolide after CRS surgery may not significantly improve the quality of life and disease severity of the patients but may play a role in improving postoperative NES in patients with CRS. There is still no sufficient evidence to determine whether the disease phenotype of CRS or the patient's race will affect the efficacy of long-term use of macrolide after CRS.
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Affiliation(s)
- Fu Shu
- College of Traditional Chinese Medicine, Chongqing Medical University, Chongqing, People's Republic of China
| | - Chan-Xiu Li
- Graduate School, Liaoning University of Traditional Chinese Medicine, Shenyang, People's Republic of China
| | - Feng Zhang
- Department of Otorhinolaryngology, Yongchuan Chinese Medicine Hospital Affiliated to Chongqing Medical University, Chongqing, People's Republic of China
| | - Mingwei Peng
- College of Pharmaceutical Sciences, Southwest University, Chongqing, People's Republic of China
| | - Lei Shi
- Department of Otorhinolaryngology, The Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, Shenyang, People's Republic of China
| | - Linglong Li
- Department of Otorhinolaryngology, Yongchuan Chinese Medicine Hospital Affiliated to Chongqing Medical University, Chongqing, People's Republic of China
| | - Juan Xiong
- Department of Otorhinolaryngology, Yongchuan Chinese Medicine Hospital Affiliated to Chongqing Medical University, Chongqing, People's Republic of China
| | - Zengyi Mu
- Graduate School, Liaoning University of Traditional Chinese Medicine, Shenyang, People's Republic of China
| | - Yaping Wang
- Department of Otorhinolaryngology, Yongchuan Chinese Medicine Hospital Affiliated to Chongqing Medical University, Chongqing, People's Republic of China
| | - Dehong Mao
- Department of Otorhinolaryngology, Yongchuan Chinese Medicine Hospital Affiliated to Chongqing Medical University, Chongqing, People's Republic of China
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Ryu G, Lee E, Park SI, Park M, Hong SD, Jung YG, Kim HY. The Mechanism of Action and Clinical Efficacy of Low-Dose Long-Term Macrolide Therapy in Chronic Rhinosinusitis. Int J Mol Sci 2023; 24:ijms24119489. [PMID: 37298439 DOI: 10.3390/ijms24119489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/12/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
Various chronic inflammatory airway diseases can be treated with low-dose, long-term (LDLT) macrolide therapy. LDLT macrolides can be one of the therapeutic options for chronic rhinosinusitis (CRS) due to their immunomodulatory and anti-inflammatory actions. Currently, various immunomodulatory mechanisms of the LDLT macrolide treatment have been reported, as well as their antimicrobial properties. Several mechanisms have already been identified in CRS, including reduced cytokines such as interleukin (IL)-8, IL-6, IL-1β, tumor necrosis factor-α, transforming growth factor-β, inhibition of neutrophil recruitment, decreased mucus secretion, and increased mucociliary transport. Although some evidence of effectiveness for CRS has been published, the efficacy of this therapy has been inconsistent across clinical studies. LDLT macrolides are generally believed to act on the non-type 2 inflammatory endotype of CRS. However, the effectiveness of LDLT macrolide treatment in CRS is still controversial. Here, we reviewed the immunological mechanisms related to CRS in LDLT macrolide therapy and the treatment effects according to the clinical situation of CRS.
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Affiliation(s)
- Gwanghui Ryu
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Eunkyu Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Song I Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang 10380, Republic of Korea
| | - Minhae Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Sang Duk Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Yong Gi Jung
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Hyo Yeol Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
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Askari M, Khezri M, Zoghi G. Introducing a Novel Combination Therapy with Macrolides for the Treatment of Chronic Rhinosinusitis: A Randomized Controlled Trial. IRANIAN JOURNAL OF MEDICAL SCIENCES 2022; 47:533-540. [PMID: 36380971 PMCID: PMC9652494 DOI: 10.30476/ijms.2021.91813.2303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/25/2021] [Accepted: 11/21/2021] [Indexed: 06/16/2023]
Abstract
BACKGROUND Macrolides have shown beneficial effects in the treatment of chronic rhinosinusitis (CRS). This study aimed to compare the effect of azithromycin and clarithromycin in combination with conventional therapies for the treatment of CRS. METHODS This single-blind randomized controlled trial was conducted during 2018-2019 at the Otorhinolaryngology Clinic of Shahid Mohammadi Hospital, Bandar Abbas, Iran. Out of 102 selected patients, 90 were included in the analysis. Patients were selected through convenience sampling and randomly assigned to two equal groups. In addition to conventional therapies (nasal irrigation, betamethasone injection, oxymetazoline and fluticasone spray, guaifenesin syrup, and steam inhalation), the patients in the clarithromycin group received clarithromycin 500 mg tablets twice daily for four weeks. The other group received azithromycin 500 mg tablets daily for four weeks. Patients' symptoms were evaluated pre- and post-intervention, and the Lund-Mackay (LM) scoring system was used for the staging of CRS based on computed tomography scan findings. Data were analyzed using SPSS software, and P<0.05 was considered statistically significant. RESULTS Patients in both groups were comparable in terms of age and sex. Complete resolution of symptoms was significantly higher in the azithromycin group than the clarithromycin group (71.1% vs. 24.4%, P<0.001). Baseline LM scores did not differ significantly between the groups (P=0.120). However, post-intervention, LM scores reduced considerably in both groups, but the change was significantly higher in the azithromycin group (P<0.001). CONCLUSION In combination with conventional therapies for CRS in adults, a four-week course of treatment with azithromycin is more effective than clarithromycin.Trial Registration Number: IRCT20201209049661N1.
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Affiliation(s)
- Mehdi Askari
- Department of Otorhinolaryngology, School of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Mehrdad Khezri
- Department of Radiology, School of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Ghazal Zoghi
- Endocrinology and Metabolism Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
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Lieu JEC, Rybak L. Possibility of Macrolides Causing Hearing Loss in Children-What Did You Say? JAMA Otolaryngol Head Neck Surg 2022; 148:827-829. [PMID: 35862064 DOI: 10.1001/jamaoto.2022.1292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Judith E C Lieu
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Leonard Rybak
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield
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Xu X, Ong YK, Wang DY. Precision Medicine in Chronic Rhinosinusitis: Where Does Allergy Fit In? Handb Exp Pharmacol 2022; 268:151-170. [PMID: 34085123 DOI: 10.1007/164_2021_489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Chronic rhinosinusitis (CRS) is a clinical syndrome stemming from persistent inflammation of the sinonasal mucosa. Phenotypically, it is traditionally and widely described according to the presence or absence of polyps. While this distinction is simple to use, it has little bearing on prognosis and treatment, for CRS is essentially an inflammatory disease resulting from dysregulated interaction between a multitude of host and environmental factors. Allergy is merely one of them and, like many of the proposed aetiologies, has been subject to much debate which will be discussed here. As our understanding of CRS continues to evolve, previous so-called conventional wisdom about phenotypes (e.g. CRS with nasal polyps is associated with Type 2 inflammation) is being challenged, and new phenotypes are also emerging. In addition, there is growing interest in defining the endotypes of CRS to deliver precise and personalised treatment, especially pertaining to the development of biologics for the group of severe, difficult-to-treat CRS patients. A proposed model of precision medicine tailored to management of CRS will also be introduced to readers, which can be continually modified to adapt to new discoveries about this exciting condition.
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Affiliation(s)
- Xinni Xu
- Department of Otolaryngology-Head and Neck Surgery, National University Hospital System (NUHS), Singapore, Singapore
| | - Yew Kwang Ong
- Department of Otolaryngology-Head and Neck Surgery, National University Hospital System (NUHS), Singapore, Singapore
| | - De Yun Wang
- Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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Long-term, low-dose macrolide antibiotic treatment in pediatric chronic airway diseases. Pediatr Res 2022; 91:1036-1042. [PMID: 34120139 PMCID: PMC9122820 DOI: 10.1038/s41390-021-01613-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/27/2021] [Accepted: 05/17/2021] [Indexed: 02/05/2023]
Abstract
Macrolide antibiotics are one of the most commonly used broad-spectrum antibiotics. They have an inhibitory effect on a variety of respiratory pathogens; besides, they have non-anti-infective effects, including anti-inflammatory, regulating airway secretion, immune regulation, and other effects. A growing number of studies have shown that the non-anti-infective effects of macrolides have important and potential value in the treatment of pediatric chronic airway diseases; the therapy was described as "long-term, low-dose usage"; unfortunately, there is no guideline or consensus that applies to children. To better carry out the mechanism and clinical research of non-anti-infective effect and promote its rational use in children, the authors summarize the evidence of the usage of long-term, low-dose macrolide antibiotic therapy (LLMAT) in the treatment of chronic airway diseases in children and the progress in recent years. IMPACT: This review summarizes the evidence (mostly in recent 5 years) of the usage of long-term, low-dose macrolide antibiotic therapy in the treatment of chronic airway diseases. The recent studies and guidelines support and enrich the point that long-term, low-dose macrolide antibiotic therapy has potential benefit for children with severe asthma, CF, non-CF bronchiectasis, and BO, which provides clinical references and is of clinical interest. Long-term, low-dose macrolide antibiotic therapy has good safety, and no serious events have been reported; however, potential cardiac side effects and macrolide resistance should be clinically noted.
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Ranford D, Hopkins C. Safety review of current systemic treatments for severe chronic rhinosinusitis with nasal polyps and future directions. Expert Opin Drug Saf 2021; 20:1177-1189. [PMID: 33957840 DOI: 10.1080/14740338.2021.1926981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Chronic rhinosinusitis is a common condition characterized by inflammation of the nasal and sinus linings, rhinorrhea, nasal blockage, facial pain, and loss of sense of smell for longer than 12 weeks. CRS can occur with or without nasal polyps.Areas covered: First-line treatment in chronic rhinosinusitis with nasal polyps is long-term intranasal corticosteroids, which have few adverse events associated with their use, as second-generation intranasal corticosteroids having a bioavailability of <0.5%. Systemic corticosteroids are used when intranasal steroids fail to achieve symptom control. However, the repeated use of oral corticosteroids is associated with numerous adverse events and the benefit from a course of oral corticosteroids is lost within three to six months.Expert opinion: Antibiotics are commonly prescribed in nasal polyposis although there is also very little evidence for their use outside of acute infection. Macrolide antibiotics are also associated with a transient increase in the risk of arrhythmias. Biologics offer a steroid-sparing alternative to the treatment of severe nasal polyposis. They have shown to be relatively well tolerated in studies to date; however, studies suggest that there is no disease modifying effect and that any benefit is lost within weeks of finishing treatment.
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Affiliation(s)
- David Ranford
- ENT Department, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Claire Hopkins
- ENT Department, Guy's and St Thomas NHS Foundation Trust, London, UK
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12
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Ta NH, Gao J, Philpott C. A systematic review to examine the relationship between objective and patient-reported outcome measures in sinonasal disorders: recommendations for use in research and clinical practice. Int Forum Allergy Rhinol 2021; 11:910-923. [PMID: 33417297 PMCID: PMC8248036 DOI: 10.1002/alr.22744] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 11/01/2020] [Accepted: 11/12/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Common sinonasal disorders include chronic rhinosinusitis (CRS), allergic rhinitis (AR), and a deviated nasal septum (DNS), which often coexist with shared common symptoms including nasal obstruction, olfactory dysfunction, and rhinorrhea. Various objective outcome measures and patient-reported outcome measures (PROMs) are used to assess disease severity; however, there is limited evidence in the literature on the correlation between them. This systematic review aims to examine the relationship between them and provide recommendations. METHODS A search of MEDLINE and EMBASE identified studies quantifying correlations between objective outcome measures and PROMs for the sinonasal conditions using a narrative synthesis. RESULTS In total, 59 studies met inclusion criteria. For nasal obstruction, rhinomanometry shows a lack of correlation whereas peak nasal inspiratory flow (PNIF) shows the strongest correlation with PROMs (r > 0.5). The Sniffin' Stick test shows a stronger correlation with PROMs (r > 0.5) than the University of Pennsylvania Smell Identification Test (UPSIT) (r < 0.5). Computed tomography (CT) sinus scores show little evidence of correlation with PROMs and nasal endoscopic ratings (weak correlation, r < 0.5). CONCLUSION Overall, objective outcome measures and PROMs assessing sinonasal symptoms are poorly correlated, and we recommend that objective outcome measures be used with validated PROMs depending on the setting. PNIF should be used in routine clinical practice for nasal obstruction; rhinomanometry and acoustic rhinometry may be useful in research. The Sniffin' Sticks test is recommended for olfactory dysfunction with UPSIT as an alternative. CT scores should be excluded as a routine CRS outcome measure, and endoscopic scores should be used in combination with PROMs until further research is conducted.
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Affiliation(s)
- Ngan Hong Ta
- Norwich Medical SchoolUniversity of East AngliaNorwichUK
| | - Jack Gao
- ENT DepartmentEast Suffolk and North Essex NHS Foundation TrustColchesterUK
| | - Carl Philpott
- ENT DepartmentJames Paget University Hospital NHS Foundation TrustGreat YarmouthUK
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13
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Siu J, Mackenzie BW, Klingler L, Biswas K, Wang Y, Hung CT, Jeong SH, Barnett D, Tingle MD, Douglas RG. Sinonasal and gastrointestinal bacterial composition and abundance are stable after 1 week of once-daily oral antibiotic treatment for chronic rhinosinusitis. Int Forum Allergy Rhinol 2021; 11:1355-1366. [PMID: 33877743 DOI: 10.1002/alr.22799] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Despite the widespread prescription of antibiotics for the treatment of chronic rhinosinusitis (CRS), their efficacy remains uncertain. Limited penetration of systemic antibiotics into the sinonasal mucosa has been reported previously by this group. This study aimed to investigate the short-term effects of antibiotics on the sinus and gut microbiota as well as any relationships these had with drug distribution. METHODS Thirty subjects undergoing functional endoscopic sinus surgery for CRS were randomized to one of three groups: (1) doxycycline (100 mg daily for 7 days); (2) roxithromycin (300 mg daily for 7 days); and (3) control (no antibiotics given). Sinonasal and stool samples collected before and after treatment were analyzed using 16S ribosomal RNA (rRNA) gene-targeted amplicon sequencing and Droplet Digital polymerase chain reaction (PCR) for bacterial community composition and the quantification of bacterial DNA, respectively. RESULTS There were no significant major bacterial community shifts or changes to bacterial diversity and load following the treatment period in all patient groups. Non-significant trend reductions were observed in gut microbial diversity with antibiotics. For the roxithromycin group, sinonasal bacterial diversity was negatively correlated with serum drug levels and reduced overall compared to controls (p < 0.05). The relative abundance of Staphylococcus ASV129 in sinonasal samples reduced with increasing mucus doxycycline levels (p = 0.01). CONCLUSION Antibiotic prescription for CRS should be further investigated because of preliminary evidence of poor sinonasal drug penetration, unproven efficacy, and the potential impact of dysbiosis in the sinuses and off-target sites. Further studies should consider distinguishing the presence of DNA from viable and nonviable bacteria.
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Affiliation(s)
- Joey Siu
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Lilian Klingler
- Research and Development, Zenith Technology Corporation Limited, Dunedin, New Zealand
| | - Kristi Biswas
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Yi Wang
- Research and Development, Zenith Technology Corporation Limited, Dunedin, New Zealand
| | - Cheung-Tak Hung
- Research and Development, Zenith Technology Corporation Limited, Dunedin, New Zealand
| | - Soo Hee Jeong
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Daniel Barnett
- Department of Statistics, University of Auckland, Auckland, New Zealand
| | - Malcolm Drummond Tingle
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
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14
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Orlandi RR, Kingdom TT, Smith TL, Bleier B, DeConde A, Luong AU, Poetker DM, Soler Z, Welch KC, Wise SK, Adappa N, Alt JA, Anselmo-Lima WT, Bachert C, Baroody FM, Batra PS, Bernal-Sprekelsen M, Beswick D, Bhattacharyya N, Chandra RK, Chang EH, Chiu A, Chowdhury N, Citardi MJ, Cohen NA, Conley DB, DelGaudio J, Desrosiers M, Douglas R, Eloy JA, Fokkens WJ, Gray ST, Gudis DA, Hamilos DL, Han JK, Harvey R, Hellings P, Holbrook EH, Hopkins C, Hwang P, Javer AR, Jiang RS, Kennedy D, Kern R, Laidlaw T, Lal D, Lane A, Lee HM, Lee JT, Levy JM, Lin SY, Lund V, McMains KC, Metson R, Mullol J, Naclerio R, Oakley G, Otori N, Palmer JN, Parikh SR, Passali D, Patel Z, Peters A, Philpott C, Psaltis AJ, Ramakrishnan VR, Ramanathan M, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Sedaghat AR, Senior BA, Sindwani R, Smith K, Snidvongs K, Stewart M, Suh JD, Tan BK, Turner JH, van Drunen CM, Voegels R, Wang DY, Woodworth BA, Wormald PJ, Wright ED, Yan C, Zhang L, Zhou B. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol 2021; 11:213-739. [PMID: 33236525 DOI: 10.1002/alr.22741] [Citation(s) in RCA: 408] [Impact Index Per Article: 136.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
I. EXECUTIVE SUMMARY BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. METHODS ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. RESULTS ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. CONCLUSION This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.
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Affiliation(s)
| | | | | | | | | | - Amber U Luong
- University of Texas Medical School at Houston, Houston, TX
| | | | - Zachary Soler
- Medical University of South Carolina, Charleston, SC
| | - Kevin C Welch
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Claus Bachert
- Ghent University, Ghent, Belgium.,Karolinska Institute, Stockholm, Sweden.,Sun Yatsen University, Gangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David A Gudis
- Columbia University Irving Medical Center, New York, NY
| | - Daniel L Hamilos
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Richard Harvey
- University of New South Wales and Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | | | - Amin R Javer
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital, UCLH, London, UK
| | - Kevin C McMains
- Uniformed Services University of Health Sciences, San Antonio, TX
| | | | - Joaquim Mullol
- IDIBAPS Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Alkis J Psaltis
- University of Adelaide, Adelaide, South Australia, Australia
| | | | | | | | - Luke Rudmik
- University of Calgary, Calgary, Alberta, Canada
| | - Raymond Sacks
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - De Yun Wang
- National University of Singapore, Singapore, Singapore
| | | | | | | | - Carol Yan
- University of California San Diego, La Jolla, CA
| | - Luo Zhang
- Capital Medical University, Beijing, China
| | - Bing Zhou
- Capital Medical University, Beijing, China
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15
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Swords CE, Wong JJ, Stevens KN, Psaltis AJ, Wormald PJ, Tan NCW. The Use of Postoperative Antibiotics Following Endoscopic Sinus Surgery for Chronic Rhinosinusitis: A Systematic Review and Meta-analysis. Am J Rhinol Allergy 2021; 35:700-712. [PMID: 33487001 DOI: 10.1177/1945892421989142] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Endoscopic sinus surgery is performed for medically recalcitrant chronic rhinosinusitis. There is no universally accepted strategy regarding post-operative antibiotics despite the high rates of usage worldwide. The aim of this study was to analyse patient-reported and objective outcomes behind antibiotic use following endoscopic sinus surgery. METHODS A search of electronic databases was performed. Eligible randomised controlled trials (RCTs) and observational trials were included. The primary outcome was patient reported outcome measures. Secondary outcomes were local infections, endoscopy scores and adverse events. Meta-analysis was performed. RESULTS Of 1045 publications identified, 7 were included in the qualitative synthesis and 5 RCTs were included in meta-analysis. Antibiotic regimens varied between studies in terms of antibiotic selection, timing commenced and duration of use. Meta-analysis suggested no significant difference between placebo and antibiotics in patient reported outcome measures (standardised mean difference (SMD) -0.215, 95% confidence interval (CI) -0.637 to 0.207) or endoscopic scores (SMD -2.86, 95% CI -0.846 to 0.273). There was no consistent definition in reporting of infection; therefore, this outcome cannot be comprehensively considered. No severe adverse events were attributable to antibiotics. CONCLUSIONS From the studies analysed, there is no level 1 evidence to suggest that antibiotics improved patient outcomes following sinus surgery. However, there was significant heterogeneity in outcome measures and no clear data exists regarding the effects of antibiotics on postoperative infections. The available evidence at present is not enough to make a recommendation in either direction. Further designed larger RCTs are required to investigate these questions in more detail.
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Affiliation(s)
- Chloe E Swords
- Department of Otolaryngology, West Suffolk Hospital, Bury St Edmunds, UK
| | - Jeremy J Wong
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Kara N Stevens
- Medical Statistics, University of Plymouth, Plymouth, UK
| | - Alkis J Psaltis
- Department of Otolaryngology, University of Adelaide, Adelaide, Australia
| | - Peter J Wormald
- College of Medicine and Health, University of Exeter Medical School, Exeter, UK
| | - Neil C-W Tan
- College of Medicine and Health, University of Exeter Medical School, Exeter, UK.,Department of Otolaryngology, Royal Cornwall Hospital, Truro, UK
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16
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Zhou AS, Prince AA, Maxfield AZ, Corrales CE, Shin JJ. Sinonasal Outcome Scores and Imaging: A Concurrent Assessment of Factors Influencing Their Association. Otolaryngol Head Neck Surg 2020; 165:215-222. [PMID: 33170758 DOI: 10.1177/0194599820972672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The overall discriminatory ability of validated instrument scores for computed tomography (CT) findings of chronic rhinosinusitis has limitations and may be modified by multiple factors. To support optimal methods for assessment, we studied which factors could influence this relationship, including the concurrent impact of multiple discrete CT scoring mechanisms, colocalized imaging findings, and nasal comorbid conditions. STUDY DESIGN Observational outcomes study. SETTING Academic medical center. METHODS Patients with sinonasal complaints who completed the 22-item Sinonasal Outcome Test (SNOT-22) and underwent CT were included. Multivariate ordinal regression was utilized to assess associations. CT data were quantified with the Lund-Mackay system, Zinreich system, and a direct measure of maximal mucosal thickness. The impact of incidental findings (mucous retention cysts, periapical dental disease) and nasal comorbid conditions was also assessed. RESULTS A total of 233 patients were included. SNOT-22 nasal scores were significantly associated with CT results when those with incidental findings were excluded, regardless of the radiologic scoring mechanism utilized: Lund-Mackay regression coefficient, 0.321 (P = .046); Zinreich, 0.340 (P = .033); and maximum mucosal thickness, 0.316 (P = .040). This relationship subsided when incidental findings were present. SNOT-22 overall scores, sleep scores, and psychological domain scores had no significant association with imaging results, regardless of radiologic scoring system utilized. Nasal comorbid conditions had inconsistent associations. CONCLUSIONS SNOT-22 nasal domain scores were associated with all 3 radiologic scoring systems when incidental findings were absent but not when they were present. Delineating the presence or absence of these colocalized findings affected the relationship between SNOT-22 scores and radiological results, beyond other concurrent factors.
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Affiliation(s)
- Allen S Zhou
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony A Prince
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Alice Z Maxfield
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - C Eduardo Corrales
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer J Shin
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
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17
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Maniakas A, Asmar MH, Renteria AE, Nayan S, Alromaih S, Endam LM, Sampalis JS, Desrosiers M. Azithromycin in high-risk, refractory chronic rhinosinusitus after endoscopic sinus surgery and corticosteroid irrigations: a double-blind, randomized, placebo-controlled trial. Int Forum Allergy Rhinol 2020; 11:747-754. [PMID: 32929891 DOI: 10.1002/alr.22691] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 08/23/2020] [Accepted: 08/24/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Refractory chronic rhinosinusitis (CRS) remains a significant burden for patients, often leaving them with few therapeutic options that provide low-morbidity, long-term, and meaningful symptomatologic and endoscopic disease improvement. Macrolides have long been thought to offer both an immunomodulatory and antimicrobial effect. Our objective was to evaluate the efficacy of low-dose, long-term azithromycin in a carefully selected high-risk population failing appropriate medical therapy of budesonide nasal irrigations (BNIs) and endoscopic sinus surgery (ESS). METHODS A double-blind, randomized, placebo-controlled trial was completed in a single tertiary-care center assessing the addition of 250 mg azithromycin, 3 times per week for 16 weeks, in adults failing ESS and high-volume BNIs. Associated comorbidities, as well as symptomatologic, microbiologic, and serologic values, were systematically collected. RESULTS A total of 128 patients were enrolled and underwent ESS followed by BNI. At the 4-month post-ESS visit, 48 patients showed disease persistence and were randomized to azithromycin or placebo. Overall, azithromycin, when compared with placebo, did not show a statistically significant difference in disease clearance (54% vs 33%, respectively; p = 0.146), although patients with disease clearance who were on azithromycin showed significantly better 22-item Sino-Nasal Outcome Test score improvements than patients on placebo (18 vs -0.9, respectively; p = 0.046). In a subgroup analysis excluding aspirin-exacerbated respiratory disease (AERD) patients, azithromycin significantly improved disease clearance when compared with placebo (71% vs 35%, respectively; p = 0.031), with a number needed to treat of 3 (2.8). CONCLUSION Low-dose azithromycin is a therapeutic option with few side effects. Its use can show favorable clinical outcomes in this difficult-to-treat population, especially if patients are AERD-negative.
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Affiliation(s)
- Anastasios Maniakas
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
- Division of Otolaryngology-Head & Neck Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
- Division of Experimental Surgery, McGill University, Montréal, Québec, Canada
- Division of Otolaryngology-Head & Neck Surgery, Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada
| | - Marc-Henri Asmar
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Axel Eluid Renteria
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
- Division of Otolaryngology-Head & Neck Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Smriti Nayan
- Division of Otolaryngology-Head & Neck Surgery, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, Cambridge Memorial Hospital, Cambridge, Ontario, Canada
| | - Saud Alromaih
- Division of Otolaryngology-Head & Neck Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
- Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Leandra Mfuna Endam
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - John Sam Sampalis
- Division of Experimental Surgery, McGill University, Montréal, Québec, Canada
- Medical Affairs, JSS Medical Research, Montréal, Québec, Canada
| | - Martin Desrosiers
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
- Division of Otolaryngology-Head & Neck Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
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18
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Zhou AS, Prince AA, Maxfield AZ, Corrales CE, Shin JJ. The Sinonasal Outcome Test-22 or European Position Paper: Which Is More Indicative of Imaging Results? Otolaryngol Head Neck Surg 2020; 164:212-218. [PMID: 32867591 PMCID: PMC7464048 DOI: 10.1177/0194599820953834] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objective The 22-item Sinonasal Outcome Test (SNOT-22) is a trusted measure of symptom severity in chronic rhinosinusitis. The European Position Paper on Rhinosinusitis (EPOS) provides widely accepted diagnostic criteria, which include sinonasal symptoms, their duration, and imaging results. Our objective was to compare these approaches to assessing symptoms to determine if either was more indicative of radiologic findings, to support decisions in telehealth. Study Design Observational outcomes study. Setting Tertiary care center. Methods In total, 162 consecutive patients provided a structured sinonasal history, completed the SNOT-22, and underwent sinus computed tomography (CT) within 1 month. SNOT-22 scores, EPOS-defined symptom sets, and Lund-Mackay results were assessed. To facilitate direct comparisons, we performed stepwise evaluations of sinonasal symptoms alone and combined with duration. The discriminatory capacity for imaging results was determined through areas under the receiver operating characteristic curves (ROC-AUC) for dichotomous outcomes and ordinal regression for multilevel outcomes. Results In ROC-AUC analyses, SNOT-22 and EPOS-defined symptoms had similar discriminatory capacity for Lund-Mackay scores, regardless of duration. Within ordinal regression analyses, SNOT-22 nasal scores were significantly associated with Lund-Mackay scores, while EPOS-defined nasal symptoms were not statistically significantly related. Conclusions SNOT-22 nasal scores and EPOS-defined nasal symptoms may have similar associations with imaging results when assessed via ROC-AUC, while SNOT-22 may have more association within ordinal data. Understanding the implications of discrete patterns of symptoms may confer benefit, particularly when in-person and fiberoptic exams are limited.
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Affiliation(s)
- Allen S Zhou
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony A Prince
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Alice Z Maxfield
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - C Eduardo Corrales
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer J Shin
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, USA
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Thompson HM, Lim D, Banks C, Grayson JW, Ayinala S, Cho D, Woodworth BA. Antibiotic eluting sinus stents. Laryngoscope Investig Otolaryngol 2020; 5:598-607. [PMID: 32864430 PMCID: PMC7444760 DOI: 10.1002/lio2.423] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/29/2020] [Accepted: 06/12/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Chronic rhinosinusitis (CRS) is a multifactorial disease affecting up to 16% of the United States population and disproportionately affecting the cystic fibrosis (CF) patient population. Despite treating the underlying infection, the use of systemic antibiotics has shown little efficacy in alleviation of symptom burden. This review seeks to discuss recent research on novel antibiotic eluting stent therapy in vitro and within animal models as well as the factors that contribute to its efficacy. DATA SOURCES PubMed literature review. REVIEW METHODS A review of all published literature related to antibiotic eluting sinus stents was conducted to integrate and summarize this innovative approach to chronic sinus infections. RESULTS Placement of the ciprofloxacin sinus stent (CSS) and ciprofloxacin-ivacaftor sinus stent (CISS) exhibited improvement in endoscopic and radiographic findings in rabbit CRS models. While the CSS showed an overall trend toward improvement in microscopic findings and a reduction in biofilm mass, there remained a significant quantity of planktonic bacteria due to antibiotic depletion from an initial burst release in the first 48 hours of stent placement. The CISS and ciprofloxacin-azithromycin sinus stents (CASSs) exhibited controlled antibiotic release over the study period leading to greatly reduced planktonic bacterial load and biofilm mass. In vitro studies indicate that CASS may be just as efficacious at reducing biofilm mass. CONCLUSION Antibiotic eluting sinus stents show significant promise as a novel therapeutic strategy for CRS. The CISS may have particular promise for the CF patient population by addressing both the infectious and genetic components of disease. Animal studies demonstrate significant promise for translation into human studies. Human clinical trials are warranted to determine the efficacy of antibiotic sinus stents in human patients. LEVEL OF EVIDENCE NA.
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Affiliation(s)
- Harrison M. Thompson
- Department of Otolaryngology Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Dong‐Jin Lim
- Department of Otolaryngology Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Catherine Banks
- Prince of Wales and Sydney HospitalsUniversity of New South WalesSydneyNew South WalesAustralia
| | - Jessica W. Grayson
- Department of Otolaryngology Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Samrath Ayinala
- Department of Otolaryngology Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Do‐Yeon Cho
- Department of Otolaryngology Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Gregory Fleming James Cystic Fibrosis Research CenterBirminghamAlabamaUSA
| | - Bradford A. Woodworth
- Department of Otolaryngology Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Gregory Fleming James Cystic Fibrosis Research CenterBirminghamAlabamaUSA
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20
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Lim DJ, Thompson HM, Walz CR, Ayinala S, Skinner D, Zhang S, Grayson JW, Cho DY, Woodworth BA. Azithromycin and ciprofloxacin inhibit interleukin-8 secretion without disrupting human sinonasal epithelial integrity in vitro. Int Forum Allergy Rhinol 2020; 11:136-143. [PMID: 32725797 DOI: 10.1002/alr.22656] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/16/2020] [Accepted: 06/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND We recently developed a ciprofloxacin and azithromycin sinus stent (CASS) to target recalcitrant infections in chronic rhinosinusitis (CRS). The objective of this study was to evaluate the anti-inflammatory activity of azithromycin released from the CASS and assess the impact on the integrity and function of primary human sinonasal epithelial cells (HSNECs). METHODS Pseudomonas aeruginosa lipopolysaccharide (LPS)-stimulated HSNECs were treated with azithromycin and/or ciprofloxacin at concentrations attainable from CASS release. Interleukin-8 (IL-8) secretion was quantified by enzyme-linked immunosorbent assay (ELISA). Epithelial integrity (transepithelial resistance [TEER], paracellular permeability [fluorescein isothiocyanate-labeled dextran], lactate dehydrogenase [LDH] assays) and function (ciliary beat frequency [CBF]) were also evaluated. RESULTS Azithromycin significantly reduced secreted IL-8 from P. aeruginosa LPS-stimulated HSNECs at all concentrations tested (mean ± standard deviation; control = 5.77 ± 0.39 ng/mL, azithromycin [6 μg/mL] = 4.58 ± 0.40 ng/mL, azithromycin [60 µg/mL] = 4.31 ± 0.06, azithromycin [180 µg/mL] = 4.27 ± 0.26 ng/mL, p < 0.05). Co-incubation with azithromycin (6 µg/mL) and ciprofloxacin (2.4 µg/mL) in LPS-stimulated HSNECs also displayed a significant reduction in secreted IL-8 when compared to P. aeruginosa LPS alone (co-treatment = 4.61 ± 0.29 ng/mL, P. aeruginosa LPS = 7.35 ± 0.89 ng/mL, p < 0.01). The drugs did not negatively impact TEER, paracellular permeability, LDH release, or CBF, indicating retention of cell integrity and function. CONCLUSION Azithromycin decreased P. aeruginosa LPS IL-8 production in HSNECs at drug concentrations attainable with sustained release of azithromycin from the CASS. In addition to antibacterial activity, anti-inflammatory properties of the CASS should provide further benefit for patients with recalcitrant CRS.
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Affiliation(s)
- Dong-Jin Lim
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL
| | | | | | - Samrath Ayinala
- Department of Biology, University of Alabama at Birmingham, Birmingham, AL
| | - Daniel Skinner
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Shaoyan Zhang
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jessica W Grayson
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Do-Yeon Cho
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL.,Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL.,Division of Otolaryngology, Department of Surgery, Veterans Affairs, Birmingham, AL
| | - Bradford A Woodworth
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, AL.,Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, AL
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21
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Lees KA, Orlandi RR, Oakley G, Alt JA. The Role of Macrolides and Doxycycline in Chronic Rhinosinusitis. Immunol Allergy Clin North Am 2020; 40:303-315. [PMID: 32278453 DOI: 10.1016/j.iac.2019.12.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Antibiotic therapy has become an important adjunct in the management of recalcitrant chronic rhinosinusitis (CRS) because of some antibiotics' immunomodulatory properties even at subtherapeutic antimicrobial levels. Macrolide antibiotics, such as clarithromycin and azithromycin, decrease production of proinflammatory cytokines, impair neutrophil recruitment, inhibit bacterial biofilm formation, and improve mucus quality. Doxycycline, a tetracycline antibiotic, inhibits the activity of matrix metalloproteinases in CRS with nasal polyposis. This article reviews the clinical applications for macrolide and doxycycline use in CRS, considerations for dosing and duration of treatment, and important side effects and drug interactions associated with these medications.
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Affiliation(s)
- Katherine A Lees
- Rhinology and Anterior Skull Base Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Utah, 50 North Medical Drive, #3C120, Salt Lake City, UT 84132, USA. https://twitter.com/TheSnotShot
| | - Richard R Orlandi
- Division of Otolaryngology-Head and Neck Surgery, University of Utah, 50 North Medical Drive, #3C120, Salt Lake City, UT 84132, USA
| | - Gretchen Oakley
- Division of Otolaryngology-Head and Neck Surgery, University of Utah, 50 North Medical Drive, #3C120, Salt Lake City, UT 84132, USA
| | - Jeremiah A Alt
- Division of Otolaryngology-Head and Neck Surgery, University of Utah, 50 North Medical Drive, #3C120, Salt Lake City, UT 84132, USA.
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22
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Gohy S, Hupin C, Ladjemi MZ, Hox V, Pilette C. Key role of the epithelium in chronic upper airways diseases. Clin Exp Allergy 2019; 50:135-146. [PMID: 31746062 DOI: 10.1111/cea.13539] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/15/2019] [Accepted: 11/15/2019] [Indexed: 12/18/2022]
Abstract
The respiratory epithelium of the upper airways is a first-line defence against inhaled irritants, pathogens and allergens. It ensures a physical barrier provided by apical junctions and mucociliary clearance to avoid excessive activation of the immune system. The epithelium also forms a chemical and immunological barrier, extensively equipped to protect the airways against external aggressions before the adaptive immune system is required. Under normal circumstances, the epithelium is capable of recovering rapidly after damage. This manuscript reviews these main properties of the upper airway epithelium as well as its reported impairments in chronic inflammatory diseases. The knowledge on normal epithelial functions and their dysregulation in upper airway diseases should help to design new epithelial-targeted treatments.
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Affiliation(s)
- Sophie Gohy
- Pole of Pneumology, ENT and Dermatology, Université catholique de Louvain (UCL), Brussels, Belgium.,Department of Pneumology, Cliniques universitaires, Brussels, Belgium
| | - Cloé Hupin
- Pole of Pneumology, ENT and Dermatology, Université catholique de Louvain (UCL), Brussels, Belgium
| | - Maha Zohra Ladjemi
- Institut Cochin, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Valérie Hox
- Department of Otorhinolaryngology, Cliniques universitaires, Brussels, Belgium
| | - Charles Pilette
- Pole of Pneumology, ENT and Dermatology, Université catholique de Louvain (UCL), Brussels, Belgium.,Department of Pneumology, Cliniques universitaires, Brussels, Belgium
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23
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Bezerra TFP, Pezato R, de Barros PM, Coutinho LL, Costa LF, Pinna F, Voegels R. Prospective evaluation of clarithromycin in recurrent chronic rhinosinusitis with nasal polyps. Braz J Otorhinolaryngol 2019; 87:298-304. [PMID: 32144032 PMCID: PMC9422620 DOI: 10.1016/j.bjorl.2019.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 06/18/2019] [Accepted: 09/11/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction The antiinflammatory effects of macrolides, especially clarithromycin, have been described in patients with chronic rhinosinusitis without polyps and also other chronic inflammatory airway diseases. There is no consensus in the literature regarding the effectiveness of clarithromycin in patients with chronic rhinosinusitis with sinonasal polyposis and the national literature does not report any prospective studies on the efficacy of clarithromycin in chronic rhinosinusitis in our population. Objective To evaluate the effect of clarithromycin in the adjunctive treatment of recurrent chronic rhinosinusitis with sinonasal polyposis refractory to clinical and surgical treatment. Methods Open prospective study with 52 patients with chronic rhinosinusitis and recurrent sinonasal polyposis. All subjects received nasal lavage with 20 mL 0.9% SS and fluticasone nasal spray, 200 mcg / day, 12/12 h for 12 weeks; and clarithromycin 250 mg 8/8 h for 2 weeks and, thereafter, 12/12 h for 10 weeks. The patients were assessed by SNOT 20, NOSE and Lund-Kennedy scales before, immediately after treatment and 12 weeks after treatment. The patients were also evaluated before treatment with paranasal cavity computed tomography (Lund-Mackay) and serum IgG, IgM, IgA, IgE and eosinophil levels. The outcomes evaluated were: SNOT-20, NOSE and Lund-Kennedy. Results Most patients were women, aged 47 (15) years (median / interquartile range), and 61.5% (32/52) had asthma. All patients completed the follow-up after 12 weeks and 42.3% (22/52) after 24 weeks. Treatment resulted in a quantitative decrease in the SNOT-20 [2.3 (1.6) vs. 1.4 (1.6); Δ = −0.9 (1.1); p < 0.01]; NOSE [65 (64) vs. 20 (63); Δ = −28 (38), p < 0.01] and Lund-Kennedy [11 (05) vs. 07 (05); Δ = −2 (05); p < 0.01] scores. SNOT-20 showed a qualitative improvement (>0.8) in 54% (28/52, p < 0.04) of patients, a group that showed lower IgE level [108 (147) vs. 289 (355), p < 0.01]. The group of patients who completed follow-up 12 weeks after the end of treatment (n = 22) showed no worsening of outcomes. Conclusion Long-term adjuvant use of low-dose clarithromycin for chronic rhinosinusitis patients with recurrent sinonasal polyposis refractory to clinical and surgical treatment has resulted in improved quality of life and nasal endoscopy findings, especially in patients with normal IgE levels. This improvement persisted in the patient group evaluated 12 weeks after the end of the treatment.
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Affiliation(s)
- Thiago Freire Pinto Bezerra
- Universidade Federal de Pernambuco (UFPE), Hospital das Clínicas, Departamento de Otorrinolaringologia, Recife, PE, Brazil; Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil.
| | - Rogério Pezato
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil; Escola Paulista de Medicina (EPM/Unifesp), São Paulo, SP, Brazil
| | - Pâmella Marletti de Barros
- Universidade Federal de Pernambuco (UFPE), Hospital das Clínicas, Departamento de Otorrinolaringologia, Recife, PE, Brazil
| | - Larissa Leal Coutinho
- Universidade Federal de Pernambuco (UFPE), Hospital das Clínicas, Departamento de Otorrinolaringologia, Recife, PE, Brazil
| | - Leidianny Firmino Costa
- Instituição Materno Infantil de Pernambuco (IMIP), Departamento de Otorrinolaringologia, Recife, PE, Brazil
| | - Fabio Pinna
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Richard Voegels
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
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24
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Yancey KL, Lowery AS, Chandra RK, Chowdhury NI, Turner JH. Advanced age adversely affects chronic rhinosinusitis surgical outcomes. Int Forum Allergy Rhinol 2019; 9:1125-1134. [PMID: 31454179 PMCID: PMC6773466 DOI: 10.1002/alr.22404] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 07/09/2019] [Accepted: 07/18/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patient-specific and disease-specific factors shape the course of chronic rhinosinusitis (CRS) and its response to treatment, with optimal management involving interventions tailored to these factors. Recent evidence suggests CRS inflammatory signatures depend on age. The objective of this study was to determine whether age also influences quality-of-life (QOL) and postoperative outcomes. METHODS Retrospective analysis of prospectively collected QOL data from 403 adults with medically refractory CRS who underwent functional endoscopic sinus surgery (FESS) at a tertiary care medical center between 2014 and 2018 was undertaken. Total and subdomain scores from the 22-item Sino-Nasal Outcome Test (SNOT-22) and the Short Form 8 Health Survey (SF-8) measure of general health completed at preoperative and postoperative visits were reviewed. RESULTS Patients were divided into young (18 to 39 years, n = 100), middle-aged (40 to 59 years, n = 172), and elderly (≥60 years, n = 131) groups. Baseline total SNOT-22 scores differed between groups (p = 0.01), with middle-aged patients having the highest symptom burden and elderly patients having the lowest. Similar patterns were observed for SNOT-22 subdomains. Elderly patients reported smaller improvements and were less likely to achieve a minimally important clinical difference. CRS patients had worse SF-8 scores compared to the general population, and elderly patients were the least likely to match population norms following surgery. Age was an independent predictor of QOL outcomes after FESS. CONCLUSION Age may play a significant role in CRS pathophysiology, symptom burden, and surgical outcomes. Elderly patients report smaller improvements in disease-specific and general health QOL after surgery. CRS management in the elderly population should incorporate age-dependent differences in symptom burden and expectations into treatment algorithms.
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Affiliation(s)
- Kristen L Yancey
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Anne S Lowery
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Rakesh K Chandra
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Naweed I Chowdhury
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Justin H Turner
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN
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25
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Wu SH, Hsu SH, Liang KL, Jiang RS. The effects of erythromycin towards the treatment of persistent rhinosinusitis after functional endoscopic sinus surgery: A randomized, active comparator-controlled study. J Chin Med Assoc 2019; 82:322-327. [PMID: 30946210 DOI: 10.1097/jcma.0000000000000041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Long-term, low-dose macrolide treatment has been in recent use to treat chronic rhinosinusitis. In this study, we investigated the effect of long-term, low-dose erythromycin on patients who had persistent rhinosinusitis after functional endoscopic sinus surgery (FESS). METHODS Patients with persistent rhinosinusitis for 3 months after FESS were recruited and randomly assigned to two groups. Patients in the erythromycin group took erythromycin (250 mg twice a day) for 12 weeks, while those in the intranasal steroid group were administered with mometasone furoate nasal spray for 12 weeks. Both before and after treatment, sino-nasal symptoms were assessed via questionnaires. Patients also received an endoscopic examination, acoustic rhinometry, smell test, and saccharine transit test. A bacterial culture was obtained from the middle meatus. RESULTS Seventy-two patients completed the study, with 35 in the erythromycin group and 37 in the intranasal steroid group. Endoscopic scores decreased significantly after treatment in both groups. Erythromycin improved the smell threshold and saccharine transit time better than the intranasal steroid. In contrast, the intranasal steroid increased the second minimal cross-sectional area of the nasal cavity at a level greater than erythromycin had. CONCLUSION Our study showed that long-term, low-dose erythromycin treatment improved the endoscopic score, smell threshold, and saccharine transit time in patients with persistent rhinosinusitis after FESS.
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Affiliation(s)
- Shang-Heng Wu
- Department of Otolaryngology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Shuo-Hsiu Hsu
- Department of Otolaryngology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Kai-Li Liang
- Department of Otolaryngology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
- Faculty of Medicine, National Yang-Ming Medical University, Taipei, Taiwan, ROC
| | - Rong-San Jiang
- Department of Otolaryngology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
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26
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Seresirikachorn K, Suwanparin N, Srisunthornphanich C, Chitsuthipakorn W, Kanjanawasee D, Snidvongs K. Factors of success of low-dose macrolides in chronic sinusitis: Systematic review and meta-analysis. Laryngoscope 2019; 129:1510-1519. [DOI: 10.1002/lary.27865] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Kachorn Seresirikachorn
- Department of Otolaryngology; Bangkok Thailand
- Endoscopic Nasal and Sinus Surgery Excellence Center; King Chulalongkorn Memorial Hospital; Bangkok Thailand
| | | | | | | | - Dichapong Kanjanawasee
- Department of Otolaryngology; Bangkok Thailand
- Endoscopic Nasal and Sinus Surgery Excellence Center; King Chulalongkorn Memorial Hospital; Bangkok Thailand
| | - Kornkiat Snidvongs
- Department of Otolaryngology; Bangkok Thailand
- Endoscopic Nasal and Sinus Surgery Excellence Center; King Chulalongkorn Memorial Hospital; Bangkok Thailand
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27
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Hansen MP, Scott AM, McCullough A, Thorning S, Aronson JK, Beller EM, Glasziou PP, Hoffmann TC, Clark J, Del Mar CB. Adverse events in people taking macrolide antibiotics versus placebo for any indication. Cochrane Database Syst Rev 2019; 1:CD011825. [PMID: 30656650 PMCID: PMC6353052 DOI: 10.1002/14651858.cd011825.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Macrolide antibiotics (macrolides) are among the most commonly prescribed antibiotics worldwide and are used for a wide range of infections. However, macrolides also expose people to the risk of adverse events. The current understanding of adverse events is mostly derived from observational studies, which are subject to bias because it is hard to distinguish events caused by antibiotics from events caused by the diseases being treated. Because adverse events are treatment-specific, rather than disease-specific, it is possible to increase the number of adverse events available for analysis by combining randomised controlled trials (RCTs) of the same treatment across different diseases. OBJECTIVES To quantify the incidences of reported adverse events in people taking macrolide antibiotics compared to placebo for any indication. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which includes the Cochrane Acute Respiratory Infections Group Specialised Register (2018, Issue 4); MEDLINE (Ovid, from 1946 to 8 May 2018); Embase (from 2010 to 8 May 2018); CINAHL (from 1981 to 8 May 2018); LILACS (from 1982 to 8 May 2018); and Web of Science (from 1955 to 8 May 2018). We searched clinical trial registries for current and completed trials (9 May 2018) and checked the reference lists of included studies and of previous Cochrane Reviews on macrolides. SELECTION CRITERIA We included RCTs that compared a macrolide antibiotic to placebo for any indication. We included trials using any of the four most commonly used macrolide antibiotics: azithromycin, clarithromycin, erythromycin, or roxithromycin. Macrolides could be administered by any route. Concomitant medications were permitted provided they were equally available to both treatment and comparison groups. DATA COLLECTION AND ANALYSIS Two review authors independently extracted and collected data. We assessed the risk of bias of all included studies and the quality of evidence for each outcome of interest. We analysed specific adverse events, deaths, and subsequent carriage of macrolide-resistant bacteria separately. The study participant was the unit of analysis for each adverse event. Any specific adverse events that occurred in 5% or more of any group were reported. We undertook a meta-analysis when three or more included studies reported a specific adverse event. MAIN RESULTS We included 183 studies with a total of 252,886 participants (range 40 to 190,238). The indications for macrolide antibiotics varied greatly, with most studies using macrolides for the treatment or prevention of either acute respiratory tract infections, cardiovascular diseases, chronic respiratory diseases, gastrointestinal conditions, or urogynaecological problems. Most trials were conducted in secondary care settings. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin.Most studies (89%) reported some adverse events or at least stated that no adverse events were observed.Gastrointestinal adverse events were the most commonly reported type of adverse event. Compared to placebo, macrolides caused more diarrhoea (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.34 to 2.16; low-quality evidence); more abdominal pain (OR 1.66, 95% CI 1.22 to 2.26; low-quality evidence); and more nausea (OR 1.61, 95% CI 1.37 to 1.90; moderate-quality evidence). Vomiting (OR 1.27, 95% CI 1.04 to 1.56; moderate-quality evidence) and gastrointestinal disorders not otherwise specified (NOS) (OR 2.16, 95% CI 1.56 to 3.00; moderate-quality evidence) were also reported more often in participants taking macrolides compared to placebo.The number of additional people (absolute difference in risk) who experienced adverse events from macrolides was: gastrointestinal disorders NOS 85/1000; diarrhoea 72/1000; abdominal pain 62/1000; nausea 47/1000; and vomiting 23/1000.The number needed to treat for an additional harmful outcome (NNTH) ranged from 12 (95% CI 8 to 23) for gastrointestinal disorders NOS to 17 (9 to 47) for abdominal pain; 19 (12 to 33) for diarrhoea; 19 (13 to 30) for nausea; and 45 (22 to 295) for vomiting.There was no clear consistent difference in gastrointestinal adverse events between different types of macrolides or route of administration.Taste disturbances were reported more often by participants taking macrolide antibiotics, although there were wide confidence intervals and moderate heterogeneity (OR 4.95, 95% CI 1.64 to 14.93; I² = 46%; low-quality evidence).Compared with participants taking placebo, those taking macrolides experienced hearing loss more often, however only four studies reported this outcome (OR 1.30, 95% CI 1.00 to 1.70; I² = 0%; low-quality evidence).We did not find any evidence that macrolides caused more cardiac disorders (OR 0.87, 95% CI 0.54 to 1.40; very low-quality evidence); hepatobiliary disorders (OR 1.04, 95% CI 0.27 to 4.09; very low-quality evidence); or changes in liver enzymes (OR 1.56, 95% CI 0.73 to 3.37; very low-quality evidence) compared to placebo.We did not find any evidence that appetite loss, dizziness, headache, respiratory symptoms, blood infections, skin and soft tissue infections, itching, or rashes were reported more often by participants treated with macrolides compared to placebo.Macrolides caused less cough (OR 0.57, 95% CI 0.40 to 0.80; moderate-quality evidence) and fewer respiratory tract infections (OR 0.70, 95% CI 0.62 to 0.80; moderate-quality evidence) compared to placebo, probably because these are not adverse events, but rather characteristics of the indications for the antibiotics. Less fever (OR 0.73, 95% 0.54 to 1.00; moderate-quality evidence) was also reported by participants taking macrolides compared to placebo, although these findings were non-significant.There was no increase in mortality in participants taking macrolides compared with placebo (OR 0.96, 95% 0.87 to 1.06; I² = 11%; low-quality evidence).Only 24 studies (13%) provided useful data on macrolide-resistant bacteria. Macrolide-resistant bacteria were more commonly identified among participants immediately after exposure to the antibiotic. However, differences in resistance thereafter were inconsistent.Pharmaceutical companies supplied the trial medication or funding, or both, for 91 trials. AUTHORS' CONCLUSIONS The macrolides as a group clearly increased rates of gastrointestinal adverse events. Most trials made at least some statement about adverse events, such as "none were observed". However, few trials clearly listed adverse events as outcomes, reported on the methods used for eliciting adverse events, or even detailed the numbers of people who experienced adverse events in both the intervention and placebo group. This was especially true for the adverse event of bacterial resistance.
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Affiliation(s)
| | - Anna M Scott
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Amanda McCullough
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Sarah Thorning
- Gold Coast Hospital and Health ServiceGCUH LibraryLevel 1, Block E, GCUHSouthportQueenslandAustralia4215
| | - Jeffrey K Aronson
- Oxford UniversityNuffield Department of Primary Care Health SciencesOxfordOxonUKOX26GG
| | - Elaine M Beller
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Paul P Glasziou
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Tammy C Hoffmann
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Justin Clark
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
| | - Chris B Del Mar
- Bond UniversityCentre for Research in Evidence‐Based Practice (CREBP)14 University DriveGold CoastQueenslandAustralia4229
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28
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Shen S, Lou H, Wang C, Zhang L. Macrolide antibiotics in the treatment of chronic rhinosinusitis: evidence from a meta-analysis. J Thorac Dis 2018; 10:5913-5923. [PMID: 30505500 DOI: 10.21037/jtd.2018.10.41] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The purpose of this study was to systematically assess the subjective and objective outcomes of macrolide therapy for chronic rhinosinusitis (CRS). Methods PubMed, Embase and Cochrane databases were searched for clinical trials detailing the effects of macrolide therapy in patients with CRS and published up to December 2017. Sino-Nasal Outcome Test (SNOT), endoscopic scores and computed tomography scans (CT) scores were assessed by mean difference (MD) or standardized mean difference (SMD) with 95% confidence interval. Subgroup analyses were performed to evaluate the source of heterogeneity according to study design and geographic locations. I2 metric was used to assess the heterogeneity. Results Seven randomised clinical trials (RCTs) and four cohort trials meeting pre-determined selection criteria were enrolled in this meta-analysis. Assessment of the findings for SNOT after 12 weeks' macrolide treatment demonstrated a significant improvement in subgroup of trials in Asian patients (SMD =-0.51; 95% CI: -0.96, -0.02; P=0.04), but not in non-Asians (SMD =-0.01; 95% CI: -0.65, 0.63; P=0.98). At 12 or 24 weeks' visit no significant difference in SNOT was noted compared with control group, either in RCTs or cohort trials subgroups. However, findings for endoscopic scores were found to be significantly improved compared to placebo in the subgroup of non-RCT studies after 8 weeks (SMD =-0.77; 95% CI: -1.07, -0.46; P<0.00001) and 12 weeks (SMD=-1.40; 95% CI: -1.97, -0.82; P<0.00001) of macrolide therapy. Similarly, findings for CT scores showed significant improvements in CT scores compared to baseline after 12 weeks' treatment (MD=-5.81; 95% CI: -8.10, -3.52; P<0.00001) in cohort trials. Conclusions Macrolide therapy can significantly improve endoscopic and CT scores in CRS patients, compared to baseline. Further well-designed studies are needed to confirm the efficacy and safety of macrolides in CRS treatment.
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Affiliation(s)
- Shen Shen
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Hongfei Lou
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China.,Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing 100005, China
| | - Chengshuo Wang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China.,Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing 100005, China
| | - Luo Zhang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China.,Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing 100005, China.,Department of Allergy, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
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Maniakas A, Asmar MH, Renteria Flores AE, Nayan S, Alromaih S, Mfuna Endam L, Desrosiers MY. Staphylococcus aureus on Sinus Culture Is Associated With Recurrence of Chronic Rhinosinusitis After Endoscopic Sinus Surgery. Front Cell Infect Microbiol 2018; 8:150. [PMID: 29868506 PMCID: PMC5962714 DOI: 10.3389/fcimb.2018.00150] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 04/20/2018] [Indexed: 01/20/2023] Open
Abstract
Objectives: Identify whether identification of S. aureus on conventional culture is a predictor of success or failure after ESS followed by budesonide nasal irrigations (BUD) in chronic rhinosinusitis (CRS) patients at high risk of recurrence. Methodology: Prospective clinical trial including 116 patients from a tertiary care center at high-risk of disease recurrence following ESS+BUD. Blood samples, microbial swabs, and SNSS/SNOT-22 were taken on the day of surgery (Visit-1) and 4 months postoperatively (Visit-2). Outcomes were evaluated using symptoms and mucosal status as assessed by the Lund-Kennedy endoscopic score. Results: Seventy-five patients (69.4%) attained SNOT-22 MCID or higher. (Mean = 33.4, range 9–75). Objective documentation of recurrence of disease, as defined by combined endoscopic/symptomatic criteria, was noted in 58/116 patients (50%). Revision surgery was associated with a significantly higher rate of disease recurrence (60.0 vs. 28.0%; p < 0.001). Culture for Staphylococcus aureus was associated with disease recurrence, preoperatively and at 4 months post-surgery (p = 0.020; p < 0.001). This was restricted to post-operative cultures in the revision group (10.0 vs. 48.8%; p < 0.001). Other factors associated with poor outcome included intolerance to non-steroidal anti-inflammatory drugs (NSAID) (p = 0.036). Significantly higher Lund-Kennedy scores in the recurrence groups despite similar symptom intensity, emphasizing the importance of considering objective outcome in addition to patient-reported ones. Conclusion: Patients undergoing revision ESS are at high risk of disease recurrence, even when budesonide irrigations are used post operatively. Presence of S. aureus on culture pre-operatively or at 4 months post-ESS is associated with a negative outcome. This suggests that S. aureus negatively influences outcome, possibly via a number of mechanisms, including interactions with the (i) immune system, (ii) regeneration and repair of the sinus epithelium, or (iii) via interference with the sinus microbiome. This suggests that S. aureus may be a simple and inexpensive biomarker for disease severity and indicates a clear need to better appreciate S. aureus on how it contributes mechanistically to disease development and persistence in order to develop targeted therapeutic strategies.
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Affiliation(s)
- Anastasios Maniakas
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.,Division of Otolaryngology-Head and Neck Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Marc-Henri Asmar
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Axel E Renteria Flores
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Smriti Nayan
- Division of Otolaryngology-Head and Neck Surgery, McMaster University, Hamilton, ON, Canada.,Department of Surgery, Cambridge Memorial Hospital, Cambridge, ON, Canada
| | - Saud Alromaih
- Division of Otolaryngology-Head and Neck Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.,Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Leandra Mfuna Endam
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Martin Y Desrosiers
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.,Division of Otolaryngology-Head and Neck Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
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Soler ZM, Jones R, Le P, Rudmik L, Mattos JL, Nguyen SA, Schlosser RJ. Sino-Nasal outcome test-22 outcomes after sinus surgery: A systematic review and meta-analysis. Laryngoscope 2017; 128:581-592. [PMID: 29164622 DOI: 10.1002/lary.27008] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/15/2017] [Accepted: 10/19/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVES/HYPOTHESIS The goal of the study was to perform a systematic review with meta-analysis to determine the mean change in the 22-item Sino-Nasal Outcome Test (SNOT-22) across patients who have had endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) in the literature. METHODS A literature search was performed to identify studies that assessed SNOT-22 scores before and after ESS in adult patients with CRS. A random effects model with inverse variance weighting was used to generate the mean change after surgery, along with the forest plot and 95% confidence interval (CI). The impact of patient-specific factors across studies was assessed using a mixed-effects meta-regression. RESULTS The final study list included 40 unique patient cohorts published from 2008 to 2016. All studies showed a statistically significant change in mean SNOT-22 scores between baseline and postoperative time points (P < .001), ranging from 12.7 to 44.8, at an average follow-up of 10.6 months. The summary change in mean SNOT-22 across all studies was 24.4 (95% CI: 22.0-26.8). After forward, step-wise multivariate modeling, studies with higher mean preoperative SNOT-22 score and higher asthma prevalence were associated with greater changes in SNOT-22 score after ESS, whereas studies with longer mean follow-up had smaller changes in SNOT-22 score. CONCLUSIONS Studies evaluating quality-of-life outcomes after sinus surgery using the SNOT-22 instrument universally show significant improvement after ESS. Across the published literature, the magnitude of change is quite variable and appears to be influenced by a number of factors including baseline SNOT-22 score, asthma prevalence, and length of follow-up. Laryngoscope, 128:581-592, 2018.
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Affiliation(s)
- Zachary M Soler
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Rabun Jones
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Phong Le
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Luke Rudmik
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Jose L Mattos
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Shaun A Nguyen
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Rodney J Schlosser
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A
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Abstract
PURPOSE OF REVIEW We assess the literature on the pharmacokinetics, indications, important considerations, and effectiveness of long-term, low-dose macrolide antibiotics in chronic rhinosinusitis (CRS). RECENT FINDINGS The key to effective implementation of macrolide therapy in CRS is appropriate patient selection. Macrolides have demonstrated the most benefit in Th1-mediated non-eosinophilic CRS when used for durations of at least 3 months. Macrolide antibiotics have demonstrated great benefit when used for their anti-inflammatory or immunomodulatory properties, which include the blockage of pro-inflammatory cytokines, such as interleukin (IL)-8 and tumor necrosis factor-α (TNF-α). They have been used in CRS patients not responding to traditional corticosteroid-based treatment regimens, but appear to be most effective specifically in Th1-mediated non-eosinophilic CRS in long durations and low doses. Further research is needed to better identify characteristics known to correlate with macrolide response so early directed therapy can be implemented.
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Lasso A, Masoudian P, Quinn J, Cowan J, Labajian V, Bonaparte J, Kilty S. Long-term low-dose macrolides for chronic rhinosinusitis in adults - a systematic review of the literature. Clin Otolaryngol 2016; 42:637-650. [DOI: 10.1111/coa.12787] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2016] [Indexed: 12/17/2022]
Affiliation(s)
- A. Lasso
- The Ottawa Hospital Research Institute; Ottawa ON Canada
| | - P. Masoudian
- Faculty of Medicine; The University of Ottawa; Ottawa ON Canada
| | - J.G. Quinn
- Department of Pathology and Laboratory Medicine; Dalhousie University; Halifax NS Canada
| | - J. Cowan
- Division of Infectious Diseases; Department of Medicine; University of Ottawa; Ottawa ON Canada
| | - V. Labajian
- Department of Otolaryngology- Head and Neck Surgery; The University of Ottawa; Ottawa ON Canada
| | - J.P. Bonaparte
- The Ottawa Hospital Research Institute; Ottawa ON Canada
- Department of Otolaryngology- Head and Neck Surgery; The University of Ottawa; Ottawa ON Canada
| | - S. Kilty
- The Ottawa Hospital Research Institute; Ottawa ON Canada
- Department of Otolaryngology- Head and Neck Surgery; The University of Ottawa; Ottawa ON Canada
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Head K, Chong LY, Piromchai P, Hopkins C, Philpott C, Schilder AGM, Burton MJ. Systemic and topical antibiotics for chronic rhinosinusitis. Cochrane Database Syst Rev 2016; 4:CD011994. [PMID: 27113482 PMCID: PMC8763400 DOI: 10.1002/14651858.cd011994.pub2] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Systemic and topical antibiotics are used with the aim of eliminating infection in the short term (and some to reduce inflammation in the long term), in order to normalise nasal mucus and improve symptoms. OBJECTIVES To assess the effects of systemic and topical antibiotics in people with chronic rhinosinusitis. SEARCH METHODS The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; CENTRAL (2015, Issue 8); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 29 September 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) with a follow-up period of at least three months comparing systemic or topical antibiotic treatment to (a) placebo or (b) no treatment or (c) other pharmacological interventions. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the commonest adverse event - gastrointestinal disturbance. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of suspected allergic reaction (rash or skin irritation) and anaphylaxis or other very serious reactions. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS We included five RCTs (293 participants), all of which compared systemic antibiotics with placebo or another pharmacological intervention.The varying study characteristics made comparison difficult. Four studies recruited only adults and one only children. Three used macrolide, one tetracycline and one a cephalosporin-type antibiotic. Three recruited only patients with chronic rhinosinusitis without nasal polyps, one recruited patients with chronic rhinosinusitis with nasal polyps and one had a mixed population. Three followed up patients for 10 to 12 weeks after treatment had finished. Systemic antibiotics versus placebo Three studies compared antibiotics with placebo (176 participants).One study (64 participants, without polyps) reported disease-specific HRQL using the SNOT-20 (0 to 5, 0 = best quality of life). At the end of treatment (three months) the SNOT-20 score was lower in the group receiving macrolide antibiotics than the placebo group (mean difference (MD) -0.54 points, 95% confidence interval (CI) -0.98 to -0.10), corresponding to a moderate effect size favouring antibiotics (moderate quality evidence). Three months after treatment, it is uncertain if there was a difference between groups.One study (33 participants, with polyps) provided information on gastrointestinal disturbances and suspected allergic reaction (rash or skin irritation) after a short course of tetracycline antibiotic compared with placebo. We are very uncertain if antibiotics were associated with an increase in gastrointestinal disturbances (risk ratio (RR) 1.36, 95% CI 0.22 to 8.50) or skin irritation (RR 6.67, 95% CI 0.34 to 128.86) (very low quality evidence). Systemic antibiotics plus saline irrigation and intranasal corticosteroids versus placebo plus saline irrigation and intranasal corticosteroids One study (60 participants, some with and some without polyps) compared a three-month course of macrolide antibiotic with placebo; all participants also used saline irrigation and 70% used intranasal corticosteroids. Disease-specific HRQL was reported using SNOT-22 (0 to 110, 0 = best quality of life). Data were difficult to interpret (highly skewed and baseline imbalances) and it is unclear if there was an important difference at any time point (low quality evidence). To assess patient-reported disease severity participants rated the effect of treatment on a five-point scale (-2 for "desperately worse" to 2 for "cured") at the end of treatment (three months). For improvement in symptoms there was no difference between the antibiotics and placebo groups; the RR was 1.50 (95% CI 0.81 to 2.79; very low quality evidence), although there were also slightly more people who felt worse after treatment in the antibiotics group. There was no demonstrable difference in the rate of gastrointestinal disturbances between the groups (RR 1.07, 95% CI 0.16 to 7.10). General HRQL was measured using the SF-36. The authors stated that there was no difference between groups at the end of treatment (12 weeks) or two weeks later. Systemic antibiotics versus intranasal corticosteroids One study (43 participants, without polyps) compared a three-month course of macrolide antibiotic with intranasal corticosteroids. Patient-reported disease severity was assessed using a composite symptom score (0 to 40; 0 = no symptoms). It is very uncertain if there was a difference as patient-reported disease severity was similar between groups (MD -0.32, 95% CI -2.11 to 1.47; low quality evidence). Systemic antibiotics versus oral corticosteroids One study (28 participants, with polyps) compared a short course of tetracycline antibiotic (unclear duration, ˜20 days) with a 20-day course of oral corticosteroids. We were unable to extract data on any of the primary efficacy outcomes. It is uncertain if there was a difference ingastrointestinal disturbances (RR 1.00, 95% CI 0.16 to 6.14) or skin irritation (RR 2.00, 95% CI 0.20 to 19.62) as the results for these outcomes were similar between groups (very low quality evidence). AUTHORS' CONCLUSIONS We found very little evidence that systemic antibiotics are effective in patients with chronic rhinosinusitis. We did find moderate quality evidence of a modest improvement in disease-specific quality of life in adults with chronic rhinosinusitis without polyps receiving three months of a macrolide antibiotic. The size of improvement was moderate (0.5 points on a five-point scale) and only seen at the end of the three-month treatment; by three months later no difference was found.Despite a general understanding that antibiotics can be associated with adverse effects, including gastrointestinal disturbances, the results in this review were very uncertain because the studies were small and few events were reported.No RCTs of topical antibiotics met the inclusion criteria.More research in this area, particularly evaluating longer-term outcomes and adverse effects, is required.
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Affiliation(s)
- Karen Head
- UK Cochrane CentreSummertown Pavilion18 ‐ 24 Middle WayOxfordUK
| | - Lee Yee Chong
- UK Cochrane CentreSummertown Pavilion18 ‐ 24 Middle WayOxfordUK
| | - Patorn Piromchai
- Faculty of Medicine, Khon Kaen UniversityDepartment of OtorhinolaryngologyKhon KaenThailand
| | - Claire Hopkins
- Guy's HospitalENT DepartmentGerat Maze PondLondonUKSE1 9RT
| | - Carl Philpott
- Norwich Medical School, University of East AngliaDepartment of MedicineNorwichUKNR4 7TJ
| | - Anne GM Schilder
- Faculty of Brain Sciences, University College LondonevidENT, Ear Institute330 Grays Inn RoadLondonUKWC1X 8DA
| | - Martin J Burton
- UK Cochrane CentreSummertown Pavilion18 ‐ 24 Middle WayOxfordUK
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Sindwani R. Understanding the basic science and augmenting the clinical knowledge base of rhinologic disorders. Am J Rhinol Allergy 2015; 29:405-7. [PMID: 26637577 DOI: 10.2500/ajra.2015.29.4269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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