In-office Placement of Mometasone Furoate Sinus Implants for Recurrent Nasal Polyps: A Pooled Analysis

Background

A mometasone furoate (MF) sinus implant (1350 mcg) was evaluated in 2 randomized controlled trials (RCTs) in 400 adults with nasal polyps (NP) who were candidates for revision endoscopic sinus surgery (RESS). We conducted a pooled analysis to evaluate the efficacy of MF implant in specific subgroups of NP patients.

Methods

Pooled data from 2 RCTs for 375 patients were analyzed across prespecified subjective and objective end points through day 90.

Results

At day 90, patients receiving implants and MF nasal spray (MFNS) experienced significant improvements in nasal obstruction/congestion (NO/C) score ( P = .0095), bilateral polyp grade (BPG, P = .0008), and ethmoid sinus obstruction ( P < .0001) compared to control using MFNS alone. Fewer treatment than control patients remained candidates for RESS (41.0% vs 69.3%, P < .0001). All subgroups experienced significant treatment effects, except NO/C in smokers ( P = .0509) and patients without altered smell ( P = .1873). Subgroups without asthma and with only 1 prior ESS experienced largest treatment effect on NO/C, and those with recent surgery <24 months and BPG >5 showed largest effect on endoscopic end points and RESS. Control patients with ESS <24 months were at 7 times highest risk for RESS ( P < .0001). One (0.4%) patient experienced implant-related serious adverse event (epistaxis).

Conclusion

On pooled analysis, MF implants with MFNS showed more favorable results than MFNS alone across several subjective and objective end points at day 90 and may play an important role in management of NP patients, especially those who have allergic rhinitis, expanded polyposis, altered smell, or had most recent ESS < 24 months.

Medical Therapy Versus Balloon Sinus Dilation in Adults With Chronic Rhinosinusitis (MERLOT): 12-Month Follow-up

Background Chronic rhinosinusitis (CRS) is a devastating disease affecting nearly 30 million people in the United States. An interim analysis of data from the present study suggested that, in patients who had previously failed medical therapy, balloon sinus dilation (BSD) plus medical management (MM) provides a significant improvement in the quality of life (QOL) at 24 weeks postprocedure compared to MM alone. Objective The primary objective of this final analysis was to evaluate the durability of treatment effects through the 52-week follow-up. Methods Adults aged 19 and older with CRS who had failed MM elected either BSD plus MM or continued MM. Patients were evaluated at 2 (BSD arm only), 12, 24, and 52 weeks posttreatment. Balloon dilations were performed either as an office-based procedure under local anesthesia or in the operating room per physicians' and patients' discretion. The primary end point was change in patient-reported QOL as measured by Chronic Sinusitis Survey (CSS) total score from baseline to the 24-week follow-up. Secondary outcomes including changes in CSS, Rhinosinusitis Disability Index (RSDI), and Sino-Nasal Outcome Test (SNOT) total and subscores, sinus medication usage, missed days of work/school, number of medical care visits, and sinus infections from baseline to the 52-week follow-up are reported here within. Results BSD led to sustained greater improvements in self-reported QOL using the CSS and RSDI total scores with a trend toward improvement in the SNOT-20 total score from baseline to the 52-week follow-up compared to continued MM. There were no changes in medication usage apart from nasal steroid usage for which the MM cohort had an increase in usage. There were no device-related serious adverse events. Conclusion The current analysis highlights the safety, effectiveness, and durability of BSD in CRS patients aged 19 and older who had previously failed MM.

A phase 3 trial of mometasone furoate sinus implants for chronic sinusitis with recurrent nasal polyps

Background

Topical intranasal corticosteroid sprays (INCSs) are standard treatment for nasal polyps (NPs), but their efficacy is reduced by poor patient compliance and impaired access of drug to the sinus mucosa. A corticosteroid‐eluting sinus implant was designed to address these limitations in patients with recurrent polyposis after sinus surgery by delivering 1350 μg of mometasone furoate (MF) directly to the ethmoid sinus mucosa over approximately 90 days.

Methods

A randomized, sham‐controlled, double‐blind trial was undertaken in 300 adults with refractory chronic rhinosinusitis with NPs (CRSwNP), who were candidates for repeat surgery. Eligible patients were randomized (2:1) and underwent in‐office bilateral placement of 2 implants or a sham procedure. All patients used the MF INCS 200 μg once daily. Co‐primary efficacy endpoints were the change from baseline in nasal obstruction/congestion score and bilateral polyp grade, as determined by an independent panel based on centralized, blinded videoendoscopy review.

Results

Patients treated with implants experienced significant reductions in both nasal obstruction/congestion score (p = 0.0074) and bilateral polyp grade (p = 0.0073) compared to controls. At day 90, implants were also associated with significant reductions in 4 of 5 prespecified secondary endpoints compared to control: proportion of patients still indicated for repeat sinus surgery (p = 0.0004), percent ethmoid sinus obstruction (p = 0.0007), nasal obstruction/congestion (p = 0.0248), and decreased sense of smell (p = 0.0470), but not facial pain/pressure (p = 0.9130). One patient experienced an implant‐related serious adverse event (epistaxis).

Conclusion

Significant improvements over a range of subjective and objective endpoints, including a reduction in the need for sinus surgery by 61%, suggest that MF sinus implants may play an important role in management of recurrent NP.

RESOLVE: bioabsorbable steroid-eluting sinus implants for in-office treatment of recurrent sinonasal polyposis after sinus surgery: 6-month outcomes from a randomized, controlled, blinded study

BACKGROUND

Patients with recurrent sinonasal polyposis after endoscopic sinus surgery (ESS) have limited treatment options. Safety and efficacy were previously reported for a bioabsorbable sinus implant that elutes mometasone furoate for 3 months. Here we summarize longer-term outcomes.

METHODS

A randomized, controlled, blinded study with 100 chronic rhinosinusitis with nasal polyps (CRSwNP) patients who failed medical treatment and were considered candidates for revision ESS. Treated patients (n = 57) underwent in-office implant placement. Control patients (n = 43) underwent a sham procedure. Endoscopic grading at 3 months by clinicians was corroborated by an independent review of randomized videoendoscopies by a panel of 3 sinus surgeons. Six-month follow-up included endoscopic grading and patient-reported outcomes.

RESULTS

At 6 months, treated patients experienced significant improvement in Nasal Obstruction Symptom Evaluation (NOSE) score (p = 0.021) and >2-fold improvement in mean nasal obstruction/congestion score (-1.06 ± 1.4 vs -0.44 ± 1.4; p = 0.124). Endoscopically, treated patients experienced significant reduction in ethmoid sinus obstruction (p < 0.001) and bilateral polyp grade (p = 0.018) compared to controls. Panel review confirmed a significant reduction in ethmoid sinus obstruction (p = 0.010) and 2-fold improvement in bilateral polyp grade (p = 0.099), which reached statistical significance (p = 0.049) in a subset of 67 patients with baseline polyp burden ≥2 bilaterally. At 6 months, control patients were at 3.6 times higher risk of remaining indicated for ESS than treated patients.

CONCLUSION

The symptomatic and endoscopic improvements observed confirm the efficacy of the steroid-eluting implant for in-office treatment of CRSwNP after ESS. These longer-term 6-month study results demonstrate that the steroid-eluting implant represents a durable, safe, and effective treatment strategy for this patient population.

Bioabsorbable steroid-releasing sinus implants in the frontal and maxillary sinuses: 2-year follow-up

Background:

Mometasone furoate-releasing implants have been approved for use in the ethmoid sinuses following endoscopic sinus surgery (ESS) to reduce the need for medical and surgical intervention postoperatively. Outcomes have not yet been studied when these implants are utilized in other paranasal sinuses after ESS.

Objective:

To present a case in which bioabsorbable steroid-eluting implants were used to maintain patency and to decrease inflammation in the frontal and maxillary sinuses after revision ESS.

Methods:

52-year-old male with lifelong allergic rhinitis, chronic allergic fungal rhinosinusitis, and inflammatory bowel disease had previously undergone four endoscopic sinus surgeries, subcutaneous injection immunotherapy, and topical therapy with budesonide and amphotericin sinus irrigations. In July, 2012, during revision left frontal sinusotomy and right maxillary antrostomy (the fifth ESS), two bioabsorbable steroid-releasing implants were placed in the left frontal recess and the right maxillary sinus respectively and followed clinically, endoscopically, and radiographically for two years.

Results:

Two year followup demonstrated near complete clinical, endoscopic, and radiographic resolution of the patient's signs and symptoms of chronic rhinosinusitis.

Conclusions:

The steroid-releasing implants during the critical phase of wound-healing appear to have allowed the patient, now over two years postoperatively, to achieve a healthier state and to allow more successful management than the preceding 15–20 years.

RESOLVE: a randomized, controlled, blinded study of bioabsorbable steroid-eluting sinus implants for in-office treatment of recurrent sinonasal polyposis

BACKGROUND

Patients with recurrent sinonasal polyposis after endoscopic sinus surgery (ESS) have limited treatment options. This study evaluated the safety and efficacy of a bioabsorbable steroid-eluting implant with 1350 μg of mometasone furoate for its ability to dilate obstructed ethmoid sinuses, reduce polyposis, and reestablish sinus patency.

METHODS

This was a randomized, controlled, blinded study including 100 patients chronic rhinosinusitis with nasal polyposis (CRSwNP) refractory to medical therapy and considered candidates for revision ESS. Follow-up included endoscopic grading by investigators and patient-reported outcomes.

RESULTS

Treated patients (n = 53; age as mean ± standard deviation [SD] 47.8 ± 12.6 years; 55% male) underwent in-office bilateral placement. Control patients (n = 47; age 51.6 ± 13.1 years; 66% male) underwent a sham procedure. At 3 months, treated patients experienced a significant reduction in bilateral polyp grade (p = 0.0269) and ethmoid sinus obstruction (p = 0.0001) compared to controls. Treated patients also experienced a 2-fold improvement in the mean nasal obstruction/congestion score (-1.33 ± 1.47 vs -0.67 ± 1.45; p = 0.1365). This improvement reached statistical significance (p = 0.025) in patients with greater polyp burden (grade ≥2 bilaterally; n = 74). At 3 months, 53% of treated patients compared to only 23% of controls were no longer indicated for repeat ESS. There was no serious adverse event or clinically significant increases in intraocular pressure or cataract formation.

CONCLUSION

The symptomatic improvement and statistically significant reduction in polyp grade and ethmoid sinus obstruction supported the efficacy of the steroid-eluting implant for in-office treatment of CRS patient with recurrent polyposis after ESS. The study results demonstrated that the steroid-eluting implant represents a safe and effective alternative to current management for this patient population.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Self-cross-linked hyaluronic acid hydrogel in ethmoidectomy: a randomized, controlled trial

BACKGROUND

This study was designed to evaluate the safety and efficacy of a novel, self-cross-linked hyaluronic acid (HA) hydrogel compared with carboxymethylcellulose (CMC) viscous foam in promoting healing when applied after ethmoidectomy. A prospective, randomized, controlled, blinded clinical trial was performed. The study was performed by four surgeons operating in two community hospitals.

METHODS

Thirty patients with bilateral chronic rhinosinusitis underwent bilateral total ethmoidectomy. Intraoperatively, each patient received 5 mL of HA hydrogel in one ethmoid cavity and 5 mL of CMC contralaterally. The material applied within each ethmoid cavity was randomly assigned before surgery. An independent surgeon, blinded to the material used to treat each ethmoid cavity, evaluated postoperative endoscopic video at 1 and 2 weeks for edema, crusting, and mucopurulence and at 6 and 12 weeks for remucosalization and scarring/synechiae. Twenty-item Sino-Nasal Outcome Test SNOT-20 data were collected at each visit. A small sample underwent endoscopic mucosal biopsy.

RESULTS

Twenty-nine of 30 patients completed the protocol. The difference in edema, crusting, and mucopurulence at 1 and 2 weeks was not statistically significant; however, at 6 and 12 weeks, the HA hydrogel showed statistically significant reduction in both overall endoscopic grade (p < 0.05), as well as synechiae formation (p < 0.05), with a trend toward superiority in remucosalization (p = 0.08). Histological analysis of six subjects at 12 weeks showed a nonsignificant trend toward a greater amount of regenerated cilia present with the HA hydrogel (p = 0.23). SNOT-20 scores declined 78.8% from preoperative scores.

CONCLUSION

Self-cross-linked HA hydrogel provides superior wound healing to CMC after ethmoidectomy.

Self-Crosslinked Hyaluronic Acid Hydrogel (PureRegen Gel Sinus) in Ethmoidectomy: A Randomized, Controlled Trial

Objectives:

Evaluate the safety and efficacy of a novel, self-crosslinked hyaluronic acid (HA) hydrogel (PureRegen Gel Sinus) compared with carboxymethylcellulose (CMC) viscous foam (Stammberger SinuFoam) in promoting healing when applied following ethmoidectomy.

Methods:

Prospective, randomized, controlled, double-blinded clinical trial, with 4 surgeons operating in 2 community hospitals. Thirty patients with bilateral chronic rhinosinusitis underwent bilateral ethmoidectomy. Intraoperatively, each patient received 2 mL of HA hydrogel in one ethmoid cavity, and 2 mL of CMC contralaterally. The material applied within each ethmoid cavity was randomly assigned before surgery. A fifth independent surgeon, blinded to the material used to treat each ethmoid cavity, evaluated postoperative endoscopic video at 1 and 2 weeks for edema, crusting, and mucopurulence and at 6 and 12 weeks for re-mucosalization and scarring/synechiae. SinoNasal Outcome Test (SNOT-20) data were collected preoperatively and at each postoperative visit. A small sample of the cohort underwent endoscopic mucosal biopsy for histologic analysis.

Results:

Twenty-nine of 30 patients completed the protocol. The difference in edema, crusting, and mucopurulence at 1 and 2 weeks was not statistically significant; however, at 6 and 12 weeks, the HA hydrogel showed statistically significant reduction in synechiae formation ( P < .05), with a trend toward superiority in re-mucosalization ( P = .08). Histologic analysis of 6 subjects at 12 weeks also showed a trend toward a greater amount of regenerated cilia present in the HA hydrogel-treated ethmoid cavities ( P = .22). The cohort showed a 75.18% improvement in SNOT-20 analysis.

Conclusions:

Self-crosslinked hyaluronic acid hydrogel provides superior wound healing to carboxymethylcellulose after ethmoidectomy.

Dominant Negative p63 Isoform Expression in Head and Neck Squamous Cell Carcinoma

OBJECTIVES/HYPOTHESIS

p63, a member of the p53 family of genes, is vital for normal epithelial development and may play a critical role in epithelial tumor formation. Although p63 has been identified in various head and neck malignancies, a detailed analysis of which of the six isoforms of the p63 gene is present in normal mucosa and head and neck malignancies has not yet been performed. The study analyzed p63 isoform expression on the RNA and protein level in normal, diseased, and malignant mucosa of the head and neck to examine the differential expression of p63 isoforms in head and neck tumors versus adjacent nonmalignant tissue and to identify the predominant p63 isoform expressed in head and neck squamous cell carcinoma (HNSCC).

STUDY DESIGN

Three experiments were performed. In experiment 1, p63 expression was analyzed by immunohistochemical analysis in 36 HNSCC specimens and matched normal tissue control specimens harvested from the same patient. Western blot analysis was also performed on matched specimens to confirm the identity of the p63 isoforms that were found. In experiment 2, reverse transcriptase polymerase chain reaction (RT-PCR) analysis was performed on matched normal and tumor specimens to analyze and quantitatively compare p63 isoform expression at the RNA level. In experiment 3, p63 expression was evaluated by immunohistochemical analysis in oral lichen planus, a benign mucosal lesion marked by hyperdifferentiation and apoptosis.

METHODS

Immunohistochemical analysis, RT-PCR, and Western blot analysis of p63 were performed on HNSCC specimens and matched normal tissue control specimens. p63 expression in oral lichen planus specimens was also examined by immunohistochemical analysis.

RESULTS

In experiment 1, analysis of 36 HNSCC specimens from various head and neck subsites showed p63 expression in all tumors and matched normal tissue specimens (36 of 36). Western blot analyses indicated that dominant negative (DeltaN) isoform p63alpha (DeltaNp63alpha) is the major isoform expressed at the protein level in tumors and adjacent normal tissue. In experiment 2, RT-PCR analyses of 10 matched specimens confirmed that, although all three DeltaNp63 isoforms (DeltaNp63alpha, DeltaNp63beta, and DeltaNp63gamma) are expressed in normal and malignant mucosa of the head and neck, DeltaNp63alpha is the predominant transcript expressed. In experiment 3, immunohistochemical analysis of p63 in the pro-apoptotic condition of lichen planus indicated that p63 is underexpressed as compared with normal mucosal specimens.

CONCLUSION

Although all three DeltaNp63 isoforms are present in HNSCC, DeltaNp63alpha protein is the predominant isoform expressed in these malignancies. DeltaNp63alpha is also overexpressed in tumors compared with matched normal tissue specimens and is underexpressed in the pro-apoptotic condition of lichen planus. These findings suggest that DeltaNp63alpha plays an anti-differentiation and anti-apoptotic role in the mucosal epithelium of the head and neck, possibly playing a pivotal role in the formation of HNSCC. Currently, DeltaNp63alpha is an attractive target for mechanistic study aimed at therapeutic intervention.

Contemporary indications for the Caldwell-Luc procedure

The Caldwell-Luc operation was first described in the late 19th century as a technique to remove infection and diseased mucosa from the maxillary sinus via the canine fossa, while creating intranasal counterdrainage through the inferior meatus. This operation has been performed countless times over the past century, but it has come under increased scrutiny within the past 20 years. This criticism is multifactorial. Medical management of allergic and infectious sinus disease has continued to improve, and endoscopic sinus surgery techniques have proven to be safe and effective in the vast majority of patients requiring surgical management. Additionally, several retrospective studies have shown high complication rates with the operation. Recent studies have illustrated both the histologic benefit of complete removal of diseased mucosa, as well as better patient outcomes with minimal morbidity when a safer operative technique is used. Overall, the Caldwell-Luc procedure is safe and effective as described, and should remain in the repertoire of surgeons managing the maxillary sinus.

Inhibition of epidermal growth factor receptor signaling decreases p63 expression in head and neck squamous carcinoma cells

OBJECTIVES/HYPOTHESIS

Both the epidermal growth factor receptor (EGFR) and the p53 homologue p63 are overexpressed in a significant number of cases of head and neck squamous cell carcinoma (HNSCC). Epidermal growth factor receptor and p63 both possess oncogenic properties, including the potential to increase cell proliferation and antagonize apoptosis. ZD1839 ("Iressa") is an adenosine triphosphate-competitive inhibitor specific to the EGFR tyrosine kinase currently under evaluation as a chemotherapeutic agent in HNSCC. The objective was to investigate whether p63 expression is decreased after treatment of HNSCC cells with ZD1839. Downregulation of p63 by ZD1839 would identify a potential molecular relationship between EGFR signaling and p63 and could provide insight into the mechanism of action of ZD1839.

STUDY DESIGN

In vitro examination of p63 expression after ZD1839 treatment.

METHODS

A human HNSCC cell line, SCC-012, was treated with varying doses of ZD1839. p63 protein and messenger RNA levels were analyzed by Western and Northern blot analyses. The effect of ZD1839 on SCC-012 cell cycle was analyzed by flow cytometric analysis.

RESULTS

In SCC-012 cells there was a dose-dependent decrease in p63 protein and messenger RNA levels over the course of ZD1839 treatment. Levels of phosphorylated MAPK decreased and p27KIP-1 levels increased after ZD1839 treatment. ZD1839 treatment induced a twofold increase in G1-phase cells and a 3.5-fold decrease in S-phase cells consistent with growth arrest.

CONCLUSION

ZD1839 downregulates p63 expression at the messenger RNA level, suggesting that p63 is a downstream target of EGFR signaling.

Expression of p63 and 14-3-3sigma in normal and hyperdifferentiated mucosa of the upper aerodigestive tract

OBJECTIVE

Our goal was to analyze p63 and 14-3-3sigma expression in normal and hyperdifferentiated head and neck mucosa.

STUDY DESIGN

Compare the in vivo expression of p63 and 14-3-3sigma by immunohistochemistry in normal mucosa and oral lichen planus, a benign mucosal lesion marked by hyperdifferentiation and apoptosis.

RESULTS AND CONCLUSION

p63 is underexpressed and 14-3-3sigma is overexpressed in lichen planus on immunohistochemical analysis.

SIGNIFICANCE

The findings support the hypothesis that p63 plays an antidifferentiation role, whereas 14-3-3sigma plays a prodifferentiation role in the upper aerodigestive tract epithelium. Lichen planus is a valuable model for the study of p63, 14-3-3sigma, and mucosal differentiation. p63 and 14-3-3sigma may be molecular markers for oral lichen planus.

Predictors of weight loss during radiation therapy

OBJECTIVE

To define risk factors for weight loss or dehydration during radiation therapy (RT).

STUDY DESIGN AND SETTING

Retrospective chart review, academic tertiary care center.

RESULTS

The incidence of severe weight loss during RT was 32.7%, the incidence of dehydration was 10.9%, and the rate of prophylactic feeding gastrostomy tube placement was 32%. The patients most likely to suffer severe weight loss included patients with tumor sites of nasopharynx and base of tongue, those treated with chemoradiation, and patients with severe pretreatment weight loss. Prophylactic feeding gastrostomy tube placement before RT significantly reduced the incidence of severe weight loss and hospitalization during RT.

CONCLUSION

Severe weight loss and dehydration during RT for head and neck cancer is common. Prophylactic feeding gastrostomy tubes significantly reduce the incidence of severe weight loss and hospitalization for dehydration during RT when placed before onset of RT. Patients at risk for severe weight loss include those with severe pretreatment weight loss, tumors of the nasopharynx and base of tongue, or treatment with chemoradiation.