Approaching Chronic Sinusitis
Approaching Chronic Sinusitis
CRS is a disease of inflammation; therefore, inflammatory triggers should be sought and treated. The Table outlines treatment recommendations for CRSsNP and CRSwNP from available data. Historically, there has been an overreliance on antibiotics. The 2012 European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS2012) downgraded their previous recommendation in favor of long-term antibiotics to a treatment option if steroids and nasal saline irrigation fail. This change was a result of a placebo-controlled randomized study, as well as other smaller studies. The authors note that several other factors could have affected the response to treatment, with smokers having a lower response rate and those with normal IgE levels having a higher response rate. The Cochrane Database attempted a meta-analysis of systemic antibiotics for CRSwNP in adults and only one study met the inclusion criteria. In that study, 3 months of low-dose roxithromycin (a drug not available in the United States) reduced the mean response score of patients modestly (by 0.73 points on a 1- to 6-point scale) at 3 months after the start of treatment. Comparisons of pre- and posttreatment scores of the sinonasal-outcome test, a validated, disease-specific QOL instrument, show that the roxithromycin group fared no better than the placebo group. The study concluded that routine long-course antibiotics in patients with chronic rhinosinusitis are not warranted; however, roxithromycin is a semisynthetic macrolide, a class of antibiotic with known anti-inflammatory effects. Multiple studies have demonstrated both in vitro and in vivo effects of macrolides to decrease bacterial virulence and biofilm formation, as well as to downregulate proinflammatory cytokines. Additional prospective randomized controlled trials with strict inclusion criteria are required before the subset of patients with CRS who will benefit from antibiotics are identified. Perhaps prescribing a long course of antibiotics for any patient with CRS should be decided on a case-by-case basis, taking into account the individual's symptoms, physical examination findings, risk factors, and comorbidities.
Topical antibiotic therapy can provide high local drug concentrations in the sinuses while minimizing systemic absorption of the drug. This treatment method has significant appeal for biofilm-related diseases, which can require antibiotic concentrations up to 1000 times the minimum inhibitory concentration to eradicate. There have been a small number of retrospective studies and one prospective study supporting the efficacy of this treatment method. Although further studies are necessary to determine the exact pharmacodynamics of topical antibiotics, their use is promising in the treatment of recalcitrant disease after sinus surgery.
Intranasal steroids have been proven effective in improving nasal polyps, decreasing nasal congestion and drainage, and improving overall QOL. Effective treatment may require higher dosages than those used for allergic rhinitis. Double-blind, randomized controlled studies of CRSwNP have shown benefit, with fluticasone using dosages of 400 to 800 μg/day for durations ranging from 12 to 26 weeks. Mometasone 200 to 400 μg once or twice daily for 16 weeks also improved symptoms of CRSwNP. With such relatively high doses of steroids, much attention is focused on the systemic adverse effects of intranasal application. Both fluticasone and mometasone have systemic bioavailability of <1%. No significant effects have been shown on the hypothalamic–pituitary axis with prolonged treatment.
Oral corticosteroids are another common modality of treatment for CRS because of their ability to decrease inflammation. Lal and Hwang conducted a systematic review of 33 publications showing that oral steroids, in combination with other treatment modalities, increased the time interval to recurrence and improved both nasal endoscopy and CT scores. Oral steroids appear to be especially beneficial in patients with AFS and with CRSwNP. Dosing and duration of treatment have not been standardized. In a double-blind placebo-controlled study, Van Zele et al showed that a steroid taper starting at 32 mg of methylprednisolone daily and tapering to 8 mg during a period of 20 days significantly decreased polyp size and levels of inflammatory cytokines.
Nasal saline irrigation with isotonic or hypertonic saline is an effective, inexpensive treatment for all types of CRS. Benefits of nasal irrigation include improved mucociliary function, decreased nasal mucosal edema, and mechanical removal of infectious debris and allergens. The symptomatic improvement from nasal irrigation has been demonstrated in many randomized controlled trials. A Cochrane Database systematic review concluded that the beneficial effects outweigh minor adverse effects. The AAO-HNS recommends sinus irrigation as a primary preventive practice, a secondary preventive practice after surgery, and part of a combined treatment for all types of sinusitis.
Finally, if CRS symptoms continue despite a thorough workup and medical treatment, and CT demonstrates persistent sinus disease, an otolaryngology consultation is indicated. For patients with AFS, sinus surgery is almost always warranted. Functional endoscopic sinus surgery via traditional endoscopy or under image guidance (used in revision or complex surgery to aid in orientation within the paranasal sinuses) allows for removal of inflammatory drivers (nasal polyps, purulence, or allergic fungal mucin). In addition, functional endoscopic sinus surgery opens and widens the natural drainage pathways to allow the mucociliary blanket to trap and transport antigens out of the sinonasal cavities and to create sinus access for topical medications. Balloon sinuplasty has become available as a minimally invasive therapeutic option to open the sinus ostia, but it has not been validated in any randomized controlled trials. Sinus ostia must be at least 4.7 mm for nasal irrigation to reliably penetrate the sinuses and the solution should penetrate all of the sinuses. Irrigation with a high-volume, low-pressure irrigator (eg, NeilMed sinus rinse plastic squeeze bottle [NeilMed Pharmaceuticals, Santa Rosa, CA]) with the head tilted downward 45° and the bottle aligned on an axis parallel to the nasal dorsum and aimed toward the ipsilateral medial canthus is most effective.
In caring for postoperative patients with CRS, the treatment goals are controlling nasal mucosa inflammatory responses to optimize nasociliary function. This may be done almost entirely with topical medications delivered through a sinus rinse bottle or nebulizer. Topical medications include surfactants, antibiotics, and steroids. Surfactants work by decreasing mucous viscosity and altering the microbial–surface interface. They cause cell membrane disruption and increase cell membrane permeability, which disrupts the complex interactions and mechanical defenses of biofilms. Baby shampoo is a simple, inexpensive surfactant that is commercially available and safe to use. A University of Pennsylvania study determined the optimal concentration of Johnson's Baby Shampoo (Johnson & Johnson, New Brunswick, NJ) to nasal irrigation is 1% (approximately ½ teaspoon in an 8-oz irrigation bottle). Chiu et al found that it not only improved symptoms of thick mucous and postnasal drip but it also significantly inhibited the formation of Pseudomonas biofilms. The duration of treatment was twice daily for 4 weeks. Although this was a small, uncontrolled study, no significant adverse effects were reported and it may prove beneficial in some patients while keeping costs at a minimum.
Treatment
CRS is a disease of inflammation; therefore, inflammatory triggers should be sought and treated. The Table outlines treatment recommendations for CRSsNP and CRSwNP from available data. Historically, there has been an overreliance on antibiotics. The 2012 European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS2012) downgraded their previous recommendation in favor of long-term antibiotics to a treatment option if steroids and nasal saline irrigation fail. This change was a result of a placebo-controlled randomized study, as well as other smaller studies. The authors note that several other factors could have affected the response to treatment, with smokers having a lower response rate and those with normal IgE levels having a higher response rate. The Cochrane Database attempted a meta-analysis of systemic antibiotics for CRSwNP in adults and only one study met the inclusion criteria. In that study, 3 months of low-dose roxithromycin (a drug not available in the United States) reduced the mean response score of patients modestly (by 0.73 points on a 1- to 6-point scale) at 3 months after the start of treatment. Comparisons of pre- and posttreatment scores of the sinonasal-outcome test, a validated, disease-specific QOL instrument, show that the roxithromycin group fared no better than the placebo group. The study concluded that routine long-course antibiotics in patients with chronic rhinosinusitis are not warranted; however, roxithromycin is a semisynthetic macrolide, a class of antibiotic with known anti-inflammatory effects. Multiple studies have demonstrated both in vitro and in vivo effects of macrolides to decrease bacterial virulence and biofilm formation, as well as to downregulate proinflammatory cytokines. Additional prospective randomized controlled trials with strict inclusion criteria are required before the subset of patients with CRS who will benefit from antibiotics are identified. Perhaps prescribing a long course of antibiotics for any patient with CRS should be decided on a case-by-case basis, taking into account the individual's symptoms, physical examination findings, risk factors, and comorbidities.
Topical antibiotic therapy can provide high local drug concentrations in the sinuses while minimizing systemic absorption of the drug. This treatment method has significant appeal for biofilm-related diseases, which can require antibiotic concentrations up to 1000 times the minimum inhibitory concentration to eradicate. There have been a small number of retrospective studies and one prospective study supporting the efficacy of this treatment method. Although further studies are necessary to determine the exact pharmacodynamics of topical antibiotics, their use is promising in the treatment of recalcitrant disease after sinus surgery.
Intranasal steroids have been proven effective in improving nasal polyps, decreasing nasal congestion and drainage, and improving overall QOL. Effective treatment may require higher dosages than those used for allergic rhinitis. Double-blind, randomized controlled studies of CRSwNP have shown benefit, with fluticasone using dosages of 400 to 800 μg/day for durations ranging from 12 to 26 weeks. Mometasone 200 to 400 μg once or twice daily for 16 weeks also improved symptoms of CRSwNP. With such relatively high doses of steroids, much attention is focused on the systemic adverse effects of intranasal application. Both fluticasone and mometasone have systemic bioavailability of <1%. No significant effects have been shown on the hypothalamic–pituitary axis with prolonged treatment.
Oral corticosteroids are another common modality of treatment for CRS because of their ability to decrease inflammation. Lal and Hwang conducted a systematic review of 33 publications showing that oral steroids, in combination with other treatment modalities, increased the time interval to recurrence and improved both nasal endoscopy and CT scores. Oral steroids appear to be especially beneficial in patients with AFS and with CRSwNP. Dosing and duration of treatment have not been standardized. In a double-blind placebo-controlled study, Van Zele et al showed that a steroid taper starting at 32 mg of methylprednisolone daily and tapering to 8 mg during a period of 20 days significantly decreased polyp size and levels of inflammatory cytokines.
Nasal saline irrigation with isotonic or hypertonic saline is an effective, inexpensive treatment for all types of CRS. Benefits of nasal irrigation include improved mucociliary function, decreased nasal mucosal edema, and mechanical removal of infectious debris and allergens. The symptomatic improvement from nasal irrigation has been demonstrated in many randomized controlled trials. A Cochrane Database systematic review concluded that the beneficial effects outweigh minor adverse effects. The AAO-HNS recommends sinus irrigation as a primary preventive practice, a secondary preventive practice after surgery, and part of a combined treatment for all types of sinusitis.
Finally, if CRS symptoms continue despite a thorough workup and medical treatment, and CT demonstrates persistent sinus disease, an otolaryngology consultation is indicated. For patients with AFS, sinus surgery is almost always warranted. Functional endoscopic sinus surgery via traditional endoscopy or under image guidance (used in revision or complex surgery to aid in orientation within the paranasal sinuses) allows for removal of inflammatory drivers (nasal polyps, purulence, or allergic fungal mucin). In addition, functional endoscopic sinus surgery opens and widens the natural drainage pathways to allow the mucociliary blanket to trap and transport antigens out of the sinonasal cavities and to create sinus access for topical medications. Balloon sinuplasty has become available as a minimally invasive therapeutic option to open the sinus ostia, but it has not been validated in any randomized controlled trials. Sinus ostia must be at least 4.7 mm for nasal irrigation to reliably penetrate the sinuses and the solution should penetrate all of the sinuses. Irrigation with a high-volume, low-pressure irrigator (eg, NeilMed sinus rinse plastic squeeze bottle [NeilMed Pharmaceuticals, Santa Rosa, CA]) with the head tilted downward 45° and the bottle aligned on an axis parallel to the nasal dorsum and aimed toward the ipsilateral medial canthus is most effective.
In caring for postoperative patients with CRS, the treatment goals are controlling nasal mucosa inflammatory responses to optimize nasociliary function. This may be done almost entirely with topical medications delivered through a sinus rinse bottle or nebulizer. Topical medications include surfactants, antibiotics, and steroids. Surfactants work by decreasing mucous viscosity and altering the microbial–surface interface. They cause cell membrane disruption and increase cell membrane permeability, which disrupts the complex interactions and mechanical defenses of biofilms. Baby shampoo is a simple, inexpensive surfactant that is commercially available and safe to use. A University of Pennsylvania study determined the optimal concentration of Johnson's Baby Shampoo (Johnson & Johnson, New Brunswick, NJ) to nasal irrigation is 1% (approximately ½ teaspoon in an 8-oz irrigation bottle). Chiu et al found that it not only improved symptoms of thick mucous and postnasal drip but it also significantly inhibited the formation of Pseudomonas biofilms. The duration of treatment was twice daily for 4 weeks. Although this was a small, uncontrolled study, no significant adverse effects were reported and it may prove beneficial in some patients while keeping costs at a minimum.