Latest developments on topical therapies in chronic rhinosinusitis.

PURPOSE OF REVIEW: Topical therapies play an important role in the management of chronic rhinosinusitis (CRS). A detailed literature review was undertaken to appraise recent evidence surrounding current topical therapies and novel treatments used in the setting of recalcitrant CRS. RECENT FINDINGS: Effective sinus surgery aids in the delivery of topical therapies. Budesonide nasal rinses delivered by saline irrigation offer clinical and symptomatic improvements pre and postoperatively with a well-proven safety profile. Topical steroids may additionally offer direct antibacterial effects as per in-vitro testing. Topical antibiotics are not recommended in routine practice; however, they may be of benefit for short-term eradication therapy. Novel treatments are under keen investigation and include bacteriophage, colloidal silver and manuka honey. The evidence base for these treatments is not robust enough to recommend their routine use at present. SUMMARY: Topical steroids delivered in conjunction with saline nasal irrigation offer the best combination of treatments in CRS and should be considered a standard of care. Wide surgical access and aggressive surgical debridement of polyposis facilitates the delivery of steroid irrigations to sinonasal mucosa and is associated with improved long-term outcomes following endoscopic sinus surgery. The use of novel treatments remains within the research setting alone.

Manuka honey sinus irrigations in recalcitrant chronic rhinosinusitis: phase 1 randomized, single-blinded, placebo-controlled trial.

BACKGROUND: Manuka honey (MH) has significant antibiofilm activity in vitro and in vivo against Staphylococcus aureus, methicillin-resistant S aureus (MRSA), and Pseudomonas aeruginosa. This is the first randomized, single-blinded, placebo-controlled phase 1 clinical trial investigating the safety and preliminary efficacy of MH with augmented methylglyoxal (MGO) rinses in recalcitrant chronic rhinosinusitis (CRS). METHODS: Patients were included after previously undergoing endoscopic sinus surgery and presenting with signs and symptoms of sinus infection with positive bacterial cultures on sinus swabs. Patients were randomized to receive 14 days of twice-daily 16.5% MH + 1.3 mg/mL MGO sinonasal rinses and concurrent 10 days of placebo tablets (MH), or 14 days of twice-daily saline sinonasal rinses and concurrent 10 days of culture-directed antibiotic therapy (CON). Safety observations included the University of Pennsylvania Smell Identification Test (UPSIT) and adverse-event (AE) reporting. Efficacy was assessed comparing microbiology results, Lund-Kennedy scores (LKSs), and symptom scores using the visual analog scale (VAS) and 22-item Sino-Nasal Outcome Test (SNOT-22). RESULTS: Twenty-five patients completed the study. MH demonstrated a good safety profile with no major AEs and no changes in UPSIT. Six of 10 (60%) MH patients had a reduction in bacterial culture rate with 1 of 10 of those having negative cultures, compared with 12 of 15 (80%) in the control group with 7 of 15 having negative cultures upon completion of the study. CONCLUSION: This study concludes that twice-daily 16.5% MH augmented with 1.3 mg/mL MGO sinonasal rinses alone for 14 days is safe but not superior to culture-directed oral antibiotics and twice-daily saline rinses.

Olfactory outcomes in chronic rhinosinusitis with nasal polyposis after medical treatments: a systematic review and meta-analysis.

BACKGROUND: Olfactory dysfunction is common among patients with chronic rhinosinusitis and has a negative impact upon quality of life. Olfactory dysfunction can be both subjective and objective and appears to be more predominant in patients with concomitant nasal polyposis. The efficacy of medical interventions on olfaction among patients with CRS with nasal polyposis (CRSwNP) is not well known. Our aim was to perform a systematic review with meta-analysis of the efficacy of medical therapies on objective and subjective hyposmia among patients with CRSwNP. METHODS: Olfaction specific outcomes from randomized controlled trials evaluating medical interventions on patients with CRSwNP were evaluated. Interventions included corticosteroids, antibacterials, antifungals, diuretics, herbals and anti-immunoglobulin E (IgE) medications. RESULTS: A total of 28 randomized control trials evaluation olfaction in CRSwNP was identified and systematically reviewed. Sufficient data for meta-analysis was retrieved for 5 trials. In the meta-analysis, oral steroids showed significant improvement in subjective olfaction scores compared to placebo (standardized mean difference [SMD] -2.22; 95% confidence interval [CI], -3.94 to -0.49). Oral steroids also showed significant improvement in objective olfaction scores compared to placebo (SMD 0.65; 95% CI, 0.28 to 1.01). In the systematic review, both topical steroids and combined topical and oral steroid groups showed overall improvement in subjective olfaction outcomes. Antibacterials, antifungals, herbals, and anti-IgE medications had no impact on overall olfaction scores. CONCLUSION: The results of this meta-analysis demonstrated that oral and topical steroids significantly improve olfaction in patients suffering from CRSwNP.

Isotonic saline nasal irrigation is an effective adjunctive therapy to intranasal corticosteroid spray in allergic rhinitis.

BACKGROUND: This study was designed to determine if the addition of large-volume, low-positive pressure nasal irrigations delivered with isotonic sodium chloride (hereinafter "saline") added to intranasal corticosteroid therapy improves quality of life and objective measures of nasal breathing in patients with allergic rhinitis when compared with intranasal corticosteroid alone. METHODS: A prospective, unblinded, single-arm pilot study was performed of patients with allergic rhinitis already on intranasal corticosteroid pharmacotherapy. Patients added large-volume low-pressure saline irrigation twice daily for 8 weeks to their ongoing regiment of nasal corticosteroid. Mini-Rhinoconjunctivitis Quality of life Questionnaire (mRQLQ) assessment and nasal peak inspiratory flow (NPIF) were performed at baseline and at 4 and 8 weeks. RESULTS: A total of 40 patients were enrolled. Twice-daily nasal irrigation with isotonic saline significantly (p < 0.001) reduced mRQLQ scores, from 36.7 ± 20.48 (baseline) to 14.9 ± 11.03 (4 weeks) to 10.10 ± 10.65 (8 weeks). No significant changes were seen in NPIF, pattern use of nasal steroid use, or adverse events. CONCLUSION: Large-volume, low-positive pressure nasal irrigation with isotonic saline is an effective adjunctive therapy to improve quality of life in patients with allergic rhinitis already on intranasal corticosteroid therapy. This study was a part of the clinical trial NCT01030146 registered at clinicaltrials.gov.