Complications Associated with PROPEL Mometasone Furoate Bioabsorbable Drug-eluting Sinus Stents From 2012 to 2020

Choanal atresia: a review of contemporary treatment strategies

PURPOSE OF REVIEW

Choanal atresia (CA) is a congenital nasal airway anomaly that, when present bilaterally, requires urgent surgical intervention. Surgical technique has evolved since its inception with most practices now favoring an endoscopic repair. Restenosis requiring revision surgery is a frequent complication, occurring in as many as 50% of cases. This review aims to highlight the most common surgical approaches, techniques used to prevent restenosis, and newer adjuncts to surgery that may improve outcomes.

RECENT FINDINGS

Bioabsorbable, steroid-eluting stents were first developed for the adult chronic rhinosinusitis population but have been adapted for use in choanal atresia since 2017. The existing literature consists of multiple case series and one case-control study comparing these stents to traditional stents. To date, there have been no reports of restenosis or stent-related complications with these newer products.

SUMMARY

Choanal atresia remains a difficult surgical pathology for which sustainable surgical results can be challenging. There is reason for optimism in bioabsorbable, steroid-eluting stents as an adjunct to CA repair if future studies expound upon their safety and efficacy.

Sustained co-release of ciprofloxacin and dexamethasone in rabbit maxillary sinus using polyvinyl alcohol-based hydrogel microparticle

Topical delivery to paranasal sinuses through sustained-release stents is one of the new horizons in treating chronic rhinosinusitis (CRS). This study aims to introduce and evaluate sustained co-release of encapsulated ciprofloxacin (CIP) and dexamethasone (DEX) in polyvinyl alcohol-based carriers within the maxillary sinus of rabbit animals. DEX and CIP were loaded in a tyramine-substituted polyvinyl alcohol microparticle (PVATyr MP). The mechanical stability, degradability, and sustained-release patterns of both drugs as well as cellular cytocompatibility were assessed in vitro. The PVATyr MPs were then injected into the maxillary sinus of rabbits and they were monitored weekly for 21 days. Nasal endoscopy, MRI imaging, and tissue microscopy were used to follow the changes and compared them with the control condition. Also, the concentrations of drugs were evaluated in the maxillary sinus and blood samples over the study period. Produced PVA-based MPs possessed a relatively narrow particle size distribution (CV 7.7%) with proper physical stability until 30 days of incubation. The uniform-sized PVATyr MPs and their surrounding hydrogel showed sustained-release profiles for DEX and CIP for up to 32 days in vitro. The injected drugs-loaded hydrogel showed complete clearance from the maxillary sinus of rabbits within 28 days. The concentrations of DEX and CIP in mucosal remained within the therapeutic window when measured on days 7, 14, and 21, which were well above the plasma concentrations without any pathological changes in endoscopy, MRI imaging, and histological examinations. DEX/CIP loaded PVATyr MPs provided an effective, controlled, and safe sustained-drug delivery in both in vitro and in vivo analyses at therapeutic concentrations with minimal systemic absorption, suggesting a promising treatment approach for CRS.

Assessing the effect of absorbable steroid sinus implant: a state-of-the-art systematic review

OBJECTIVES

Endoscopic sinus surgery is not a definitive treatment for chronic rhinosinusitis (CRS). The use of sinus stents after surgery to maintain sinus patency and deliver local steroids has gained popularity. The first steroid-eluting bioabsorbable implant (SEBI) approved for this indication, later Propel, was developed in 2011. This state-of-the-art review aims to summarize the available evidence, as well as to point out potential pitfalls and lack of specific analyses to guide future research on this new therapeutic option.

DATA SOURCES

Pubmed (Medline), the Cochrane Library, EMBASE, SciELO.

REVIEW METHODS

Nine research questions were defined: Are steroid-eluting Sinus implants useful for the control of CRS symptoms after surgery? Do they improve surgical field healing after CRS surgery? Do they decrease polyp regrowth after ESS? Do they decrease the need for ESS? Are they useful in symptom control as in-office procedure? Are they better than other steroid-impregnated resorbable materials? Do they have a positive impact on olfaction? Are they safe? Are they cost-effective? Retrieved articles were reviewed by two authors.

RESULTS

Twenty nine studies were included: 3 metanalysis, 1 systematic review, 10 randomized clinical trials, 4 quasi-experimental studies, 1 retrospective cohort study, 4 cost studies, 3 case series and 2 expert consensus. The review encompassed a population of 3,012 patients treated with SEBI and 2826 controls.

CONCLUSIONS

This is the first state-of-the-art review assessing steroid eluting bioabsorbable stent evidence. Despite the effort in recent years, still several questions remain unanswered. This review will hopefully guide future research efforts to better define the role of SEBI in the otolaryngology practice.

Assessing the Reproducibility of Research Based on the Food and Drug Administration Manufacturer and User Facility Device Experience Data

OBJECTIVE

This article aims to assess the reproducibility of Manufacturer and User Facility Device Experience (MAUDE) data-driven studies by analyzing the data queries used in their research processes.

METHODS

Studies using MAUDE data were sourced from PubMed by searching for "MAUDE" or "Manufacturer and User Facility Device Experience" in titles or abstracts. We manually chose articles with executable queries. The reproducibility of each query was assessed by replicating it in the MAUDE Application Programming Interface. The reproducibility of a query is determined by a reproducibility coefficient that ranges from 0.95 to 1.05. This coefficient is calculated by comparing the number of medical device reports (MDRs) returned by the reproduced queries to the number of reported MDRs in the original studies. We also computed the reproducibility ratio, which is the fraction of reproducible queries in subgroups divided by the query complexity, the device category, and the presence of a data processing flow.

RESULTS

As of August 8, 2022, we identified 523 articles from which 336 contained queries, and 60 of these were executable. Among these, 14 queries were reproducible. Queries using a single field like product code, product class, or brand name showed higher reproducibility (50%, 33.3%, 31.3%) compared with other fields (8.3%, P = 0.037). Single-category device queries exhibited a higher reproducibility ratio than multicategory ones, but without statistical significance (27.1% versus 8.3%, P = 0.321). Studies including a data processing flow had a higher reproducibility ratio than those without, although this difference was not statistically significant (42.9% versus 17.4%, P = 0.107).

CONCLUSIONS

Our findings indicate that the reproducibility of queries in MAUDE data-driven studies is limited. Enhancing this requires the development of more effective MAUDE data query strategies and improved application programming interfaces.

Steroid-Eluting Implants: An Adjunctive Therapy After Double-Stage Laryngotracheal Reconstruction

OBJECTIVES

The primary objective is to describe a case in which a steroid-eluting implant was utilized to help prevent postoperative granulation and restenosis in a patient who underwent double-stage laryngotracheal reconstruction (dsLTR) for subglottic stenosis.

METHODS

This case presents a 3-year-old female who underwent dsLTR with anterior cartilage graft placement and posterior sagittal split for subglottic stenosis. A silicone stent was placed at the time of the dsLTR. After stent removal, direct laryngoscopy and bronchoscopy (DLB) was performed at 4 to 5 week intervals. These visits revealed a significant amount of supraglottic and glottic edema, and granulation tissue at the proximal aspect of the graft contributing to airway obstruction and restenosis. This was treated twice with CO2 laser excision, balloon dilation, and triamcinolone injection. On the third treatment with these modalities, a mometasone furoate implant was inserted as an adjunctive therapy. The implant was inserted to lateralize the vocal folds, prevent webbing, and to extend to the narrowed area within the subglottis to prevent granulation and restenosis. These same treatments were repeated at the fourth visit with another mometasone furoate implant of a smaller size placed in the same location.

RESULTS

Findings on DLB since treatment with the steroid-eluting implants have shown persistent granulation tissue limited to the tracheostomy stoma site. Treatments with CO2 laser, balloon dilation, and triamcinolone injection have continued, with occasional use of silver nitrate cautery at the external stoma site. There has not been any significant evidence of edema, granulation, or stenosis in the glottis or subglottis to require another steroid-eluting implant.

CONCLUSIONS

Steroid-eluting implants appear to be a safe and effective adjunctive therapy in the routine surveillance of pediatric patients with a tracheostomy who have undergone dsLTR. They may help combat granulation formation and restenosis seen in some dsLTR patients.

Corticosteroid-eluting implants for the management of chronic rhinosinusitis with or without nasal polyps

INTRODUCTION

Topical corticosteroid therapies are the most popular prescribed medications for patients with chronic rhinosinusitis (CRS). While topical corticosteroids effectively reduce the inflammatory burden associated with CRS, their distribution inside the nasal cavity is limited and primarily dependent on their delivery device. Corticosteroid-eluting implants serve as relatively novel technology, allowing targeted, sustained release of a high concentration of corticosteroids directly onto the sinus mucosa. Three types of corticosteroid-eluting implants can be characterized: 1. intraoperatively inserted corticosteroid-eluting sinus implants, 2. postoperatively inserted, office-based corticosteroid-eluting sinus implants, and 3. office-based corticosteroid-eluting implants for naïve paranasal sinuses.

AREAS COVERED

The review summarizes the different steroid-eluting sinus implants, their indications for use in CRS patients, and the existing evidence regarding their clinical efficacy. We also highlight potential areas for improvement and development.

EXPERT OPINION

Corticosteroid-eluting sinus implants highlight an evolving field that is constantly investigating and adding new treatment options to the market. Presently, corticosteroid-eluting implants for CRS are most commonly applied intraoperatively and postoperatively with endoscopic sinus surgery, providing significant improvements in mucosal healing and reducing the amount of surgical failures. Future development around corticosteroid-eluting implants should focus on strategies to reduce the amount of crusting around the implants.

Biomechanical characteristics of self-expanding sinus stents during crimping and deployment_A comparison between different biomaterials

Self-expanding sinus stents are often used in functional endoscopic sinus surgery to treat inflamed sinuses. The PROPEL self-expanding sinus stent offers mechanical support to the sinus cavity to prevent restenosis. The stent is made of a bioabsorbable material (PLGA) that disappears after wound healing. However, complications such as foreign body sensation and severe stent migration/expulsion have been reported after implantation. Little is known about the contact characteristics of self-expanding sinus stents from when the stent is crimped into the insertion device through to deployment into the sinus cavity. This current study developed a test platform to analyze the biomechanical behavior of the stent during this process. Three common bioabsorbable materials, PLGA, PCL and Mg alloy, were evaluated to understand how the choice of material affects the biomechanical characteristics of self-expanding sinus stents. The results showed that the material can have a considerable influence on the contact characteristics during crimping and deployment. When crimped, the PLGA and Mg alloy stents showed much higher plastic strain and contact stress than the PCL stent. When deployed, the PCL stent had the largest contact area (4.3 mm²) and the lowest contact pressure (0.1 MPa) on the inner surface of the sinus canal. The results indicate that PCL could be a suitable choice for self-expanding sinus stents. This current study provides a method for observing the biomechanical characteristics of sinus stents during stent crimping and deployment.

Image-Guided Surgical Device Failures in Functional Endoscopic Sinus Surgery: A MAUDE Analysis

OBJECTIVE

Image-guided surgery (IGS) devices have become widely used for anatomic localization during functional endoscopic sinus surgery (FESS). However, there are no studies that analyze the post-market complications associated with IGS device use during FESS. The objective of this study was to better characterize post-market complications associated with the use of IGS devices during sinus surgery.

METHODS

The US Food and Drug Administration's Manufacturer and User Facility Device Experience database was queried for event reports associated with neurological stereotaxic devices utilized in IGS between the dates of January 1, 2016 and December 31, 2020. Medical device reports that were analyzed for this study pertained strictly to FESS.

RESULTS

There were 1873 reports involving IGS devices for FESS included in this study. Fifty-five reports involved adverse events to patients (2.9%) and 1818 (97.1%) involved device malfunctions. Of the adverse events to patients, the most common included cerebrospinal fluid leakage (45.6%), tissue damage (12.7%), and nervous system injury (3.6%). The most commonly reported device malfunction was imprecision (21.1%).

CONCLUSION

IGS devices are widely utilized in FESS. Of the medical device reports between 2016 and 2020, less than 3% resulted in adverse events. Further studies of the infrequent post-market complications of IGS devices used in FESS can help guide surgeons on the risks of their clinical use.

LEVEL OF EVIDENCE

4-Retrospective database survey without controls Laryngoscope, 2022.

Real-world evidence analysis of the impact of steroid-eluting implants on healthcare resource use among chronic rhinosinusitis patients undergoing sinus surgery

OBJECTIVE

To compare healthcare resource use (HCRU) in patients undergoing sinus surgery with or without steroid-eluting sinus implants.

METHODS

A retrospective, observational cohort study using real-world evidence data (OM1, Inc, Boston, MA, USA) was conducted on adult patients with chronic rhinosinusitis (CRS) with or without nasal polyps who underwent endoscopic sinus surgery between 2014 and 2019 and had at least 18 months of data both before and after surgery. Patients receiving implants ("implant cohort") were matched to patients who did not receive implants ("non-implant cohort") based on a propensity score developed using baseline characteristics. Chi-square for binary variables and analysis of variance tests for continuous variables were applied to compare HCRU measures.

RESULTS

Comparison of the implant (N = 1983) and non-implant (N = 1983) cohorts during the 18-month follow-up period demonstrated significantly lower HCRU in those receiving implants, including all-cause outpatient visits (94.3% vs. 96.6%, p < .001), all-cause otolaryngologist visits (47.3% vs. 59.6%, p < .001) and all cause ER/urgent care visits (9.2% vs. 11.8%, p = .007), as well as sinus-related endoscopies (39.1% vs. 43.8%, p = .003). Although not statistically significant, fewer patients in the implant cohort had undergone repeat surgeries (4.6% vs. 5.3%, p = .273).

CONCLUSION

Patients with steroid-eluting sinus implants had lower HCRU over a post-operative period of 18 months. These findings support the contention that reductions in HCRU may be achieved using steroid-eluting implants during sinus surgery.What is known on this topicChronic rhinosinusitis (CRS) causes severe symptoms that lead to poor quality of life.Endoscopic sinus surgery (ESS) is 76-98% effective in improving CRS patients' symptoms.Surgical outcomes can be compromised in the immediate post-operative period by scarring, adhesion formation, and early polyp recurrence.Oral and topical corticosteroid therapy has become integral to the maintenance of successful surgical outcomes, the management of post-operative scarring and edema, and the prevention of nasal polyp recurrence.Steroid-eluting sinus implants have been shown in clinical trials to improve postoperative outcomes after ESS by delivering localized, sustained release of corticosteroids directly onto inflamed sinus tissue.What this study addsThis observational study is one of the first to use real-world evidence to assess the effect of steroid-eluting sinus implants on healthcare resource use (HCRU) in patients with chronic rhinosinusitis who underwent sinus surgery with or without implants.Use of implants significantly reduced HCRU, including all-cause outpatient visits (94.3% vs 96.6%, p < .001), all-cause otolaryngologist visits (47.3% vs 59.6%, p < .001), and all-cause ER/urgent care visits (9.2% vs 11.8%, p = .007), as well as sinus endoscopy (39.1% vs 43.8%, p = .003).Use of implants had no significant effect on sinus procedures such as debridement and polypectomy, as well as sinus-related imaging such as CT, MRI, and x-ray.