Deposition of aerosolized particles in the maxillary sinuses before and after endoscopic sinus surgery

Improved Olfactory Deposition of Theophylline Using a Nanotech Soft Mist Nozzle Chip

Currently, nasal administration of active pharmaceutical ingredients is most commonly performed using swirl-nozzle-based pump devices or pressurized syringes. However, they lead to limited deposition in the more active regions of the nasal cavity, especially the olfactory region, which is crucial for nose-to-brain drug delivery. This research proposes to improve deposition in the olfactory region by replacing the swirl nozzle with a nanoengineered nozzle chip containing micrometer-sized holes, which generates smaller droplets of 10-50 μm travelling at a lower plume velocity. Two nanotech nozzle chips with different hole sizes were tested at different inhalation flow rates to examine the deposition patterns of theophylline, a hyposmia treatment formulation, using a nasal cavity model. A user study was also conducted and showed that the patient instructions influenced the inhalation flow rate characteristics. Targeted flow rates of between 0 and 25 L/min were used for the in vitro deposition study, yielding 21.5-31.5% olfactory coverage. In contrast, the traditional swirl nozzle provided only 10.8% coverage at a similar flow rate. This work highlights the potential of the nanotech soft mist nozzle for improved intranasal drug delivery, particularly to the olfactory region.

Fluorescence-enabled evaluation of nasal tract deposition and coverage of pharmaceutical formulations in a silicone nasal cast using an innovative spray device

INTRODUCTION

The characterisation of nasal formulations is a critical point. However, there are still no recommendations or guidelines in terms of standard approaches for evaluating the formulation's nasal deposition and/or coverage profile. This study optimises a method for quantifying silicone nasal cast deposition and coverage of liquid formulations using different nasal devices.

OBJECTIVES

The present work investigates the nasal deposition and coverage patterns of innovative nasal spray nozzles producing slow velocity soft mists, using a nasal cavity replica and a fluorescent dye.

METHODS

The study of the deposition pattern of a fluorescent liquid formulation in a transparent nasal cast was carried out in both the presence and absence of a simulated inhalation flow. The extent of the deposition pattern was investigated using ImageJ and fluorescence in the nasal cast, quantified by fluorometric analysis. The particle size distribution and initial droplet velocity were determined using a laser diffractometer and a high-speed camera with a frame rate of 1000 fps.

RESULTS

A uniform intranasal coverage was obtained with droplets of a volume median particle size (Dv50) between 15 and 25 µm in airflow between 10 and 30 L/min. In these conditions, aerosol formulations can be uniformly deposited in the vestibule and turbinate cavity nasal regions, with less than 10 % passing beyond the nasopharyngeal region.

CONCLUSION

The method applied allowed for the determination of the coverage of the nasal cast in different regions using images analysis and fluorometric analysis. Droplet velocity is a critical parameter in the deposition in the nasal cavity. With standard swirl nozzles, many droplets are found on the surface of the nasal vestibule. Soft mist nozzles produce smaller droplets at a much lower initial velocity (<1 m/s), resulting in a more uniform coverage.

Use of Off-Label Nasal Steroid Irrigations in Long-Term Management of Chronic Rhinosinusitis

OBJECTIVE

Chronic rhinosinusitis (CRS) is an inflammatory disease of the paranasal sinuses and mucosa. Topical nasal corticosteroids are a mainstay treatment for CRS by reducing sinonasal inflammation and improving mucociliary clearance. However, topical corticosteroids have limited paranasal distribution, and patient response to treatment has been variable in randomized controlled trials (RCT). Thus, there is significant interest in evaluating the efficacy of nasal steroids delivered by nasal irrigation in order to improve penetration and absorption of topical steroids into the sinonasal mucosa. In this review, we discuss the use of off-label nasal steroid irrigations in the management of CRS.

METHODS

A review of clinical trials evaluating the use of nasal steroid irrigations for CRS in the PubMed electronic database was performed.

RESULTS

Of the 12 clinical studies identified, 10 evaluated budesonide irrigations while the remaining 2 focused on mometasone. The overwhelming majority of studies for both budesonide and mometasone supported the use of nasal irrigations with corticosteroids over nasal corticosteroid sprays alone. However, the heterogeneity in study design, patient cohort, and volume of steroid irrigation limit the interpretations of these studies.

CONCLUSIONS

Nasal irrigation with corticosteroids is beneficial and safe for the treatment of CRS. Future RCTs controlling for type of surgical intervention, CRS pheno- and endo-type, as well as dosing and duration of nasal corticosteroid irrigations are warranted.

In vitro - in vivo correlation of intranasal drug deposition

In vitro - in vivo correlation (IVIVC) allows prediction of in vivo drug deposition from a nasally inhaled drug based on in vitro drug measurements. In vitro measurements include physical particle characterization and, more recently, deposition studies using anatomical models. Currently, there is a lack of IVIVC for deposition measurements in anatomical models, especially for deposition patterns in various nasal cavity regions. Therefore, improvement of in vitro and in vivo measurement methods and knowledge about nasal deposition mechanisms should help IVIVC in the future.

In-Office Corticosteroid Placement in the Management of Chronic Rhinosinusitis

OBJECTIVES

Corticosteroids represent one of the mainstays of medical management of chronic rhinosinusitis (CRS) in both locally acting topical and systemic derivations. The application of topical corticosteroids is limited by a variety of factors including patient compliance, positioning, and nasal anatomy. Systemic corticosteroids confer a risk of medical complication that restricts their ability to be used repeatedly. The objective of this publication is to review the evolution of the in-office intranasal placement of corticosteroids in the management of CRS. The efficacy, outcomes, and safety of a variety of corticosteroid-containing devices meant to be placed in an office setting are reviewed.

METHODS

Pertinent literature was reviewed and summarized beginning with the earliest reports of direct intralesional injection of corticosteroids up through manufactured modern-day bioresorbable implants that contain corticosteroids.

RESULTS

The utilization of in-office placement of corticosteroid-containing material and implants has rapidly evolved since the concept was introduced, particularly in the last decade. Modern-day corticosteroid-eluting implants are reliably placed in the office, yield results across a range of objective and subjective outcomes, may decrease the need for revision endoscopic sinus surgery, and have a favorable safety profile.

CONCLUSIONS

In-office placement of corticosteroid-containing stents are a viable treatment option for select patients, particularly those wishing to avoid revision surgery, and should be considered an important adjunct for treatment of refractory CRS in an otolaryngologist's armamentarium.

Comparison of short nozzle and long nozzle spray in sinonasal drug delivery: a cadaveric study

The aim of this study is to compare the delivery site of topical drugs using the short nozzle and the long nozzle. Fourteen fresh frozen cadaver heads were obtained. All cadaver specimens underwent bilateral endoscopic wide maxillary antrostomy, frontal sinusotomy, and complete sphenoethmoidectomy. The right nasal cavity of each cadaver was sprayed with radiolabeled saline using the short nozzle (short nozzle group), while the left nasal cavity was sprayed using the long nozzle (long nozzle group). The distribution of radioactive saline within the sinus cavities was determined using single-photon emission computed tomography/computed tomography. The distribution of the radiolabeled saline in reference with the maxillary line, vestibule, maxillary, ethmoid, sphenoid, and frontal sinus was compared between the 2 groups using Fisher exact test. The number of specimens that demonstrated radioactivity above the maxillary line is higher in the long nozzle group (14 cadavers, 100%) compared to short nozzle group (9 cadavers, 64.3%; p = .02). There are fewer specimens that demonstrated deposition of radioactive saline in the vestibule in the long nozzle group (6 cadavers, 42.86%) compared to short nozzle group (13 cadavers, 92.86%; P = .006). Compared to short nozzle group, there are more specimens demonstrating radioactivity in the maxillary, ethmoid, sphenoid, and frontal sinus in the long nozzle group, but the differences were not statistically significant (p = 0.241, 0.347, 0.126, 0.5). Compared to short nozzle, long nozzle more frequently delivers intranasal drugs beyond the maxillary line and less frequently in the vestibule. These findings support the hypothesis that the use of long and narrow nozzle, instead of the conventional short nozzle, can improve sinonasal drug delivery in post-endoscopic sinus surgery nose.

[Rhinosinusitis in cystic fibrosis]

In cystic fibrosis (CF) mucociliary clearance of the entire respiratory system is impaired. This allows pathogens, such as Pseudomonas aeruginosa to persist and proliferate, which by progressive pulmonary destruction causes 90 % of premature deaths due to this inherited disease. The dramatic improvement in life expectation of patients due to intensive therapy has resulted in the inevitable but variably expressed sinonasal involvement coming into the clinical and scientific focus. Thereby, almost all CF patients reveal sinonasal pathology and many suffer from chronic rhinosinusitis. Recently, the sinonasal niche has been recognized as a site of initial and persistent colonization by pathogens. This article presents the pathophysiological background of this multiorgan disease as well as general diagnostic and therapeutic standards. The focus of this article is on sinonasal involvement and conservative and surgical options for treatment. Prevention of pathogen acquisition is an essential issue in the otorhinolaryngological treatment of CF patients.

Sino nasal inhalation of isotonic versus hypertonic saline (6.0%) in CF patients with chronic rhinosinusitis - Results of a multicenter, prospective, randomized, double-blind, controlled trial

BACKGROUND

Chronic rhinosinusitis is a hallmark of Cystic fibrosis (CF) impairing the patients' quality of life and overall health. However, therapeutic options have not been sufficiently evaluated. Bronchial inhalation of mucolytic substances is a gold standard in CF therapy. Previously, we found that sinonasal inhalation of dornase alfa as vibrating aerosol reduces symptoms of chronic rhinosinusitis more effectively than NaCl 0.9% (net treatment benefit: -5.87±2.3 points, p=0.017; SNOT-20 total score). This multicenter study compares the effect of NaCl 6.0% vs. NaCl 0.9% following the protocol from our preceding study with dornase alfa.

METHODS

Sixty nine CF patients with chronic rhinosinusitis in eleven German CF centers were randomized to receive sinonasal vibrating inhalation of either NaCl 6.0% or NaCl 0.9% for 28days. After 28days of wash-out, patients crossed over to the alternative treatment. The primary outcome parameter was symptom score in the disease-specific quality of life Sino-Nasal Outcome Test-20 (SNOT-20). Additionally, pulmonary function was assessed, as well as rhinomanometry and inflammatory markers in nasal lavage (neutrophil elastase, interleukin (IL)-1β, IL-6, and IL-8) in a subgroup.

RESULTS

Both therapeutic arms were well tolerated and showed slight improvements in SNOT-20 total scores (NaCl 6.0%: -3.1±6.5 points, NaCl 0.9%: -5.1±8.3 points, ns). In both treatment groups, changes of inflammatory parameters in nasal lavage from day 1 to day 29 were not significant. We suppose that the irritating properties of NaCl 6.0% reduced the suitability of the SNOT-20 scores as an outcome parameter. Alternative primary outcome parameters such as MR-imaging or the quantity of sinonasal secretions mobilized with both saline concentrations were, however, not feasible.

CONCLUSION

Sinonasal inhalation with NaCl 6.0% did not lead to superior results vs. NaCl 0.9%, whereas dornase alfa had been significantly more effective than NaCl 0.9%.

The effect of middle turbinate resection on topical drug distribution into the paranasal sinuses

BACKGROUND

During sinus surgery, partial or complete resection of the middle turbinate (MT) is sometimes necessary because of polypoid changes or demineralization. Topical drug delivery to the paranasal sinuses is an integral component in managing chronic rhinosinusitis (CRS) with and without nasal polyposis. The purpose of this study was to examine the role of the MT and MT resection in topical drug distribution into the sinuses via nebulization. We report on a novel technique of quantitatively evaluating the delivery of nebulized dye in cadavers.

METHODS

Endoscopic sinus surgery was performed on 5 fresh cadavers. Complementary colored dyes mixed with saline were successively nebulized using the following protocol: (1) fluorescein prior to MT resection; (2) brilliant green following partial MT resection; and (3) methylene blue following total MT resection. Photodocumentation of the sinuses was performed following each nebulization and standardized photoanalysis was performed.

RESULTS

Successive nebulizations with fluorescein, brilliant green, and methylene blue produced a complementary staining pattern that provided an easy side-by-side analysis of the extent of mucosal staining. Dye delivery to the frontal and sphenoid sinuses significantly increased following partial resection of the MT (p = 0.013 and p = 0.0027, respectively) and complete resection of the MT (p = 0.027 and p = 0.027, respectively). Following complete MTR, dye delivery to the maxillary sinus significantly increased compared to baseline (MT intact) (p = 0.0027).

CONCLUSION

Resection of the MT appears to have a significant effect on nebulized drug delivery into the frontal, maxillary, and sphenoid sinuses. Future prospective studies will help delineate the clinical relevance of this effect.

A computational study of functional endoscopic sinus surgery and maxillary sinus drug delivery

BACKGROUND

Topical medication is increasingly used following functional endoscopic sinus surgery (FESS). Information on particle sizes that maximise maxillary sinus (MS) delivery is conflicting, and the effect of antrostomy size on delivery is unclear. The purpose of this study was to estimate antrostomy and particle size effects on topical MS drug delivery.

METHODOLOGY

Sinonasal reconstructions were created from a pre- and a post-FESS CT scan in each of four chronic rhinosinusitis patients. Additional models were created from each post-FESS reconstruction representing four alternative antrostomy sizes. Airflow and particle deposition were simulated in each reconstruction using computational fluid dynamics for nebulised and sprayed delivery.

RESULTS

MS ventilation and drug delivery increased following FESS, the largest virtual antrostomy led to greatest delivery, and MS delivery was sensitive to particle size. Particles within a 5-18 μm and 5-20 μm size range led to peak MS deposition for nebulised and sprayed particles, respectively. Post-FESS increases in drug delivery varied across individuals and within individuals by the type of antrostomy created.

CONCLUSION

Our findings suggest that FESS, particularly with larger antrostomies, improves topical drug delivery, and that certain particle sizes improve this delivery. Further research is needed to contextualise these findings with other post-surgical effects.

A computational study of functional endoscopic sinus surgery and maxillary sinus drug delivery

BACKGROUND

Topical medication is increasingly used following functional endoscopic sinus surgery (FESS). Information on particle sizes that maximise maxillary sinus (MS) delivery is conflicting, and the effect of antrostomy size on delivery is unclear. The purpose of this study was to estimate antrostomy and particle size effects on topical MS drug delivery.

METHODOLOGY

Sinonasal reconstructions were created from a pre- and a post-FESS CT scan in each of four chronic rhinosinusitis patients. Additional models were created from each post-FESS reconstruction representing four alternative antrostomy sizes. Airflow and particle deposition were simulated in each reconstruction using computational fluid dynamics for nebulised and sprayed delivery.

RESULTS

MS ventilation and drug delivery increased following FESS, the largest virtual antrostomy led to greatest delivery, and MS delivery was sensitive to particle size. Particles within a 5-18 μm and 5-20 μm size range led to peak MS deposition for nebulised and sprayed particles, respectively. Post-FESS increases in drug delivery varied across individuals and within individuals by the type of antrostomy created.

CONCLUSION

Our findings suggest that FESS, particularly with larger antrostomies, improves topical drug delivery, and that certain particle sizes improve this delivery. Further research is needed to contextualise these findings with other post-surgical effects.

Protease-antiprotease imbalances differ between Cystic Fibrosis patients' upper and lower airway secretions

BACKGROUND

Balanced levels of proteases and anti-proteases are essential in host defense systems. In CF patients' lungs, elevated protease/anti-protease-ratios contribute to damage of airway tissue and premature death with the inherited disease. Little is known about upper airway protease equilibrium in CF.

METHODS

Neutrophil elastase (NE), Secretory leukocyte protease inhibitor (SLPI), matrix metalloproteinase (MMP)9, tissue inhibitors of metalloproteinase (TIMP)1, cathepsin S (CTSS) and the corresponding cellular distribution were assessed in the nasal lavage (NL) and sputum of 40 CF patients.

RESULTS

Concentrations of all proteases and anti-proteases were markedly higher in sputum than in NL (NE: 10-fold, SLPI: 5000-fold). Interestingly, the NE/SLPI ratio was 726-fold higher in NL compared to sputum, while the MMP9/TIMP1 ratio was 4.5-fold higher in sputum compared to NL.

DISCUSSION

This first study to compare protease/anti-protease networks of CF upper and lower airways by NL and sputum reveals substantial differences between both compartments' immunological responses. This finding may have implications for sinonasal and pulmonary treatment, possibly leading to new therapeutic approaches.

Sinonasal inhalation of dornase alfa administered by vibrating aerosol to cystic fibrosis patients: a double-blind placebo-controlled cross-over trial

BACKGROUND

Chronic rhinosinusitis significantly impairs CF patients' quality of life and overall health. The Pari-Sinus™ device delivers vibrating aerosol effectively to paranasal sinuses. After a small pilot study to assess sinonasal inhalation of dornase alfa and placebo (isotonic saline) on potential sinonasal outcome measures, we present the subsequent prospective double-blind placebo-controlled crossover-trial.

METHODS

23 CF patients were randomised to inhale either dornase alfa or isotonic saline for 28 days with the Pari-Sinus™ and after 28 days (wash-out) crossed over to the alternative treatment. The primary outcome parameter was primary nasal symptom score in the disease-specific quality of life Sino-Nasal Outcome-Test-20 (SNOT-20: nasal obstruction/sneezing/runny nose/thick nasal discharge/reduced smelling).

RESULTS

Primary nasal symptoms improved significantly with dornase alfa compared with no treatment, while small improvements with isotonic saline did not reach significance. SNOT-20 overall scores improved significantly after dornase alfa compared with isotonic saline (p=0.017). Additionally, sinonasal dornase alfa but not isotonic saline significantly improved pulmonary function (FEF75-25: p=0.021).

CONCLUSION

Vibrating sinonasal inhalation of dornase alfa reduces rhinosinusitis symptoms in CF.

Sinonasal inhalation of tobramycin vibrating aerosol in cystic fibrosis patients with upper airway Pseudomonas aeruginosa colonization: results of a randomized, double-blind, placebo-controlled pilot study

Rationale

In cystic fibrosis (CF), the paranasal sinuses are sites of first and persistent colonization by pathogens such as Pseudomonas aeruginosa. Pathogens subsequently descend to the lower airways, with P. aeruginosa remaining the primary cause of premature death in patients with the inherited disease. Unlike conventional aerosols, vibrating aerosols applied with the PARI Sinus™ nebulizer deposit drugs into the paranasal sinuses. This trial assessed the effects of vibrating sinonasal inhalation of the antibiotic tobramycin in CF patients positive for P. aeruginosa in nasal lavage.

Objectives

To evaluate the effects of sinonasal inhalation of tobramycin on P. aeruginosa quantification in nasal lavage; and on patient quality of life, measured with the Sino-Nasal Outcome Test (SNOT-20), and otologic and renal safety and tolerability.

Methods

Patients were randomized to inhalation of tobramycin (80 mg/2 mL) or placebo (2 mL isotonic saline) once daily (4 minutes/nostril) with the PARI Sinus™ nebulizer over 28 days, with all patients eligible for a subsequent course of open-label inhalation of tobramycin for 28 days. Nasal lavage was obtained before starting and 2 days after the end of each treatment period by rinsing each nostril with 10 mL of isotonic saline.

Results

Nine patients participated, six initially receiving tobramycin and three placebo. Sinonasal inhalation was well tolerated, with serum tobramycin <0.5 mg/L and stable creatinine. P. aeruginosa quantity decreased in four of six (67%) patients given tobramycin, compared with zero of three given placebo (non-significant). SNOT-20 scores were significantly lower in the tobramycin than in the placebo group (P=0.033).

Conclusion

Sinonasal inhalation of vibrating antibiotic aerosols appears promising for reducing pathogen colonization of paranasal sinuses and for control of symptoms in patients with CF.

Topical contrast agents to improve soft-tissue contrast in the upper airway using cone beam CT: a pilot study

The purpose of this study is to explore the topical use of radiographic contrast agents to enhance soft-tissue contrast on cone beam CT (CBCT) images. Different barium sulphate concentrations were first tested using an airway phantom. Different methods of barium sulphate application (nasal drops, syringe, spray and sinus wash) were then tested on four volunteers, and nebulized iodine was tested in one volunteer. CBCT images were performed and then assessed subjectively by two examiners for contrast agent uniformity and lack of streak artefact. 25.0% barium sulphate presented adequate viscosity and radiodensity. Barium sulphate administered via nasal drops and sprays showed non-uniform collection at the nostrils, along the inferior and/or middle nasal meatuses and posterior nasal choana. The syringe and sinus wash showed similar results with larger volumes collecting in the naso-oropharynx. Nebulized iodine failed to distribute into the nasal cavity and scarcely collected at the nostrils. All methods of nasal application failed to adequately reach or uniformly coat the nasal cavity beyond the inferior nasal meatuses. The key factors to consider for optimum topical radiographic contrast in the nasal airway are particle size, flow velocity and radio-opacity.

Functional endoscopic sinus surgery (FESS) alone versus balloon catheter sinuplasty (BCS) and ethmoidectomy: a comparative outcome analysis in pediatric chronic rhinosinusitis

OBJECTIVE

To evaluate whether the addition of BCS (balloon catheter sinuplasty) would improve the treatment outcome in children with chronic rhinosinusitis (CRS) compared to FESS (functional endoscopic sinus surgery).

STUDY DESIGN

Two-group, retrospective cohort with blinded chart review comparison.

SETTING

Children's Hospital of Michigan, Detroit, MI.

SUBJECTS AND METHODS

Chart review of 15 pediatric patients who underwent BCS with ethmoidectomy and 16 who underwent FESS from 2008 to 2011 for treatment of CRS in a tertiary care, university affiliated, pediatric institution. Pre-operative CT-scans as well as pre and post-operative sinus symptoms and medications were compared. Post-surgical outcome was examined using chi square analysis.

RESULTS

Mean age of children at the time of the procedure was 9.3 (SD=4.19; range=3-17). Both groups had similar pre-surgical Lund-Mackay CT CRS scores (FESS: mean=9.33 and t=0.67; balloon: mean=10.58, t=0.68, and p=0.51). Analyses identified significant post-treatment reductions in overall symptoms and needed interventions in both treatment groups. Side-by-side post-operative comparison of patients who underwent balloon sinuplasty to FESS demonstrated statistically significant post-operative difference between the two groups in antibiotic requirement, sinus congestion and headaches. Though not statistically significant, 62.5% of FESS patients and 80.0% of BCS patients (χ(2)=1.15) reported improvement in their overall sinus symptoms post-operatively.

CONCLUSION

Both BCS and FESS are suitable treatments for CRS in children. Both treatments significantly reduced CRS complaints post-operatively and had similar overall results. BCS patients required significantly fewer antibiotics post-operatively for CRS related disease when compared to FESS. Larger prospective studies with long-term data are needed to further evaluate.

Effects of anatomy and particle size on nasal sprays and nebulizers

OBJECTIVE

To study the effects of nasal deformity on aerosol penetration past the nasal valve (NV) for varying particle sizes using sprays or nebulizers.

STUDY DESIGN

Computed mathematical nasal airway model.

SETTING

Department computer lab.

SUBJECTS AND METHODS

Particle deposition was analyzed using a computational fluid dynamics model of the human nose with leftward septal deviation and compensatory right inferior turbinate hypertrophy. Sprays were simulated for 10 µm, 20 µm, 50 µm, or particle sizes following a Rosin Rammler particle size distribution (10-110 µm), at speeds of 1, 3, or 10 meters per second. Nebulization was simulated for 1, 3.2, 6.42, or 10 µm particles. Steady state inspiratory airflow was simulated at 15.7 liters per minute.

RESULTS

Sprays predicted higher NV penetration on the right side for particle sizes >10 µm, with comparable penetration on both sides at 10 µm. Nearly 100% deposited in the nasal passages for all spray characteristics. Nebulizer predictions showed nearly 100% of particles <6.42 µm and more than 50% of 6.42 µm bypassing both sides of the nose without depositing. Of the nebulized particles that deposited, penetration was higher on the right at 10 µm, with comparable penetration on both sides at 6.42 µm. Spray penetration was highest at 10 µm, with more than 96% penetrating on both sides at 1 and 3 meters per second. Nebulization penetration was also highest at 10 µm (40% on the left, >90% on the right).

CONCLUSION

In the presence of a septal deviation, sprays or nebulizers containing 10-µm particles may have good penetration beyond the NV. Nebulized particles <10 µm are likely to be respirable. Additionally, spray speeds above 3 meters per second may limit penetration.

Prospective evaluation of aerosol delivery by a powered nasal nebulizer in the cadaver model

BACKGROUND

The objective of this study was to compare the distribution of aerosol delivered via a powered nasal nebulizer device in 5 fresh frozen-cadaver heads (10 total sides).

METHODS

Nasoneb® (Medinvent, St. Paul, MN) was used to deliver a total volume of 10 mL (9 mL saline and 1 mL of 10% fluorescein). Aerosol distribution was assessed in 3 trials: (1) unoperated nose; (2) post-functional endoscopic sinus surgery (FESS); and (3) post-FESS with endoscopic modified Lothrop procedure (EML). Two independent observers rated the distribution of the fluorescein-dyed saline in the anterior nasal cavity (ANC), olfactory cleft (OC), middle meatus (MM), sphenoethmoid recess (SER), nasopharynx (NP), along with maxillary sinus (MS), ethmoid cavity (EC), sphenoid sinus (SS), frontal sinus (FS), and frontal neo-ostium (F-NEO) in the operated specimens.

RESULTS

The nebulizer consistently delivered aerosolized saline to the ANC, MM/EC, and SER/SS across the 3 trials. A statistically significant increase in delivery was noted to the MM (p = 0.044) post-FESS. In addition, a statistically significant increase in delivery to the F-NEO was noted post-FESS with EML (p = 0.001). Multiplicity adjustment done for the FESS group showed statistically superior delivery to the EC vs OC (p = 0.031) and FS (p = 0.02) and to the SS vs FS (p = 0.031). Multiplicity adjustment after FESS with EML improved delivery to the FS, resulting in no statistical difference in aerosol delivery between F-NEO and EC or SS.

CONCLUSION

The nebulizer consistently delivered aerosolized saline to multiple nasal subsites, with improvement in delivery seen to the middle meatal region after FESS and F-NEO after FESS with EML. This may have important implications for the delivery of topical medications to the paranasal sinuses in the postoperative setting.

Effect of head position and surgical dissection on sinus irrigant penetration in cadavers

BACKGROUND

Effective treatment for recalcitrant rhinosinusitis requires unobstructed surgical marsupialization of sinus cavities and use of delivery systems that will topically penetrate the sinuses.

AIMS

To determine the extent of sinus penetration achieved with nasal irrigation by varying the ostial size and head position.

METHODS

Ten thawed fresh-frozen cadaver heads were dissected in a staged manner. After each stage of dissection, sinus squeeze-bottle irrigations were performed in three head positions, and endoscopes placed via external ports into the sinus cavities viewed the sinus ostia. An ordinal scale was developed to grade ostial penetration of irrigations. Three reviewers independently graded the outcomes.

RESULTS

Irrigant entry into sinuses increased with ostial size (P < .001) and the greatest differential of improvement in sinus penetration is obtained at an ostial size of 4.7 mm. Stages 2 and 3 (larger sinus ostia) of maxillary and sphenoid dissections have statistically greater irrigant penetration relative to earlier stages. Frontal sinus irrigation is worse in vertex to ceiling head position. There does not appear to be any significant advantage to head position with maxillary and sphenoid sinuses.

CONCLUSIONS

This study shows that the larger the sinus ostium, the better the penetration of irrigant into the sinus, with an ostium of at least 4.7 mm allowing maximal penetration in the maxillary and sphenoid sinuses. The same benefit was not noted in the frontal sinus. Head position was only relevant to the frontal sinus where less penetration was seen with the head neutral (vertex to ceiling) position when compared to forward angled positions.

Simultaneous inferior and middle meatus antrostomies in the treatment of the severely diseased maxillary sinus

BACKGROUND

Although the majority of the maxillary pathology can be eradicated through the enlarged middle meatus antrostomy (MMA), some patients have extensive disease that is difficult to cope with. The aim of this study was to estimate the usefulness of simultaneous middle and inferior meatal antrostomies (MIMAs) in cases with severely diseased maxillary sinus by comparing the subjective and objective outcomes between patients that underwent MIMA and those who experienced maxillary clearance through conventional MMA.

METHODS

A prospective study was performed on patients with nasal polyps and severely diseased maxillary sinus (Lund-Mackay CT score = 2). All diseased sinuses were addressed with the same endoscopic sinus surgery technique; the only difference consisted of the management of the maxillary sinus: 34 patients underwent MIMAs and in 38 cases maxillary sinus was approached solely through the MMA. After 12 months of follow-up, outcomes consisted of the visual analog scale (VAS) for the main symptoms, the Lund-Mackay and maxillary sinus endoscopic scores, and the percent of airspace occluded by inflammatory mucosal thickening on CT.

RESULTS

Subjective improvement in VAS scores for nasal obstruction, facial pain, and nasal discharge/retronasal drip was significantly better in the MIMA group. The mucosal thickening as expressed by the CT scan and maxillary endoscopic score was significantly reduced in the MIMA group.

CONCLUSION

The MIMA technique is useful for removing severe disease that can not be reached through the MMA and yields both better subjective and better objective outcomes. The additional inferior antrostomy most likely improves drainage and ventilation in the postoperative period.

Role of maximal endoscopic sinus surgery techniques in chronic rhinosinusitis

There remains a continued debate regarding the extent of endoscopic sinus surgery (ESS) required for patients with chronic rhinosinusitis (CRS). By examining anatomic, etiologic, and postoperative factors that may lead to recalcitrant CRS, this article aims to highlight some of the reasons for performing maximal techniques in ESS. This concept is further expanded in various surgical maneuvers including wide maxillary antrostomy, extended frontal sinus procedures, and intraoperative computed tomography-guided ESS.

The effect of functional endoscopic sinus surgery on nasal spray distribution to the middle meatus in patients with rhinosinusitis

BACKGROUND

Because the principle behind functional endoscopic sinus surgery (FESS) recognizes the middle meatus as essential for the control of the disease, the effect of the operation in the distribution of drugs in the same area should be of similar importance. This study was designed to clarify whether nasal drug delivery is improved in patients after FESS. The study involved a prospective assessment within subject comparison. The subjects were 20 adult (>18 years old) patients on the waiting list for FESS. It was conducted within two teaching hospitals in the East of Scotland.

METHODS

A novel method was used, positioning a neurosurgical patty in the middle meatus and assessing blue dye nasal spray absorption on a 4-point scale.

RESULTS

A significant improvement was observed in the distribution of the indicator in the middle meatus postoperatively. Seventy percent of the patients showed improvement in the drug distribution after FESS. The median result for absorption score was 2 preoperatively (<50%) and 3 postoperatively (>50%). The difference was statistically significant (p<0.001).

CONCLUSION

The distribution of nasal drugs is improved in the middle meatus after FESS. This can have important clinical applications that can benefit patients in otolaryngology as well as other disciplines.

Efficacy of different techniques of sinonasal irrigation after modified Lothrop procedure

BACKGROUND

Postoperative irrigation after endoscopic sinus surgery and endoscopic modified Lothrop procedure is used to remove nasal crusts and to improve wound healing. To evaluate the optimal application protocol for irrigation of the frontal sinus, a prospective cadaver study was performed.

METHODS

An endoscopic modified Lothrop procedure and complete sphenoethmoidectomy were performed in 19 heads. Each was irrigated with a 1.5% solution of water and different colors using nasal spray and a squeeze bottle filled with 50, 100, and 200 mL. Intensity of local staining and percentage of area were documented using standardized videoendoscopy after irrigation in "bending over the sink" or "vertex to floor" position. Grading was performed by two independent observers for 23 anatomic regions, including the stained circumference of maxillary and frontal ostia. To evaluate the influence of the anatomy, acoustic rhinometry was performed. ANOVA was used to evaluate effects of application methods and head positions using GenStat 8.2 (Lawes Agricultural Trust, Rothamsted Experimental Station, Harpenden, U.K.) using an appropriate block structure.

RESULTS

With regard to the frontal sinus, we were able to show clear superiority of the squeeze bottle technique filled with 200 mL and applied in the "vertex to floor position."

CONCLUSION

In a relatively fit and flexible patient the vertex to floor position using a squeeze bottle technique is advocated. There may be some patients, however, for whom this position is not feasible. In these patients "bending over the sink," while inferior to the "vertex to floor" position, still ensures some irrigation of the frontal sinus.

A prospective controlled trial of pulsed nasal nebulizer in maximally dissected cadavers

BACKGROUND

Nasal douching is common practice in treatment of chronic sinusitis and after endoscopic sinus surgery. Current nasal delivery techniques show inconsistent sinus penetration. The aim of this study was to compare sinonasal penetration of nasal douching to an optimized nasal nebulizer in an operated cadaver model.

METHODS

Fourteen preserved cadavers were used receiving complete sphenoethmoidectomies with a Draf III, wide maxillary antrostomy, or medial maxillectomy. Seven control cadavers received nasal douching with one standardized squeeze bilaterally of a 200-mL nasal irrigation bottle and seven intervention cadavers were nebulized with 3 minutes of the PARI sinus device bilaterally. Douching solutions were stained with methylene blue. Independent observers documented sinonasal anatomy, staining intensity, and percentage area covered by dye using standardized grading protocols.

RESULTS

Combined data showed a significant increase in intensity of stain (2.06 versus 0.26, p < 0.001), percentage of stain (49.96% versus 4.19%, p < 0.001), and circumference stained (76.59% versus 12.7%, p < 0.001) with the plastic nasal irrigation squeeze bottle versus PARI device. Analysis of individual sinuses consistently showed significant increases in indices of nasal douching relative to nebulization. The PARI sinus nebulizer was noted to reach the ethmoids regularly (92% incidence), whereas the other sinuses were not reached as regularly with incidences noted at frontal (43%), maxillary (46%), and sphenoid (54%). This compares to 96% of all sinuses being stained by the squeeze bottle.

CONCLUSION

In all measured indices, the nasal douching method with the squeeze bottle was superior to the PARI sinus nebulizer in highly dissected sinonasal cadaver models.

Differential deposition of aerosols in the maxillary sinus of human cadavers by particle size

BACKGROUND

Topical delivery of nebulized antibiotics to the paranasal sinuses has been shown to improve clinical outcomes in patients with chronic sinus disease after functional endoscopic sinus surgery (FESS). The most efficient method for delivering nebulized particles to the sinuses, however, has not been established. This study investigates how the size of nebulized particles influences the efficiency of deposition in the maxillary sinus of human cadavers after FESS.

METHODS

Endoscopic maxillary antrostomy was performed on eight sides in four cadavers. Each cadaver's nasal vault was nebulized with technetium99m-labeled sulfur colloid particles of three size ranges. Anterior-posterior and left lateral static gamma-camera images of the head were captured with an acquisition cutoff limit of 30,000 gamma-count. Regions of interest were defined for the left and right maxillary sinus and gamma-photon counts were recorded. Analysis of variance (ANOVA) for repeated measures and paired t-test were used to determine statistical significance.

RESULTS

Mean diameter of particles generated was 6, 0.99, and 0.67 microm. There was a statistically significant difference in deposition between the largest particle size and the two smaller sizes, with a mean gamma-photon count of 254 for 6-microm particles versus 811 for 0.99-microm particles and 835 for 0.67-microm particles (ANOVA, p = 0.002).

CONCLUSION

Particles in the 0.67- to 0.99-microm range had improved efficiency of deposition in the maxillary sinus compared with larger particles after maxillary antrostomy. Larger particles appeared to deposit directly in the nasal vault while smaller particles were more likely to reach the maxillary sinus.

The Effect of High-dose Topical Corticosteroid Therapy on Prevention of Recurrent Nasal Polyps after Revision Endoscopic Sinus Surgery

Background

Topical corticosteroid spray is widely used after endoscopic sinus surgery (ESS) to reduce the recurrence of polyposis. However, it has not always shown satisfactory results in clinical practice. We compared the effects of topical spray and high-dose topical steroid gauze packing on the prevention of recurrent nasal polyps after ESS.

Methods

We selected 32 patients with recurrent nasal polyps after ESS. In group 1, 18 patients were treated with topical steroid spray and in group 2,14 patients were treated with triamcinolone acetonide–soaked (40 mg) gauze packing once a week for 2 months after revision ESS. We observed the recurrence of polyps between the two groups for 12 months.

Results

Polyps recurred in 8 of 18 patients in group 1 compared with 1 of 14 patients in group 2 (p = 0.044).

Conclusion

High-dose topical corticosteroid therapy may be more effective than low-dose topical therapy in preventing recurrent nasal polyps.