Effect of three-drug delivery modalities on olfactory function in chronic sinusitis

Olfactory dysfunction in chronic rhinosinusitis: insights into the underlying mechanisms and treatments

INTRODUCTION

Olfactory dysfunction (OD) is a typical symptom of chronic rhinosinusitis (CRS), which adversely affects the patient's quality of life and results in mood depression. Studies investigating the impairment of olfactory epithelium (OE) have indicated that inflammation-induced cell damage and dysfunction in OE plays a vital role in the development of OD. Consequently, glucocorticoids and biologics are beneficial in the management of OD in CRS patients. However, the mechanisms underlying OE impairment in CRS patients have not been fully elucidated.

AREAS COVERED

This review focuses on mechanisms underlying inflammation-induced cell impairment in OE of CRS patients. Additionally, the methods used for detection of olfaction and both currently available and potentially new clinical treatments for OD are reviewed.

EXPERT OPINION

Chronic inflammation in OE impairs not only olfactory sensory neurons but also non-neuronal cells that are responsible for regeneration and support for neurons. The current treatment for OD in CRS is mainly aimed at attenuating and preventing inflammation. Strategies for use of combinations of these therapies may achieve greater efficacy in restoration of the damaged OE and consequently better management of OD.

Effect of recombinant human acidic fibroblast growth factor on nasal mucosal healing after endoscopic sinus surgery

BACKGROUND

Postoperative nasal treatment is an important factor affecting the outcomes of endoscopic sinus surgery (ESS) in patients with chronic rhinosinusitis (CRS). This study aimed to determine the effect of recombinant human acidic fibroblast growth factor (rh-aFGF) on nasal mucosal healing after ESS.

METHODS

This study is a prospective, single-blind, and randomized controlled clinical study. Fifty-eight CRS patients with nasal polyps (CRSwNP) with bilateral ESS were enrolled and randomly given 1 mL of budesonide nasal spray and 2 mL of rh-aFGF solution (rh-aFGF group) or 1 mL of budesonide nasal spray and 2 mL of rh-aFGF solvent (budesonide group)-infiltrated Nasopore nasal packing after ESS. Preoperative and postoperative scores for Sino-Nasal Outcome Test (SNOT-22), Visual Analogue Scale (VAS), and Lund-Kennedy were collected and analyzed.

RESULTS

Forty-two patients completed the 12-week follow-up. Postoperative SNOT-22 scores and VAS scores showed no significant differences between the two groups. In terms of the Lund-Kennedy scores, there was a statistically significant difference between the two groups at the 2-, 4-, 8-, and 12-week postoperative visits, but not at the 1-week visit. Twelve weeks after surgery, the nasal mucosa had completely epithelialized in 18 patients in the rh-aFGF group and in 12 patients in the budesonide group (χ² = 4.200, P = 0.040).

CONCLUSION

The combined application of rh-aFGF and budesonide significantly improved postoperative endoscopic appearance in the nasal mucosal healing process.

Applications of vibrational energy in the treatment of sinonasal disease: A scoping review

BACKGROUND

Acoustic energy and vibration therapy are emerging as helpful adjuncts among many disease states. There has been interest in how this technology can either serve as an alternative treatment or enhance delivery of medications to treat pathology within the nasal cavity and paranasal sinuses. Our objective was to perform a scoping review of the state of the science of vibration treatment used in sinonasal disease.

METHODS

A search of Embase, PubMed, and CINAHL databases was performed in November 2021. Included studies evaluated acoustic energy as a means of treatment in sinonasal diseases. Data points collected included type of technology utilized, disease state treated, and outcomes.

RESULTS

The initial search identified 2902 studies, of which 44 met inclusion criteria. A wide array of vibrational technology such as ultrasound, sonic aerosols, and phonophoresis, with varying frequency and amplitude were described. Twenty-six studies evaluated the use of acoustic energy to treat sinonasal disease itself, while 18 studies evaluated the use of acoustic energy to facilitate drug delivery to the sinonasal cavity. Outcome measures among studies were highly varied.

CONCLUSIONS

Vibration technology used in patients with sinonasal pathology has been shown to improve pain, sinonasal symptoms, and radiologic outcome measures in small studies. Given the heterogeneous study populations and outcomes, no conclusion could be reached regarding overall effectiveness of acoustic energy as a primary treatment. Further research is required to study specific treatment indications in larger patient populations to fully understand the potential clinical benefit and to determine optimal therapeutic characteristics of sound energy.

Beyond aroma: A scoping review on the impact of chronic rhinosinusitis on retronasal olfaction

Background

Retronasal olfaction (RNO) refers to the perception of odorants inhaled through the mouth and carried through the nasopharynx to olfactory receptors within the olfactory cleft, enabling the perception of flavor. Although orthonasal olfactory dysfunction in chronic rhinosinusitis (CRS) has been widely described, the impact of CRS on RNO is less clear. In this study, we systematically review available literature to provide an update on RNO in the setting of CRS.

Methods

We systematically searched PubMed, Ovid Embase, Web of Science, and the Cochrane Library for studies examining RNO in patients with documented CRS. The primary outcome of interest was objective psychophysical measurement of olfaction, including characterization of RNO.

Results

We identified 404 unique references that underwent title and abstract review by two independent reviewers, with 52 articles undergoing full-text review, where 10 relevant studies underwent data extraction. Although outcome measures varied, all included studies demonstrated diminished RNO in patients with CRS. Of six studies evaluating the relationship between retronasal and orthonasal olfactory test scores in CRS patients two out of six (33%) demonstrated a correlation between both forms of olfaction and CRS, and two out of six studies (33%) found significantly lower orthonasal olfactory test scores compared to retronasal olfactory test scores. Two of three found significant improvement in RNO with treatment of underlying CRS. Of three studies examining patient reported outcome measures (PROMs) in CRS, two found significant associations between retronasal olfactory test scores and PROMs.

Conclusions

Based on the current literature, CRS patients appear to have diminished RNO, which may be associated with orthonasal olfactory dysfunction and decreased quality of life in this population. Higher level of evidence studies are required to further elucidate these relationships and the impact of medical and surgical CRS management on RNO.

Chinese expert recommendation on transnasal corticosteroid nebulization for the treatment of chronic rhinosinusitis 2021

Corticosteroids are efficacious in treating chronic rhinosinusitis (CRS), but concerns on the potential side effects remain, especially for long-term usage of systemic corticosteroids. Accumulated evidence shows that transnasal nebulization may be a reasonable solution in balancing both efficacy and safety. However, no consensus or guideline has been formulated on the use of steroid transnasal nebulization in treating CRS. The consensus is achieved through literature review and exchange of Chinese experts in Group of Otorhinolaryngology and Ophthalmology, Chinese Society of Allergy (CSA). This document covers the development, equipment, pharmacological mechanism, and evidence-based efficacy and safety, as well as the special concern of the application of steroid transnasal nebulization during the coronavirus disease (COVID-19) pandemic. The expert consensus clarifies the application of steroid transnasal nebulization in treating CRS and common comorbidities during the perioperative and postoperative periods.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

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.

Current Perspective on Nasal Delivery Systems for Chronic Rhinosinusitis

Chronic rhinosinusitis is an upper respiratory disease during which topical drug treatment via the nasal cavity is the most actively utilized therapeutic strategy. In addition to steroids, antibiotics, and antifungal agents, which are widely used in clinical practice, research on novel topical agents to improve the bacterial biofilm or mucociliary clearance remains ongoing. Moreover, owing to the complex structure of the nasal cavity, the effects of nasal drug delivery vary depending on factors related to delivery fluid dynamics, including device, volume, and compounds. In this article, we review methods and compounds that have been applied to chronic rhinosinusitis management and introduce recent advances and future perspectives in nasal drug delivery for upper respiratory diseases.

Oral Corticosteroid Regimens in the Management of Chronic Rhinosinusitis

BACKGROUND

Oral corticosteroids are often used in the medical management of chronic rhinosinusitis (CRS) with and without polyps. The purpose of our study is to review the literature for studies reporting the dosage of oral corticosteroids as part of the appropriate medical management prior to, immediately before, and after surgical intervention.

METHODS

We reviewed the literature for oral corticosteroid regimens given to patients with CRS from March 2012 to September 2018. Studies that did not disclose the exact doses of the regimen were excluded from our analysis.

RESULTS

Our search resulted in 7 articles with 4 studies of Level of Evidence (LOE) 1b, 2 studies with LOE III, and 1 study with LOE IV. The daily doses varied from 15 mg to 1 mg/kg, and with total doses ranging from 150 to 352 mg. In addition, several studies gave the same regimen to both subtypes of CRS. There was no mention of side effects in most of the studies.

CONCLUSION

There is a wide variation in the steroid doses given to patients with CRS and prospective or randomized controlled trials are needed to provide better improved evidence.

Effect of short-course glucocorticoid application on patients with chronic rhinosinusitis with nasal polyps

BACKGROUND

Local and systemic glucocorticoids are mainstay therapies for chronic rhinosinusitis. With respect to local glucocorticoids, nasal spray is used extensively, but some patients do not benefit from short-course treatment. Recently, some clinicians have focused on the effects of high-dose local glucocorticoids in chronic rhinosinusitis with nasal polyps (CRSwNP), such as treatment using nasal irrigation, transnasal nebulization, and nose-dripping therapy (nasal drop) with high-dose budesonide. However, there are little data comparing the effect of short-course high-dose local glucocorticoids with regular nasal spray and oral steroids in the treatment of preoperative CRSwNP patients. Furthermore, the appropriate use of different types of glucocorticoids in different endotypes of CRSwNP remains unclear.

METHODS

This randomized controlled clinical research study was performed at a single academic center. Patients who satisfied the criteria of chronic rhinosinusitis with bilateral nasal polyps were randomly assigned in a 1:1:1 ratio to receive oral methylprednisolone, 24 mg/d and budesonide nasal spray, 256 μg/d, or intranasal budesonide suspension, 1 mg/d and budesonide nasal spray, 256 μg/d, or budesonide nasal spray, 256 μg/d for one week. Symptoms, endoscopic scores, and tissue and blood inflammatory cells were recorded before and after the study. Adverse events were recorded by clinicians.

RESULTS

A total of 127 patients with CRSwNP underwent randomization. The total nasal symptoms scores (TNSS) decreased significantly in all groups compared to those at baseline. The assessment of the reduction in TNSS demonstrated that the change was significantly greater in the nasal drop group than in the nasal spray group (-7.47 vs -4.10, P = 0.032), and it was also greater in the oral steroid group than in the nasal spray group (-7.30 vs -4.10, P = 0.039). A similar trend also appeared in the reduction in Sinonasal-Outcome Test 22 (SNOT-22). After treatment, a significantly reduction in NP score was observed in the nasal drop group (-0.82) and oral steroid group (-0.85) compared with that in the nasal spray group (-0.10), and there was no significant difference between the nasal drop and oral steroid groups (P = 0.98). While calculating the percentage of patients who were sensitive to glucocorticoid treatment, there was 10.26% in the nasal spray group, 47.37% in the nasal drop group, and 52.50% in the oral steroid group that were sensitive to glucocorticoid treatment. The reduction in NP score was more significant in patients with eosinophilic CRSwNP in the nasal drop group and oral steroid group than in the nasal spray group. However, in patients with non-eosinophilic CRSwNP, the change in NP size was similar in the different treatment groups.

CONCLUSION

Budesonide suspension nasal drop can significantly improve the quality of life and reduce the endoscopic score following short-course treatment, and the treatment effect of nasal drop was better than that of regular nasal spray. Budesonide nasal suspension can be used as a regular treatment for eosinophilic CRSwNP and can be an alternative choice for patients with a high percentage of tissue eosinophil infiltration who cannot use oral glucocorticoids.

Diseases of the nasal cavity

Despite garnering minimal attention from the medical community overall, olfaction is indisputably critical in the manner in which we as humans interact with our surrounding environment. As the initial anatomical structure in the olfactory pathway, the nasal airway plays a crucial role in the transmission and perception of olfactory stimuli. The goal of this chapter is to provide a comprehensive overview of olfactory disturbances as it pertains to the sinonasal airway. This comprises an in-depth discussion of clinically relevant nasal olfactory anatomy and physiology, classification systems of olfactory disturbance, as well as the various etiologies and pathophysiologic mechanisms giving rise to this important disease entity. A systematic clinical approach to the diagnosis and clinical workup of olfactory disturbances is also provided in addition to an extensive review of the medical and surgical therapeutic modalities currently available.

Treatments for smell and taste disorders: A critical review

A key concern of both the patient and physician is whether treatment is available that will eliminate or quell a given chemosensory disturbance. In cases where obvious oral, nasal, or intracranial pathology is involved, rational straightforward approaches to treatment are often available. In cases where damage to the sensory pathways is secondary to chronic inflammatory disease, trauma, viral invasion, toxic exposure, or unknown causes, the direction for therapy is more challenging. Indeed, many chemosensory disorders, if present for any period of time, cannot be reversed, while others spontaneously remit without any therapeutic intervention. This review assesses the strengths and weaknesses of more than two dozen approaches to treatment that have been suggested for a wide range of taste and smell disorders.

Retronasal Olfaction Test Methods: A Systematic Review

Background

This report produces a bibliographic study of psychophysical tests proposed clinical assessments of retronasal olfaction.

Aims

We review how these tests can be utilized and discuss their methodological properties.

Study Design

Systematic review.

Methods

We undertook a systematic literature review investigating the retronasal olfaction test methods. PubMed, the free online MEDLINE database on biomedical sciences, was searched for the period from 1984 to 2015 using the following relevant key phrases: “retronasal olfaction”, “orthonasal olfaction”, “olfaction disorders”, and “olfaction test”. For each of the selected titles cited in this study, the full manuscript was read and analyzed by each of the three authors of this paper independently before collaborative discussion for summation and analytical reporting. Two reviewers independently read the abstracts and full texts and categorised them into one of three subgroups as follow, suitable, not-suitable, and unsure. Then they cross-checked the results, and a third reviewer decided assigned the group “unsure” to either the suitable group or the not-suitable group. Fifty eight studies revealed as suitable for review by two authors whereas 13 found not suitable for review. The total amount of 60 uncertain (unsure) or differently categorized articles were further examined by the third author which resulted in 41 approvals and 19 rejections. Hence 99 approved articles passed the next step. Exclusion criteria were reviews, case reports, animal studies, and the articles of which methodology was a lack of olfaction tests. By this way excluded 69 papers, and finally, 30 original human research articles were taken as the data.

Results

The study found that the three most widely used and accepted retronasal olfaction test methods are the retronasal olfaction test, the candy smell test and odorant presentation containers. All of the three psychophysical retronasal olfaction tests were combined with orthonasal tests in clinical use to examine and understand the smell function of the patient completely. There were two limitations concerning testing: “the lack concentrations and doses of test materials” and “performing measurements within the supra-threshold zone”.

Conclusion

The appropriate test agents and optimal concentrations for the retronasal olfaction tests remain unclear and emerge as limitations of the retronasal olfaction test technique. The first step to overcoming these limitations will probably require identification of retronasal olfaction thresholds. Once these are determined, the concept of retronasal olfaction and its testing methods may be thoroughly reviewed.

Challenges in nasal drug absorption: how far have we come?

The nasal route is commonly used for local delivery of drugs to treat inflammatory conditions. It is also an attractive route for systemic delivery of some drugs. Irrespective of intended use, administered drugs must permeate the epithelial or olfactory membrane to be effective. The enthusiasm for potential use of the nasal route for systemic drug delivery has not been met by comparable success. In this paper, the anatomical and physiological attributes of the nasal cavity and paranasal sinuses important for drug delivery and challenges limiting drug absorption are discussed. Efforts made so far in improving nasal drug absorption such as overcoming restrictive nasal geometry and paranasal sinuses accessibility, mucociliary clearance, absorption barriers, metabolism and drug physicochemical challenges are discussed. Highlights on future prospects of nasal drug delivery/absorption were discussed.

The prevalence of olfactory dysfunction in chronic rhinosinusitis

OBJECTIVES

Many studies have reported that olfactory dysfunction frequently occurs in chronic rhinosinusitis (CRS) populations; however, the prevalence and degree of olfactory loss has not been systematically studied. The aims of this study were to use combined data to report the prevalence of olfactory dysfunction and to calculate weighted averages of olfactory test scores in CRS patients.

DATA SOURCES

A search was conducted in PubMed and Scopus, following the methods of Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines.

REVIEW METHODS

Studies reporting the prevalence of olfactory dysfunction using objective measures or olfactory test scores using validated scales were included.

RESULTS

A total of 47 articles were included in a systematic review and 35 in the pooled data analysis. The prevalence of olfactory dysfunction in chronic rhinosinusitis was found to be 30.0% using the Brief Smell Identification Test, 67.0% using the 40-item Smell Identification Test, and 78.2% using the total Sniffin' Sticks score. Weighted averages ± standard deviation of olfactory test scores were 25.96 ± 7.11 using the 40-item Smell Identification Test, 8.60 ± 2.81 using the Brief Smell Identification Test, 21.96 ± 8.88 using total Sniffin' Sticks score, 5.65 ± 1.51 using Sniffin' Sticks-Threshold, 9.21 ± 4.63 using Sniffin' Sticks-Discrimination, 9.47 ± 3.92 using Sniffin' Sticks-Identification, and 8.90 ± 5.14 using the Questionnaire for Olfactory Disorders-Negative Statements.

CONCLUSIONS

In CRS populations, a significant percentage of patients experience olfactory dysfunction, and mean olfactory scores are within the dysosmic range. Laryngoscope, 2016 127:309-320, 2017.

Protective effects of melatonin and selenium against apoptosis of olfactory sensory neurons: A rat model study

BACKGROUND

Selenium plays a role in the prevention of oxidative damage and has been linked to regulatory functions in cell growth, apoptosis, cell survival, and cytotoxicity. Melatonin has an antioxidant effect, which protects against a number of free radical species. Given its antioxidant properties, melatonin has been widely known to inhibit neuronal apoptosis. We examined the cytoprotective effects of melatonin and selenium in rat olfactory sensory neurons after rhinosinusitis by immunohistochemical evaluation of olfactory bulb mucosa.

METHODS

Rhinosinusitis was induced bilaterally in 24 animals. Twenty-four rats were randomly divided into three equal groups. The melatonin group was treated with intraperitoneal (i.p.) melatonin and ampicillin-sulbactam, the selenium group was treated with i.p. selenium and ampicillin-sulbactam, the antibiotic group was treated with i.p. ampicillin-sulbactam; all three groups were treated for 10 days. After a period of 10 days of treatment, the animals were killed for immunohistochemical analyses. All olfactory bulb mucosae were removed immediately.

RESULTS

No histochemical differences were found in the three groups. Terminal deoxynucleotidyl transferase 2'-deoxyuridine 5'-triphosphate nick end labeling-positive cells were detected in each group. In the antibiotic group, the appearance of apoptotic cells was higher, whereas the number of apoptotic cells significantly decreased in the melatonin group. When compared with the selenium group, fewer terminal deoxynucleotidyl transferase 2'-deoxyuridine 5'-triphosphate nick end labeling-positive cells were observed in the melatonin group, which was not significant. In the antibiotic group, the cytoplasmic active caspase-3 and Bax immunostaining in the olfactory epithelium and glandular cells of stroma were higher when compared with the immunostaining in melatonin and selenium groups. Active caspase-3 and Bax immunostaining in the subepithelial stroma was dramatically reduced in the melatonin group. In contrast, the staining intensity and the number of Bcl-2 immunopositive cells were significantly increased in the melatonin group. In the selenium group, Bax and active caspase-3 were moderately immunopositive in the epithelium and subepithelial stroma. However, Bcl-2 immunostaining was more pronounced in the olfactory epithelium and some stromal cells.

CONCLUSION

Our results indicated the possibility that the supplementation of melatonin and selenium, two antioxidant agents for the treatments in the rhinosinusitis rat model, might be reduced or prevent anosmia.

Twice-daily application of topical corticosteroids with a squirt system for patients with steroid-responsive olfactory impairment

CONCLUSION

Twice-daily topical corticosteroid treatment using a squirt system was beneficial in maintaining improvements in olfactory dysfunction which had been achieved by oral steroid treatment.

OBJECTIVES

Some patients suffering from olfactory dysfunction respond well to corticosteroids. However, maintaining these improvements is challenging. The aim of this study was to evaluate the maintenance effect of twice-daily topical steroid treatment using a squirt system.

METHODS

Twenty-two anosmic patients with an increase in odor threshold, discrimination, and identification (TDI) scores in Sniffin' Sticks tests by more than six points after 1-week of oral steroid treatment were enrolled. All the patients used a squirt system to apply topical corticosteroids and were followed up at 1, 3, and 6 months.

RESULTS

Nineteen, 16, and 10 patients were followed-up at 1, 3, and 6 months after treatment, respectively. All the patients had significant visual analog scale scores improvements compared to pre-treatment. The mean improvements in TDI scores were 9.80 (p < 0.001), 11.58 (p = 0.001), and 13.87 (p = 0.005) after 1, 3, and 6 months of treatment, respectively. The self-rated and objective olfactory function scores were maintained with steroid squirt therapy without significant decline, even in the patients who were followed up for 6 months.

Olfaction in chronic rhinosinusitis: comparing two different endonasal steroid application methods

Limited olfactory improvement after topical steroid therapy in chronic rhinosinusitis (CRS) patients might result from restricted drug access to the olfactory cleft. The aim of our study was to investigate the difference between two methods to topically administer steroids with respect to olfaction: (1) conventional nasal spray and (2) a device using pressure and vibration to distribute steroid aerosol endonasally. A prospective study was performed in patients with olfactory impairment due to chronic rhinosinusitis with and without nasal polyps. While the first group used the conventional dexamethasone nasal spray, the second group used the device over a period of 12 days. Olfactory testing was done at 0, 2, and 8 weeks using Sniffin' Sticks test. A significant olfactory improvement was found after 2 weeks of treatment with either steroid (p = 0.005). However, there was no significant difference between the different methods of steroid application. There is a significant olfactory improvement in CRS patients following topical dexamethasone therapy, but no obvious superiority of one of the two ways to administer the steroid.

Olfaction in Chronic Rhinosinusitis

Olfactory dysfunction is a frequent complaint in chronic rhinosinusitis patients and has a significant impact on quality of life. Therefore, it is essential that clinicians are aware of the importance of olfactory dysfunction in chronic rhinosinusitis (CRS) patients and know how to deal with it. Notably, the evaluation of olfactory function (i.e., using psychophysical testing) and imagery of olfactory bulb play an important role in the evaluation of patients and give essential information about the "baseline" olfactory function. Because the high impact of olfactory function on quality of life and medical and/or surgical treatment should be proposed to patients. However, it remains difficult to predict the outcome of treatment as well as long-term efficacy. The first section of this review is dedicated to the assessment of olfactory function. Secondly, we will discuss the etiopathology of olfactory dysfunction in CRS with and without nasal polyps. Finally, we will review literature findings about the efficacy of different treatments on olfactory function.

Steroid transnasal nebulization in the treatment of chronic rhinosinusitis

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) is a challenging disease entity, affecting 8-15% of the general population. Topical steroids have been recommended as an integral part of the strategy for management of CRS. This review focuses on steroid transnasal nebulization as an alternative treatment option for CRS treatment.

RECENT FINDINGS

Modern inhalation devices comprise nebulizers, pressurized metered-dose inhalers and dry powder inhalers. Transnasal nebulization with pulsating flow can enhance sinus ventilation and increase drug deposition with longer residence time. Short-term steroid transnasal nebulization provides an effective and safe treatment option for CRS patients, as evidenced by significant clinically relevant improvements and lack of serious side-effects. The underlying mechanisms involve a combination of reduction in inflammatory cells, suppression of inflammatory cell-associated cytokines and chemotactic factors, and regulation of tissue remodeling. Efficacy of transnasal nebulization outweighs commonly used nasal sprays and nasal irrigation as delivery options for topical steroids; however, long-term safety with nebulized steroids needs to be investigated further.

SUMMARY

Steroid transnasal nebulization offers an alternative or a complementary treatment option to nasal sprays and nasal irrigation for management of patients with CRS. Long-term dose-dependent studies with nebulized steroids will be needed to fully appreciate the benefits of this treatment modality.

Current trends in topical therapies for chronic rhinosinusitis: update and literature review

INTRODUCTION

Chronic rhinosinusitis (CRS) affects millions of patients worldwide. The disease is multifactorial with influences including anatomic factors, immunological disturbances, and altered sinonasal microbiome. Although oral medications are effective in controlling some symptoms, they are associated with side effects and long-term use is not ideal. Thus, topical therapies have emerged as an alternative delivery method for localized, high-concentration medication with less side effects. Areas covered: This is a review of the various topical therapies available or under investigation for the management of CRS. Common medications such as saline, steroids, and antimicrobials will be discussed. Furthermore, additives including manuka honey, xylitol, surfactant, N-chlorotaurine, Dead Sea salt, and sodium hyaluronate will be addressed. Innovations in topical therapies, such as drug-eluting biomaterials and photodynamic therapy, will also be reviewed. Expert opinion: Although topical therapies provide a high dose of active substance at the site of disease, their efficacy in CRS is not clear. Topical saline and intranasal steroids appear to consistently demonstrate therapeutic benefits. However, other topical medications require further investigation to determine long-term clinical efficacy and safety. A better understanding of their effects on the sinonasal mucociliary system is needed before they become the standard of care in CRS.

Short-course oral steroids alone for chronic rhinosinusitis

BACKGROUND

This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms.

OBJECTIVES

To assess the effects of oral corticosteroids compared with placebo/no intervention or other pharmacological interventions (intranasal corticosteroids, antibiotics, antifungals) for chronic rhinosinusitis.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids with placebo or no treatment or compared with other pharmacological interventions.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included eight RCTs (474 randomised participants), which compared oral corticosteroids with placebo or no intervention. All trials only recruited adults with chronic rhinosinusitis with nasal polyps. All trials reported outcomes at two to three weeks, at the end of the short-course oral steroid treatment period. Three trials additionally reported outcomes at three to six months. Two of these studies prescribed intranasal steroids to patients in both arms of the trial at the end of the oral steroid treatment period. Oral steroids versus placebo or no intervention Disease-specific health-related quality of life was reported by one study. This study reported improved quality of life after treatment (two to three weeks) in the group receiving oral steroids compared with the group who received placebo (standardised mean difference (SMD) -1.24, 95% confidence interval (CI) -1.92 to -0.56, 40 participants, modified RSOM-31), which corresponds to a large effect size. We assessed the evidence to be low quality (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). Disease severity as measured by patient-reported symptom scores was reported by two studies, which allowed the four key symptoms used to define chronic rhinosinusitis (nasal blockage, nasal discharge, facial pressure, hyposmia) to be combined into one score. The results at the end of treatment (two to three weeks) showed an improvement in patients receiving oral steroids compared to placebo, both when presented as a mean final value (SMD -2.84, 95% CI -4.09 to -1.59, 22 participants) and as a change from baseline (SMD -2.28, 95% CI -2.76 to -1.80, 114 participants). These correspond to large effect sizes but we assessed the evidence to be low quality.One study (114 participants) followed patients for 10 weeks after the two-week treatment period. All patients in both arms received intranasal steroids at the end of the oral steroid treatment period. The results showed that the initial results after treatment were not sustained (SMD -0.22, 95% CI -0.59 to 0.15, 114 participants, percentage improvement from baseline). This corresponds to a small effect size and we assessed the evidence to be low quality.There was an increase in adverse events in people receiving orals steroids compared with placebo for gastrointestinal disturbances (risk ratio (RR) 3.45, 95% CI 1.11 to 10.78; 187 participants; three studies) and insomnia (RR 3.63, 95% CI 1.10 to 11.95; 187 participants; three studies). There was no significant impact of oral steroids on mood disturbances at the dosage used in the included study (risk ratio (RR) 2.50, 95% CI 0.55 to 11.41; 40 participants; one study). We assessed the evidence to be low quality due to the lack of definitions of the adverse events and the small number of events or sample size, or both). Other comparisons No studies that compared short-course oral steroids with other treatment for chronic rhinosinusitis met the inclusion criteria.

AUTHORS' CONCLUSIONS

At the end of the treatment course (two to three weeks) there is an improvement in health-related quality of life and symptom severity in patients with chronic rhinosinusitis with nasal polyps taking oral corticosteroids compared with placebo or no treatment. The quality of the evidence supporting this finding is low. At three to six months after the end of the oral steroid treatment period, there is little or no improvement in health-related quality of life or symptom severity for patients taking an initial course of oral steroids compared with placebo or no treatment.The data on the adverse effects associated with short courses of oral corticosteroids indicate that there may be an increase in insomnia and gastrointestinal disturbances but it is not clear whether there is an increase in mood disturbances. All of the adverse events results are based on low quality evidence.More research in this area, particularly research evaluating patients with chronic rhinosinusitis without nasal polyps, longer-term outcomes and adverse effects, is required.There is no evidence for oral steroids compared with other treatments.

Different types of intranasal steroids for chronic rhinosinusitis

BACKGROUND

This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Topical (intranasal) corticosteroids are used with the aim of reducing inflammation in the sinonasal mucosa in order to improve patient symptoms.

OBJECTIVES

To assess the effects of different types of intranasal steroids in people with chronic rhinosinusitis.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with a follow-up period of at least three months comparing first-generation intranasal corticosteroids (e.g. beclomethasone dipropionate, triamcinolone acetonide, flunisolide, budesonide) with second-generation intranasal corticosteroids (e.g. ciclesonide, fluticasone furoate, fluticasone propionate, mometasone furoate, betamethasone sodium phosphate), or sprays versus drops, or low-dose versus high-dose intranasal corticosteroids.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the commonest adverse event - epistaxis (nosebleed). Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse event of local irritation. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included nine RCTs (911 participants), including four different comparisons. None of the studies evaluated our first primary outcome measure, disease-specific HRQL. Fluticasone propionate versus beclomethasone dipropionate We identified two small studies (56 participants with polyps) that evaluated disease severity and looked at the primary adverse effect: epistaxis , but no other outcomes. We cannot report any numerical data but the study authors reported no difference between the two steroids. The evidence was of very low quality. Fluticasone propionate versus mometasone furoate We identified only one study (100 participants with polyps) that evaluated disease severity (nasal symptoms scores), which reported no difference (no numerical data available). The evidence was of very low quality. High-dose versus low-dose steroidsWe included five studies (663 participants with nasal polyps), three using mometasone furoate (400 µg versus 200 µg in adults and older children, 200 µg versus 100 µg in younger children) and two using fluticasone propionate drops (800 µg versus 400 µg). We found low quality evidence relating to disease severity and nasal polyps size, with results from the high-dose and low-dose groups being similar. Although all studies reported more improvement in polyp score in the high-dose group, the significance of this is unclear due to the small size of the improvements.The primary adverse effect, epistaxis , was more common when higher doses were used (risk ratio (RR) 2.06, 95% confidence interval (CI) 1.20 to 3.54, 637 participants, moderate quality evidence). Most of the studies that contributed data to this outcome used a broad definition of epistaxis, which ranged from frank bleeding to bloody nasal discharge to flecks of blood in the mucus. Aqueous nasal spray versus aerosol spray We identified only one poorly reported study (unclear number of participants for comparison of interest, 91 between three treatment arms), in which there were significant baseline differences between the participants in the two groups. We were unable to draw meaningful conclusions from the data.

AUTHORS' CONCLUSIONS

We found insufficient evidence to suggest that one type of intranasal steroid is more effective than another in patients with chronic rhinosinusitis, nor that the effectiveness of a spray differs from an aerosol. We identified no studies that compared drops with spray.It is unclear if higher doses result in better symptom improvements (low quality evidence), but there was moderate quality evidence of an increased risk of epistaxis as an adverse effect of treatment when higher doses were used. This included all levels of severity of epistaxis and it is likely that the proportion of events that required patients to discontinue usage is low due to the low numbers of withdrawals attributed to it. If epistaxis is limited to streaks of blood in the mucus it may be tolerated by the patient and it may be safe to continue treatment. However, it may be a factor that affects compliance.There is insufficient evidence to suggest that the different types of corticosteroid molecule or spray versus aerosol have different effects. Lower doses have similar effectiveness but fewer side effects.Clearly more research in this area is needed, with specific attention given to trial design, disease-specific health-related quality of life outcomes and evaluation of longer-term outcomes and adverse effects.

Short-course oral steroids as an adjunct therapy for chronic rhinosinusitis

BACKGROUND

This review is one of a suite of six Cochrane reviews looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is a common condition involving inflammation of the lining of the nose and paranasal sinuses. It is characterised by nasal blockage and nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Oral corticosteroids are used to control the inflammatory response and improve symptoms.

OBJECTIVES

To assess the effects of a short course of oral corticosteroids as an adjunct ('add-on') therapy in people with chronic rhinosinusitis who are already on standard treatments.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 7); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 11 August 2015.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing a short course (up to 21 days) of oral corticosteroids to placebo or no treatment, where all patients were also receiving pharmacological treatment for chronic rhinosinusitis.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity, and the adverse event of mood or behavioural disturbances. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score, and the adverse events of insomnia, gastrointestinal disturbances and osteoporosis. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

Two trials with a total of 78 participants met the inclusion criteria. Both the populations and the 'standard' treatments differed in the two studies. Oral steroids as an adjunct to intranasal corticosteroids One trial in adults with nasal polyps included 30 participants. All participants used intranasal corticosteroids and were randomised to either short-course oral steroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 21-day treatment course) or no additional treatment. None of the primary outcome measures of interest in this review were reported by the study. There may have been an important reduction in the size of the polyps (measured by the nasal polyps score, a secondary outcome measure) in patients receiving oral steroids and intranasal corticosteroids, compared to intranasal corticosteroids alone (mean difference (MD) -0.46, 95% confidence interval (CI) -0.87 to -0.05; 30 participants; scale 1 to 4) at the end of treatment (21 days). This corresponds to a large effect size, but we are very uncertain about this estimate as we judged the study to be at high risk of bias. Moreover, longer-term data were not available and the other outcomes of interest were not reported. Oral steroids as an adjunct to antibiotics One trial in children (mean age of eight years) without nasal polyps included 48 participants. The trial compared oral corticosteroids (oral methylprednisolone, 1 mg/kg and reduced progressively over a 15-day treatment course) with placebo in participants who also received a 30-day course of antibiotics. This study addressed one of the primary outcome measures (disease severity) and one secondary outcome (CT score). For disease severity the four key symptoms used to define chronic rhinosinusitis in children (nasal blockage, nasal discharge, facial pressure, cough) were combined into one score. There was a greater improvement in symptom severity 30 days after the start of treatment in patients who received oral steroids and antibiotics compared with placebo and antibiotics (MD -7.10, 95% CI -9.59 to -4.61; 45 participants; scale 0 to 40). The observed mean difference corresponds to a large effect size. At the same time point there was a difference in CT scan score (MD -2.90, 95% CI -4.91 to -0.89; 45 participants; scale 0 to 24). We assessed the quality of the evidence to be low.There were no data available for the longer term (three months).

AUTHORS' CONCLUSIONS

There might be an improvement in symptom severity, polyps size and condition of the sinuses when assessed using CT scans in patients taking oral corticosteroids when these are used as an adjunct therapy to antibiotics or intranasal corticosteroids, but the quality of the evidence supporting this is low or very low (we are uncertain about the effect estimate; the true effect may be substantially different from the estimate of the effect). It is unclear whether the benefits of oral corticosteroids as an adjunct therapy are sustained beyond the short follow-up period reported (up to 30 days), as no longer-term data were available.There were no data in this review about the adverse effects associated with short courses of oral corticosteroids as an adjunct therapy.More research in this area, particularly research evaluating longer-term outcomes and adverse effects, is required.