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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5226_Библиотеки_им_академика_М_И_Перельмана.pdf
200
Fig. 19.4 Base view of
the nasal cavity with
yellow circles showing
sites for local anesthetic
injections and treatment
sites. Image courtesy of
Aerin Medical
G. E. Davis and C. Miller
crusting. Inform patients they will have a congested nose for 1–2weeks before the
congestion starts to improve and that it can take up to 3months for the full effect of
the procedure to be noticeable. Saline spray or irrigation can be helpful to help alleviate the congestion caused by the temporary swelling of the manipulated tissue
(Video 19.2).
Tips and Pearls
• Optimize the procedure room environment with distractions for the patient
including playing music or a video monitor playing non-surgical images.
• The procedure can be used with a surgical headlight or an endoscope.
• Following an acceptable amount of time (usually 10–15min) inject local anes-
thetic with a 27g needle. Consider using 1% lidocaine with 1:200,000 epineph-
rine and 10% volume of 8.4% sodium bicarbonate to minimize the cardiovascular
and anxiety-inducing effect of epinephrine and to minimize the sting from the
anesthetic. Some surgeons nd it less painful to the patient if they apply a tap-
ping motion to the ipsilateral infraorbital region during these injections.
References
1. Uddstromer M.Nasal respiration. Acta Otolaryngol Suppl. 1940;42
2. Cottle MH, Loring RM.Corrective surgery of the external nasal pyramid and the nasal septum
for restoration of normal physiology. Ill Med J. 1946;90:119–35.
3. Rhee JS, Weaver EM, Park SS, Baker SR, Hilger PA, Kriet JD, etal. Clinical consensus statement: diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg.
2010;143(1):48–59.
4. San Nicolo M, Stelter K, Sadick H, Bas M, Berghaus A.Absorbable implant to treat nasal
valve collapse. Facial Plast Surg. 2017;33(2):233–40.
5. Kim DH, Lee HH, Kim SH, Hwang SH. Effectiveness of using a bioabsorbable implant
(Latera) to treat nasal valve collapse in patients with nasal obstruction: systemic review and
meta-analysis. Int Forum Allergy Rhinol. 2020;10(6):719–25.
19 Radiofrequency and Bioabsorbable Nasal Implantation for Treatment of Nasal…
6. Sanan A, Most SP.A bioabsorbable lateral nasal wall stent for dynamic nasal valve collapse: a
review. Facial Plast Surg Clin North Am. 2019;27(3):367–71.
7. San Nicolo M, Berghaus A.Two-year sustained benet of an absorbable implant for the treatment of NVC.OTO Open. 2017;1(3):2473974X17722982.
8. Sidle DM, Stolovitzky P, O’Malley EM, Ow RA, Nachlas NE, Silvers S. Bioabsorbable
implant for treatment of nasal valve collapse with or without concomitant procedures. Facial
Plast Surg. 2021;37(5):673–80.
9. Jacobowitz O, Driver M, Ephrat M.In-ofce treatment of nasal valve obstruction using a
novel, bipolar radiofrequency device. Laryngoscope Investig Otolaryngol. 2019;4(2):211–7.
10. Ephrat M, Jacobowitz O, Driver M.Quality-of-life impact after in-ofce treatment of nasal
valve obstruction with a radiofrequency device: 2-year results from a multicenter, prospective
clinical trial. Int Forum Allergy Rhinol. 2021;11(4):755–65.
11. Jacobowitz O, Ehmer D, Lanier B, Scurry W, Davis B.Long-term outcomes following repair
of nasal valve collapse with temperature-controlled radiofrequency treatment for patients with
nasal obstruction. Int Forum Allergy Rhinol. 2022;
12. Silvers SL, Rosenthal JN, McDufe CM, Yen DM, Han JK.Temperature-controlled radiofrequency device treatment of the nasal valve for nasal airway obstruction: a randomized controlled trial. Int Forum Allergy Rhinol. 2021;11(12):1676–84.
201
Part IV
Medical Interventions for Recalcitrant
Chronic Rhinosinusitis
Topical Antibiotics inTreatment of
Recalcitrant Chronic Rhinosinusitis
KeonhoAlbertKong andScottP.Stringer
Key Points
• The pathogenesis of chronic rhinosinusitis (CRS) is complex and multifactorial.
Bacterial biolms, microbiome dysbiosis, bacterial superantigens, antimicrobial
resistance, and fungal antigens have all been suggested as contributors to CRS.
• Topical antimicrobial therapy theoretically delivers therapeutic medication
directly to the affected sinuses of patients having undergone endoscopic sinus
surgery with a low risk of systemic absorption.
• Despite this, evidence in support of topical antimicrobial therapy remains limited
and the International Consensus Statement on Allergy and Rhinology does not
recommend topical antimicrobial treatment for the routine management of CRS.
• There may be unrealized benet in recalcitrant cases for topical antimicrobial
therapy, or even in cases where CRS is due to manifestation of systemic conditions such as cystic brosis, vasculitis, or primary ciliary dyskinesia.
20
Background
The pathogenesis of chronic rhinosinusitis (CRS) is complex and multifactorial.
The role of microorganisms in CRS has not yet been fully dened. However, biolms, microbiome dysbiosis, bacterial superantigens, antimicrobial resistance, and
K. A. Kong
Department of Otolaryngology-Head and Neck Surgery, University of Mississippi Medical
Center, Jackson, MS, USA
e-mail: kkong@umc.edu
S. P. Stringer
Department of Otolaryngology-Head and Neck Surgery, Virginia Commonwealth University
School of Medicine, Richmond, VA, USA
e-mail: Scott.Stringer@vcuhealth.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
J. T. Lee et al. (eds.), Advances in Surgical and Medical Interventions for
Recalcitrant Chronic Rhinosinusitis,
https://doi.org/10.1007/978-3-031-89191-5_20
205
206
K. A. Kong and S. P. Stringer
fungal antigens have all been suggested as contributors. The complexity of its
pathogenesis can make treatment of recalcitrant CRS especially challenging.
Topical antibiotic therapy provides direct delivery of the therapeutic agent in high
concentrations to the sinonasal mucosa. Systemic absorption from topical therapy is
low, allowing side effects of systemic antimicrobial therapy to be minimized. There
is the potential for mucociliary injury which may be associated with local adverse
effects such as nasal congestion, epistaxis, irritation, and cough [1–3].
Based on current available evidence, the International Consensus Statement on
Allergy and Rhinology does not recommend topical antimicrobial therapy (bacterial
or fungal) for routine treatment of CRS with or without polyps [4]. There is substantial heterogeneity between studies, and insufcient trials have investigated specic
subgroups of CRS.However, there may be utility for topical antimicrobials in recalcitrant CRS after endoscopic sinus surgery and in cases related to sinonasal manifestations of systemic conditions such as vasculitis, cystic brosis, primary ciliary
dyskinesia, and other disorders.
In this chapter, we review current literature covering topical antibacterial and
antifungal therapy for the treatment of chronic rhinosinusitis. We will also discuss
the senior author’s experience and recommendations with topical antimicrobial
therapy.
Topical Antibacterial Therapy
Microbial dysbiosis and colonization of Staphylococcus aureus have been implicated in pathophysiology of CRS.Topical antibiotics are used in CRS in hopes that
it would eliminate pathogenic bacteria and reset the patient’s sinonasal ora. One
prospective study evaluating the applicability of topical antibiotics, performed by
Ezzat, etal. examined patients with biolms and found that topical application of
0.3% ooxacin TID for 12weeks reduced biolm burden via scanning electron
microscopy by 80% [5]. Participants also reported a statistically signicant reduction in RSI (Rhinosinusitis Symptom Inventory), nasal endoscopic, and CT-based
CRSseverity scores.
Mupirocin is a carboxylic acid antibiotic that inhibits bacterial protein and RNA
synthesis by reversibly binding isoleucyl-transfer RNA that is commonly used to
decolonize methicillin resistant S. aureus (MRSA) and to treat skin/soft tissue
MRSA infections. MRSA has been found in higher ratios in patients with CRS and
its presence has been linked to poorer prognosis [6, 7]. A retrospective study by
Solares et al. suggested that mupirocin nasal irrigations could be of benet in
MRSA-related CRS exacerbations [8]. However, only 7/42 cultures (16.7%) were
treated with mupirocin irrigations alone, and most were treated with concurrent oral
antibiotics. Jervis-Bardy etal. performed a prospective, double-blinded, placebocontrolled study comparing mupirocin rinses to saline rinses in S. aureus positive
cultures after ESS [9]. Statistically signicant benet was noted at 1month with
S. aureus negative cultures in the mupirocin rinse group; however, the benet did
not persist to the 2–6month follow-up visit. A meta-analysis by Kim etal., which
20 Topical Antibiotics inTreatment of Recalcitrant Chronic Rhinosinusitis
207
included the two previously mentioned studies, studied the effect of mupirocin irrigations in S. aureus infection in the setting of CRS [10]. They showed a relative risk
of 0.13 of residual infection through a random effects model meta-analysis of the
pooled data. However, the proportion of residual staphylococcal infections was 0.53
at 6 months. Therefore, the authors concluded that short-term use of mupirocin
irrigations was effective for recalcitrant staphylococcal CRS.
There may be a role for topical antibiotics in patients with cystic brosis (CF).
Moss etal. performed a study of CF patients that underwent instillation of tobramycin irrigations via a secured catheter within the maxillary sinus placed intraoperatively. They found that the regular use of postoperative tobramycin irrigations
reduced the need for revision surgery in CF by up to 2years compared to those not
using tobramycin irrigations [11]. Di Cicco etal. performed a double-blind controlled study of 27 patients with a diagnosis of CF and documented infection with
Pseudomonas aeruginosa and/or S. aureus [12]. The patients were randomized to
receive either a nasal spray formulation containing 0.2% sodium hyaluronate and
3% tobramycin or 0.2% sodium hyaluronate alone for 14days. The hyaluronatetobramycin group had a signicant improvement in their hyposmia/anosmia and
headache/facial pain with additional reductions in mucopurulent secretions at the
ostiomeatal complex compared to the control group.
The utility of tobramycin irrigations has also been studied in CRS patients without cystic brosis with mixed conclusions. Derosiers etal., in a double-blind randomized controlled trial of patients with CRS refractory to medical and surgical
treatment, found that the addition of tobramycin to large-particle nebulized aerosol
therapy did not improve symptomatology or objective parameters of sinonasal
inammation [1]. Lee etal. retrospectively studied SNOT-20 outcomes of patients
with high-volume topical antibiotic irrigations in CRS patients with previous sinus
surgery [13]. A variety of antibiotics were included in the study including tobramycin, vancomycin, levooxacin, mupirocin, gentamicin, ceftriaxone, and ceftazidime.
There was no signicant improvement in SNOT-20 scores in either CF and non-CF
patients, but there was statistically signicant improvement in Lund-Kennedy endoscopic scores in the non-CF group with 72% negative culture results for the targeted
pathogen. Two systematic reviews by Rudmik etal. recommended against topical
antibacterial therapy, yet the heterogeneity of the studies and their relatively small
sample sizes were acknowledged as limitations for this recommendation [14, 15].
There are potential systemic and local side effects for topical antibacterial irrigations. These can be extrapolated from the known adverse side effects seen with
enteral or parenteral administration of antibiotics. Smaller studies have shown
increased levels of serum gentamicin without any clinically signicant negative
effect [16, 17]. Increased nasal congestion, sore throat, and cough have been
reported in literature with topical administration of antibiotics [1, 3]. Workman
etal. demonstrated that certain topical antibiotics can affect ciliary beat frequency
[18]. Specically, azithromycin and neomycin were cilio-stimulatory, and levooxacin and tobramycin were cilio-inhibitory. The clinical implications of these ciliary
changes are uncertain. A summary of the studies examining the role of topical antibacterial can be found in Table20.1.
208
K. A. Kong and S. P. Stringer
Table 20.1
Study
Kim
etal.
[10]
Ezzat
etal.
[5]
Mainz
etal.
[28]
JervisBardy
etal.
[9]
Di
Cicco
etal.
[12]
RSI rhinosinusitis symptom inventory, SEM scanning electron microscopy, OMC ostiome-
atal complex
Summary of topical antibacterial studies
Level of
evidence Medical intervention
Metaanalysis
Prospective
controlled
Double
blind RCT
Double
blind RCT
Double
blind RCT
Mupirocin irrigation 101 (3
Topical ooxacin
(0.3%) intranasal 3
drops every
8h×12weeks
Inhalation with
tobramycin
(80mg/2mL)
daily×28days using
PARI sinus™ nebulizer
Mupirocin irrigation
twice daily
3%tobramycin and
0.2% sodium
hyaluronate nasal spray
for 14days. Control
group received
hyaluronate only nasal
spray
Number of
patients
studies)
37 (27
control)
9 (6
treatment;
3 control)
22 (13
treatment;
9 control)
27 (14
treatment;
13 control)
Reported outcomes
0.13 relative risk reduction of
residual infection at 1month
after treatment (95% CI:
0.06–0.26, p<0.01).
Post-treatment reduction in
RSI scoring, nasal endoscopic
scoring, CT scan PNS score
(p<0.001), 80% biolm
disruption on SEM
6.67 point decrease in SNOT
20in subject compared to
3.34 point increase in control
(p=0.033). No changes in
endoscopy ndings. Decrease
in numbers of P.Aeruginosa
colonies in 67% of treatment
group.
Negative S aureus cultures in
8/9 mupirocin patients
compared to 0/13 placebo
control (p<0.01). Improved
LK endoscopic (p<0.01) and
SNOT 20 scores (p=0.06)
There was improvement in
mucopurulence at the OMC,
and symptoms (hyposmia/
anosmia, facial pain/
headache) in treatment group
compared to control
Overall, there is paucity of literature investigating the role and effect of topical
antibiotics in recalcitrant CRS with mixed results in existing literature. Further studies specically investigating the role of biolms in recalcitrant CRS and the role of
topical antibiotic therapy on its reduction are needed.
Topical Antifungal Therapy
Fungi are ubiquitous in the nasal cavities and sinuses of both individuals with and
without CRS [19, 20]. They have been hypothesized to contribute to CRS pathogenesis due to stimulation of the host immune response [21]. Fungi have a role in the
pathogenesis of two CRS phenotypes: allergic fungal sinusitis (AFS) and fungal
ball/mycetoma. However, the role of fungi in the pathogenesis of other CRS subtypes is unclear. Amphotericin B binds to ergosterol in the fungal cell membrane
20 Topical Antibiotics inTreatment of Recalcitrant Chronic Rhinosinusitis
209
Table 20.2
Study
Isaacs
etal.
[25]
Sacks
etal.
[2]
Wang
etal.
[26]
Summary of topical antifungal studies
Level of
evidence
Meta-
analysis
Metaanalysis
Metaanalysis
Medical
intervention
Topical
amphotericin B
Topical
amphotericin B
Topical
amphotericin B
Number of
patients
284 (6
studies)
327
patients (5
studies)
300
patients (5
studies)
Reported outcomes
There were no statistically signicant
symptom, endoscopy, or radiologic
outcomes between topical
amphotericin B vs placebo
No improvement in QoL or endoscopy
scores with topical amphotericin
compared to placebo
There was no difference between
placebo and topical amphotericin B
groups in QoL or endoscopy scores
and increases permeability, leading to cell death. Potential adverse effects of nasal
burning, epistaxis, pruritus, and exacerbation of CRS have been reported with topical antifungal use [2]. Several randomized control trials have shown that there was
no signicant improvement in symptoms, radiographic ndings, endoscopic staging
with topical amphotericin B compared to placebo in CRS [22–24]. Additionally,
three meta-analyses have demonstrated no benet with topical amphotericin B in
CRS with nasal polyps [2, 25, 26]. There are no signicant studies investigating the
role of topical amphotericin B in AFS so further studies are necessary [27]. A summary of the studies examining the role of topical antifungals in the treatment of
CRS can be found in Table20.2.
With both topical antibiotics and topical antifungal medications, it is important
to note that most of these medications are prescribed through compounding pharmacies and are not covered by most insurance plans. This may inict a nancial
burden on patients and should be discussed with them prior to prescription.
Senior Author’s Practice
The senior author (SS) agrees with the consensus statements that topical antimicrobials should not be routinely used for treatment of CRS with or without polyps.
However, we have seen anecdotal utility for topical antimicrobials in select cases.
One such group of patients are those with recalcitrant type I chronic rhinosinusitis
with chronic colonization of S. aureus that have undergone endoscopic sinus surgery. High-volume isotonic saline irrigations impregnated with mupirocin does
seem to help in some of these patients with improvement in symptoms and endoscopic ndings consistent with the previously referenced literature. Other antibiotics that have been useful include aminoglycosides, cephalosporins, and quinolones
depending on cultures, treatment response, and patient allergies. Patients with sinonasal manifestation of various autoimmune mediated diseases and subsequent atrophic rhinosinusitis may also benet. Mupirocin irrigations seem to help with the
chronic crusting in these patient populations. In patients with cystic brosis or primary ciliary dyskinesia, culture-directed irrigations may help treat persistent
chronic sinonasal disease.
210
K. A. Kong and S. P. Stringer
Conclusions
Topical antimicrobial irrigations deliver medications directly to affected sinuses in
patients who have had sinus surgery. Use of topical antimicrobial irrigations is not
recommended for treatment of routine CRS.There may be a role for it in recalcitrant cases and in cases with manifestations from a systemic disease. Further studies
that have bigger sample sizes and those that target specic patient subtypes are
needed to determine presence and magnitude of benet. Providers should consider
its use on a case-by-case basis with thoughtful discussion with the patient.
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