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Current prospects in the treatment of rhinosinusitis
ORTEGA P.
Hospital General of Móstoles. Madrid
Current Vision of Rhinosinusitis
and recent progress in advanced sinonasal endoscopic surgery
Medical forum. Valencia, March 2007
Keywords of Current Vision of Rhinosinusitis 2007 - PDF
LECTURES
Medical therapy is indicated on most occasions, in acute, acute intermittent and chronic rhinosinusitis. Surgery should be used only for certain cases of chronic or persistent rhinosinusitis or rhinosinusitis associated with nasal polyposis (and most of their complications). Medical therapy pursues various goals: facilitate clinical cure, achieve microbiological eradication, prevent relapses, prevent chronic conditions, and avoid complications.
When starting medical treatment in such cases, it is necessary to distinguish between bacterial and viral rhinosinusitis (common cold), limiting use of antibiotics to the cases considered to be bacterial infections. Thus, administration of antibiotics should be clinically delimited by the duration of the condition, the severity of its symptoms or the worsening of the clinical picture (five days after onset).
At such times, the use of antibiotics is almost universally accepted in acute bacterial rhinosinusitis. The antibiotic chosen will depend basically on the microbiological eradication rates, the degree of severity, whether or not the patient is allergic to beta-lactams and whether the patient has received antibiotic therapy during the previous four to six weeks. When choosing and classifying the antibiotic as first or subsequent lines, it is usual to use recommendations established by multidisciplinary consensus working parties that are valid in each of the respective countries, based on epidemiological criteria, bacterial resistances and other factors.
As Dr. Primitivo Ortega said, at present “two treatment schedules with antibiotics are considered:
1) a short course, lasting less than two weeks, for mild cases;
2) and a long course lasting between 4 weeks and three months, for moderate or severe cases.”
In moderately severe cases with no prior antibiotic therapy in the last 4-6 weeks, the antibiotics of choice are amoxicillin-clavulanic acid, amoxicillin and cefpodoxime proxetil; in moderately severe cases with previous use of antibiotics (in the last 4-6 weeks), the antibiotics of choice will be the new-generation fluoroquinolones (moxifloxacin, levofloxacin), amoxicillin-clavulanic acid or ceftriaxone; finally, in patients allergic to beta-lactams, it is recommended to give levofloxacin or moxifloxacin.
Supplementary therapy of both acute and chronic conditions consists of using topical Objectiveor systemic corticoid therapy, decongestants, antihistamines, mucolytics, nasal irrigation, phytotherapy, immune therapy, bacterial lysates and, recently, the new cyclamen-based agent with specific pharmacological properties (Nasodren®).
The surgical treatment of chronic rhinosinusitis is indicated when medical or conservative treatment has obtained little or no benefit. The goal of surgical therapy is to restore mucociliary drainage and ventilation of the paranasal cavities.
MEDICAL THERAPY IN CHRONIC RHINOSINUSITIS
In patients with chronic rhinosinusitis, the medical therapy will seek to achieve another type of goal: avoid surgery, improve the patients’ quality of life, break the disease’s inflammatory cycle by means of a combination of agents intended to reduce the mucosal inflammation, decrease obstruction and secretions, and eradicate infectious agents (such as bacteria and fungi).
In such cases, the drugs of choice may be topical corticoids, systemic corticoids, antimicrobials (antibiotics and antimycotics), antihistamines, leukotriene modulators, immunoglobulin E inhibitors, immune therapy, cromones and phytotherapeutic agents. Nasal irrigations and douches, topical and systemic decongestants, mucolytics and combined action agents (such as the cyclamen derivative, Nasodren®) may be useful.
Topical corticoids, such as fluticasone, budesonide, flunisolide, triamcinolone, beclometasone or mometasone, have been shown to be effective in various types of study in the medical therapy of chronic rhinosinusitis. Their efficacy has also been documented in the therapeutic management of allergic rhinitis, persistent rhinitis and polyposis.
The use of systemic glucocorticoids is also highly generalized. Their use is very popular in the management of patients during the perioperative period. They significantly reduce the mucosal oedema that contributes to obstruction and impaired sinonasal mucosa function. In any case, their adverse effects (growth impairment, osteoporosis, metabolic cataract …) severely limit their use. Antibiotics may also be drugs of choice in the medical therapy of chronic rhinosinusitis, although it is rather more difficult to determine the efficacy of an antibiotic therapy in chronic rhinosinusitis than in acute rhinosinusitis.
In certain cases, particularly patients who have already undergone surgery, it is common to find a polymicrobial flora, encompassing both aerobic and anaerobic germs. Ideally, the choice of antibiotic should be based on the results of a culture of the sinus secretion. However, the speaker reminded that “the EP3OS consensus suggests that antibiotics should only be used to treat acute exacerbations of chronic rhinosinusitis.”
It is also very common to use antihistamines (both systemic and topical) in the treatment of chronic rhinosinusitis, in spite of the fact that they have only been proven to be effective in allergic rhinitis.
The antileukotrienes, such as montelukast, have been shown to be effective in rhinitis. In this case, efficacy may be associated with the use of inhaled corticoids and beta2-agonists.
In some cases, anticholinergics and nasal vasoconstrictors may be useful in the treatment of this disease. For example, ipratropium bromide has been used in rhinitis for the treatment of watery rhinorrhoea in cases of hay fever, but its efficacy has not been proven using evidence-based criteria. The nasal vasoconstrictors (such as phenylephrine, oxymetazoline, naphazoline, ephedrine, pseudoephedrine) act on the adrenergic receptors and their use is limited due to their rebound effect and adverse reactions.
The surgical treatment of chronic rhinosinusitis is indicated when medical or conservative treatment has obtained little or no benefit. The goal of surgical therapy is to restore mucociliary drainage and ventilation of the paranasal cavities. The most commonly used surgical technique is currently the endoscopic surgery of the lateral nasal wall and the paranasal sinuses (SNES), which is mainly performed on the middle meatus. The main indications for surgical treatment of chronic rhinosinusitis listed by Dr. Primitivo Ortega were: “chronic rhinosinusitis refractory to conservative therapy, diffuse polypous chronic rhinosinusitis, ethmoid mucocele or pyocele, fungal rhinosinusitis, complicated chronic rhinosinusitis and rhinosinusitis caused by tumour obstruction.”
ROLE OF NASODREN®
In this context, the experience obtained in recent years with a new plant extract-based product is encouraging. Among the main features of Nasodren®, Dr. Ortega pointed out that “it facilitates physiological drainage and cleansing of the nasal cavities and is particularly useful in acute rhinosinusitis, acute exacerbations of chronic rhinosinusitis (when it is not associated with obstructive conditions) and in sinonasal postoperative care.”
As regards its mechanism of action, it acts on the mucosa of the nasal cavity and paranasal sinuses, inducing a reflex secretion that rapidly produces the discharge of mucus. This removes retained seromucous secretions, reducing/eliminating tissue congestion and oedema in the process. In this sense, the expert from the Hospital de Móstoles recapitulated, “it effectively opens the nasal passages.
Nasodren® facilitates physiological drainage and cleansing of the nasal cavities and is particularly useful in acute rhinosinusitis, acute exacerbations of chronic rhinosinusitis (when it is not associated with obstructive conditions) and in sinonasal postoperative care”.
This natural preparation is administered once a day (with one spray in each nostril), causing a physiological drainage effect, over a period of 7-10 days.
Using an eminently practical approach, the speaker showed several paradigmatic images, based on real cases, showing the efficacy of this natural therapy. Thus, in a case of acute rhinosinusitis, he showed the presence of hyperaemia of the nasal mucosa and purulent mucus in the middle meatus before treatment. However, just 3 minutes after the first administration of Nasodren®, mucus started to flow abundantly from the nasal cavity and, especially, from the osteomeatal complex.
After a further 5-10 minutes, 12purulent secretions started to appear. After 3 hours, the nature of the secretions changes, with a high mucus content. During the first day, as Dr. Ortega states, “the secretions increase in quantity and this process is accompanied by sneezing which, in turn, leads to the expulsion of large quantities of mucopurulent secretions.”
After three days of treatment, there are mucopurulent secretions in the middle meatus. On the third day, 5 minutes after administration, mucus and pus are discharged from the osteomeatal complex. On the third day, 20 minutes after administration, mucus and pus are discharged from the osteomeatal complex.
In controlled studies, Nasodren® has been shown to be superior to the control group in controlling the clinical signs of rhinosinusitis and, in particular, in relieving some of the more characteristic symptoms. As regards the mucopurulent or purulent secretions, just 2-3 days after starting treatment with Nasodren®, a statistically significant reduction is seen in the rate of secretion compared with the control group (and by the 4th-5th day, almost none of the patients receiving this product report mucopurulent secretions).
A similar efficacy is reported as regards relief of headaches and nasal obstruction, with highly significant differences compared with placebo after just 3-5 days of treatment. In controlled studies, Nasodren® has been shown to be superior to the control group in controlling the clinical signs of rhinosinusitis and, in particular, in relieving some of the more characteristic symptoms.
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