AAO-HNSF 2012: Choosing an Effective Topical Agent to Treat Chronic Rhinosinusitis

They’ve also identified three genes that seem to be related to the formation of the biofilm. “Alteration of this gene expression may well be involved in the innate immune system, and the greatest changes we’ve seen are in the S. aureus biofilm patients,” he said. “We may well have an innate immune defect” that contributes to the biofilm formation.

Another potential agent, though still in the early stages of evaluation, is a mix of polyhydrated ionogen solution, which has its origins in an American Indian wound dressing involving boiled red oak tree bark and magnesium bromide, a compound that was abundant in the salt deposits used by ancient Egyptians to rejuvenate the skin. Once the product, marketed under the name RhinActive, was found to be nontoxic, it was tested for sinonasal mucosal healing in rabbits, with one side of a rabbit’s snout treated with the agent and the other side with saline, said Noam Cohen, MD, PhD, director of rhinology research at the University of Pennsylvania in Philadelphia. Daily irrigation for two weeks accelerated mucosal healing with well-differentiated ciliated cells. But Dr. Cohen cautioned that the evaluation so far has only been done in cavities that are not inflamed or infected, and the findings need to be confirmed in humans. “We are looking to start doing some clinical trials with it,” he said. “We have to see if it’s going to have the same type of potency in an infected, post-surgical individual.”

Container Contamination

The quality of topical agents is constantly being improved, but what about the containers used to deliver them? Contamination rates are surprisingly high, said Alkis Psaltis, MD, PhD, a fellow in rhinology and skull base surgery with Dr. Schlosser at the Medical University of South Carolina. Studies have found that bacterial contamination can linger in more than half of bottles that have been cleaned with hot, soapy water or detergent and allowed to air dry, Dr. Psaltis said.

A 2011 study found that just five out of 20 patients sterilized their bottles after every use, and most continued to use the same bottle for 12 months, far longer than the recommended three months, he said (Int Forum Allergy Rhinol. 2011;1(4):303-307).

But, Dr. Psaltis asked, “Does this contamination actually translate into clinical infections?” Two studies have found that the contaminations are not reflected in actual patient infections (Am J Rhinol Allergy. 2009;23(4):401-404; Am J Rhinol Allergy. 2010;24(3):197-199). “I suppose this is an important finding,” he said, “because we know that irrigation is a very effective and safe treatment for our patients. And advising patients against irrigating their nose may do more harm than good.”