Immunomodulatory Approaches to Treating Chronic Rhinosinusitis Gain Importance

Drops can help with a variety of post-operative issues, most effectively when administered in the vertex-to-floor position, he said (Otolaryngol Head Neck Surg. 2005;133:735-740). But Dr. Batra cautioned that patients with cervical spine issues might not be able to tolerate certain positions for giving the drops.

A 2012 study involving 210 ethmoids in 105 patients who received the Propel stent found that the stents led to a 29 percent relative reduction in post-operative interventions, a 52 percent drop in lysis of adhesions; and a 45 percent relative reduction in frank polyposis (Otolaryngol Head Neck Surg. 2012;146:1004-1011).

Steroid-infused foam produced statistical improvement in the average patient in the Sino-Nasal Outcome Test and in endoscopy scores, according to a prospective study of eight patients and 10 treatments (Am J Rhinol Allergy. 2010;24:451-453), Dr. Batra said. Furthermore, a 2012 retrospective review found that mometasone gel led to a decrease in mucosal inflammation scores and an overall decrease in steroid use in 14 symptomatic post-ESS patients (J Otolaryngol Head Neck Surg. 2012;41:183-188).

Steroid injections, which come with a concern about blindness, might not be a viable choice, considering “the whole array of options that are now available to us,” Dr. Batra said.

With all of these treatments, the long-term effects remain largely unknown. “You have to understand that the side effects of these topical off-label therapies are not well-understood,” Dr. Batra said. “And often we’re using these therapies six months or a year, or longer, at a time, and so we don’t know what the unintended consequences are going to be down the road. That’s a critical consideration. I think cost is also important. These things can be very expensive for patients, and that’s going to be a barrier to further innovation.”

Anti-Eosinophil Therapies

Alexander Chiu, MD, chief of otolaryngology-head and neck surgery at the University of Arizona in Tucson, said that anti-eosinophil therapies can play an important part in treating CRS patients. Approximately 4.3 percent of the population has bilateral polyps, and an abundance of tissue eosinophilia is seen in 80 percent of nasal polyps in Caucasian patients, he added.

There is an elevated level of IL-5 in patients with nasal polyps compared with controls, with the highest concentration found in aspirin-sensitive patients, Dr. Chiu said. He added that CRS patients with nasal polyps and eosinophilic inflammation have been found to have higher recurrence rates after surgery, at 82 percent over three years (Ann Otol Rhinol Laryngol. 2010;119:455-459).