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Treatment Innovations for Chronic Sinusitis

From bench to clinical practice, a panel of doctors tackled the broad efforts from research labs to treatment options for chronic rhinosinusitis (CRS) during Monday’s “Innovations in Treatment of Chronic Sinusitis.” Ultimately, there are no silver bullets—although there have been advances in steroid treatment, biologics, probiotic trials, and surgical procedures.

“We don’t know why people get sinusitis,” said Andrew Lane, MD, with Johns Hopkins School of Medicine Department of OTO-HNS, who explored CRS endotypes and innate immunity.

“CRS is complicated,” he said.

He said a key challenge of defining endotypes is there are a variety of coinciding factors. These include damaged epithelium and mucociliary clearance, altered microbiota, tissue remodeling, and activation of long-term adaptive immunity.

“The bottom line is there are a million different cells. Biologics can interfere with the inflammatory pathways of CRS.”

Joseph K. Han, MD, with Eastern Virginia Medical School, reviewed biologics and recent clinical trials showing that nasal congestion got better with dupilumab. The trials showed the efficacy of treating CRS and nasal polyposis, in that its use made it three times less likely to need steroids or surgery.

However, he said there are still many questions with biologics, including which is the best to use, how long a patient should use, if it should be used preoperatively or postoperatively, and if it should be used to get rid of polyp and avoid surgery or prevent recurrence of polyps after endoscopic sinus surgery (ESS).

He concluded that doctors must incorporate the patient’s desires into the management of CRS with nasal polyps (CRSwNP). He said biologics are not the death of ESS but actually provide an option for treating patients with severe CRSwNP.

Ultimately, for patients with severe CRSwNP, he suggested performing ESS first and follow-up with postop topical steroid. If the nasal polyp recurs, consider using the biologic, he said.

He also presented the yin and yang of steroids with the benefits being that they improve nasal symptoms of inflammation, edema, scar tissue and obstruction, but the side effects include suppression of the HPA axis, osteoporosis, cataracts, glaucoma, and poor control of serum glucose levels in diabetes.

Troy D. Woodard, MD, with the Cleveland Clinic, presented information relating to steroid implants. He showed the clinical results of a study of steroid-eluting implants for CRSwNP. The bioabsorbable device is based on existing steroid-releasing stent technology and delivers the drug over three months, with 60 percent being delivered in the first 30 days.

Scott P. Stringer, MD, with the University of Mississippi Medical Center, reported on topical corticosteroids, topical antibiotic therapy, and probiotics.

Probiotics have gotten a lot of attention lately, he said, because they have the potential to inhibit pathogen growth and colonize with desirable microbes. However, he said oral and topical probiotics did not demonstrate improvement in symptom scores. Future considerations include determining which microbes for which patients, delivery methods, and timing.

He concluded by saying there are a lot of other agents being researched, including bacteriophage therapy, colloidal silver, and deferiprone and gallium-protoporhyrin.

With all of these, “we just don’t know yet,” he said.

Peter H. Hwang, MD, with Stanford University Department of OTO-HNS, spoke to the benefits of maxillary mega-antrostomy, including that it preserves the mucosa of the maxillary sinus, facilitates irrigation, allows visualization and manipulation of the anterior and lateral walls of the maxillary sinus, and preserves the anterior half of inferior turbinate for humidification.

Finally, Jivianne T. Lee, MD, UCLA School of Medicine, wrapped up the panel by discussing outside-in Draf III, a new surgical approach.

Following the presentations, Dr. Lee asked the room to vote on which of the five innovations doctors were likely to incorporate into their clinical practices. The in-office steroid-eluting implant and biologics placed first and second respectively, while probiotics placed the lowest.

“All of these innovations have a role,” Dr. Lee said. “There are many innovations in this space, and they are likely only to multiply in the future.”

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