Head & Neck Update Fall 2013
Chronic Rhinosinusitis May Respond Better to Topical Irrigations
Topical drug therapy is emerging as a possible treatment of choice for postoperative use in patients with chronic rhinosinusitis (CRS). Compared with the oral route, topical administration delivers more active drug directly to the site of infection without the risk of systemic side effects.
Studies of culture-directed antibiotic sprays have suggested that topical therapies such as mupirocin irrigation may be effective in treating both stable and acute exacerbations of CRS. Additionally, high-dose topical steroids are now being widely used by rhinologists as maintenance therapy for patients with refractory CRS with nasal polyps. In some instances, antifungals are being used topically as well. While many patients benefit from a single type of irrigation, others have more complex disease and require an irrigation that includes both antimicrobials and steroids.
The Sprays Must Not Be Cold
One particular aspect of the topical delivery of prescription drugs that might be somewhat problematic concerns their storage and the temperature at which they are administered. Many of the medicated irrigations being used today require refrigeration. However, administering a cold spray can be both unpleasant and unhealthy, so patients must be counseled on properly warming their medication before use. These irrigations must be allowed to warm naturally at room temperature. Heating them on a stovetop or in a microwave oven is not recommended since the intensified warming may alter the effectiveness of the drug.
We recently studied several standard formulations of medicated nasal solutions (containing budesonide, mupirocin, amphotericin and tobramycin) and found that it takes more than two hours for these solutions to completely reach room temperature after they are removed from the refrigerator. Therefore, it seems prudent to advise patients to wait at least 45 minutes after taking their medication from the refrigerator before using it.
One complication of cold irrigations in particular that demands attention is a condition called paranasal sinus exostoses. In patients with this new diagnostic entity, which was recently characterized by Cleveland Clinic rhinologists(1), multiple growths arise in postoperative sinus cavities as a result of contact with cold irrigation solutions. These exostoses are analogous to exostoses of the external auditory canal that are associated with cold-water surfing (“surfer’s ear”).
On endoscopy, these exostoses characteristically appear as multiple cysts, but they are actually hard to palpation with an instrument. On CT, they appear as small bony growths on the luminal surfaces of the involved sinuses. Once formed, they appear to be permanent, but they do not progress further after discontinuation of cold irrigations. They do not require surgical intervention unless the lesions progress to the point of being obstructive.
Newer methods of formulating medicated solutions by mixing a dry-powder form of a drug with room-temperature saline are being investigated. But until they become widely available, patients should be warned of the risks associated with cold irrigations and educated on the proper way to warm the nasal irrigation.
Left and middle: Endoscopic views show two postoperative sinus cavities with the hard paranasal sinus exostoses. Right: CT imaging shows paranasal sinus exotoses as bony irregularities on the luminal surfaces of the affected sinuses.
- Haffey T, Woodard T, Sindwani R. Paranasal sinus exostoses: an unusual complication of topical drug delivery using cold nasal irrigations. Laryngoscope. 2012;122(9):1893-1897.
Dr. Woodard is a staff physician in the Section of Rhinology, Sinus and Skull Base Surgery. He can be reached at 216.445.7157 or firstname.lastname@example.org.
Dr. Sindwani is Head of the Section of Rhinology, Sinus and Skull Base Surgery in the Head & Neck Institute. He can be reached at 216.445.2845 or email@example.com.
Measuring and Reporting Outcomes Promotes Quality Improvement
To encourage continuous improvement, promote transparency and highlight the quality of our care, Cleveland Clinic began publishing annual Outcomes reports several years ago. These reports summarize objective data on the performance of more than a dozen of our disease-based, patient-centered institutes, including the Head & Neck Institute.
One example of our measured outcomes concerns survival for patients treated for nasopharyngeal carcinoma.
The data on these patients clearly shows the importance of early detection. As of 2012, patients with stage I/II disease had significantly better overall and disease-specific survival at 10 years than did patients with stage III/IV disease. Our survival data in the patient population compares favorably with benchmark data (not shown but available).
Read more from the 2012 HNI Outcomes.
Katie Geelan-Hansen, MD, joins the Head & Neck Institute as a pediatric and adult otolaryngologist. Her interests include sinus disorders, ear infections, thyroid conditions, neck masses, voice changes and hearing loss. She completed her residency at Cleveland Clinic after graduating from the University of Iowa College of Medicine.
Location: Main Campus and Twinsburg Family Health & Surgery Center
Brandon Hopkins, MD, practices the full scope of pediatric otolaryngology–head and neck surgery. His specialty interests include the surgical care of patients with cleft lip, cleft palate, microtia and craniofacial abnormalities. In addition, he focuses on complex pediatric multilevel airway obstruction and sleep apnea. This includes endoscopic and open airway reconstruction, upper airway surgery and midface and mandibular distraction. He completed his fellowship at the University of California Davis following his residency at the University of Cincinnati College of Medicine and Cincinnati Children’s Hospital.
Location: Main Campus and Willoughby Hills Family Health Center
Douglas Trask, MD, PhD, a pediatric and adult otolaryngologist, joins the Head & Neck Institute with extensive experience in both academic and private practice. After completing his residency at the University of Michigan Medical Center, he served on the faculty of the University of Iowa College of Medicine for eight years and later worked in private practice in Grand Rapids, MI. His specialty interests include sleep apnea (he is board-certified in sleep medicine), nasal and sinus surgery and the surgical treatment of thyroid disease and head and neck tumors.
Location: Main Campus and Twinsburg Family Health & Surgery Center
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