Embedded Files
irrigation with budesonide as a promising new therapy for select patients with CRS. Topical Antibiotic Therapy The goal of topical antibiotic therapy is to deliver high concentrations of antibiotics directly to the site of infection with low systemic absorption and side effects (23, 33). Pseudomonas or methicillin-resistant Staphylococcus aureus (MRSA) exacerbation of CRS after endoscopic sinus surgery can be seen in up to 30% of endoscopically guided cultures (34, 35). These infections are notoriously difficult to treat and can lead to chronic mucosal inflammation, altered sinonasal ciliary function, and nasal polyp formation. Topical therapy with antibiotics such as gentamicin or tobramycin for patients with CRS can be effective in reducing pain, mucosal edema, secretions, and postnasal drip, especially after endoscopic sinus surgery (35, 36). Vaughan and Carvalho (37) used 3-week courses of culture-directed antibiotics via nebulizer and demonstrated improvements in sinus endoscopic examinations, posterior nasal discharge, facial pain/pressure, and had longer infection-free periods. The literature to date suggests that topical antibiotic therapy is a reasonable treatment option for patients with recalcitrant sinus disease. However, additional studies regarding optimal dosing schedules, treatment duration, delivery mechanisms, and efficacy are needed. Chemical Surfactant Chiu and colleagues (38) have demonstrated the efficacy of 1% baby shampoo nasal irrigations for patients with CRS. In this prospective, nonrandomized study, 18 patients with CRS were treated with twice-daily sinus irrigation with 1% baby shampoo in saline for 4 weeks. Baby shampoo irrigations led to subjective improvement in SNOT 22 scores for 46.6% of patients who were previously symptomatic despite medical and surgical management. Greatest improvements were in reducing thickened nasal secretions and postnasal drainage. Baby shampoo nasal irrigation holds promise as an inexpensive, well-tolerated adjuvant therapy to conventional medical therapies for symptomatic patients after functional endoscopic sinus surgery (FESS). ANTIBIOTICS Introduction This section examines the use and effectiveness of antibiotics in the treatment of CRS. Antibiotics are usually one component of medical therapy and should be used when purulence is identified, in conjunction with a combination of topical nasal steroids, nasal irrigation, mucolytic agents, or other adjuvant therapies. A recent survey found that 94% of otolaryngologists prescribed oral antibiotics in the treatment of CRS (39). Systemic steroids are often included in cases of CRS with nasal polyps or when there is significant mucosal edema identified on endoscopy. Microbiology The microbiology of CRS differs from that of acute rhinosinusitis. In addition to standard sinus pathogens, such as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, there is an increased prevalence of S. aureus, Pseudomonas aeruginosa, and various anaerobic bacteria in CRS. Mixed populations of bacteria and fungus are not uncommon (Figure 2). Antibiotic choice should be made based on current culture and sensitivity results when possible. Klossek and colleagues (40) evaluated the bacteria present in chronic mucopurulent secretions of 394 patients with the diagnosis of CRS. Hemophilus influenzae, streptococci, streptococcus pneumoniae, Prevotella, 134 PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY VOL 8 2011 and Fusobacterium were considered to be causative pathogens. Anaerobes were isolated from 25% of these patients. Betalactamase producers represented 27.5% of H. influenzae and 38% of Prevotella species isolates. Thirteen percent of S. pneumonia isolates
Report abuse