Background: Inhaled nasal corticosteroid sprays (INS) are often inadequate to treat chronic rhinosinusitis (CRS). The exhalation delivery system with fluticasone (EDS-FLU; XHANCE®) may improve outcomes in CRS by increasing medication delivery to target superior/posterior anatomic sites. This study assessed safety and efficacy of EDS-FLU in a large population with moderate-tosevere CRS with or without nasal polyps (CRSwNP, CRSsNP). Methods: Prospective, multicenter, 12-week, single-arm study of EDS-FLU 372 µg twice daily (BID) at 38 U.S. sites. Safety was assessed by adverse-event evaluations, nasal endoscopy, and ocular examinations. Efficacy was serially assessed by outcomes including nasal endoscopy (Lund-Kennedy Score, polyp grade), patient-and physician-reported outcomes (22-item Sinonasal Outcome Test [SNOT-22]), study-defined surgical indicator assessment, and Patient Global Impression of Change (PGIC). Results: 705 comparatively refractory subjects were enrolled, 603 CRSsNP and 102 CRSwNP [moderate-to-severely symptomatic; baseline SNOT-22 ~43, high rates of prior INS use (92.3%) and/or prior surgery (27.5%)]. More than 90% reported improvement on treatment by PGIC. SNOT-22 scores improved substantially and similarly in patients with NP (-23.7) and without NP (-24.4). Among patients with baseline Lund-Kennedy edema scores >0, 33.3% (CRSwNP) and 54.8% (CRSsNP) had complete resolution of edema. In CRSwNP patients, 48% had polyp elimination in ≥1 nostril, 63% had ≥1-point improvement in polyp grade, mean bilateral polyp grade decreased from 2.9 to 1.6, and study-defined surgical eligibility decreased. EDS-FLU was generally well tolerated, with a safety profile similar to conventional INS sprays when used to treat CRS. Conclusion: EDS-FLU 372 µg BID in the treatment of CRS with or without polyps was safe, well-tolerated, and produced substantial improvement across a broad range of both objective and subjective measures.

The study provided initial clinical evidence of the feasibility, safety, and efficacy of in-office steroid-eluting implant placement in CRS patients with recurrent polyposis after ESS. Although further studies are needed, the results suggest this therapy may provide a safe and effective, office-based option for the treatment of obstructive polyposis.

Aspergillosis is becoming an increasingly recognized pathogen in the sinonasal tract. The courses of two patients, one seemingly healthy and one with a terminal malignancy, are reviewed. These patients illustrate the clinical course, difficulties in diagnosis, and management of patients with aspergillosis of the sinonasal tract. Aspergillus is a common endogenous contaminant of the upper respiratory tract; however, bacterial sinusitis may trigger its growth and proliferation. Aspergillus fumigatus is the most common species implicated in paranasal sinus disease in the United States. The maxillary antrum is the most commonly involved site in the paranasal sinuses. Originally, aspergillosis was described in healthy patients, but it has become increasingly recognized in the immunocompromised and the chronically debilitated. Paranasal sinus Aspergillus infections are classified as non-invasive and fulminant. The treatment is primarily surgical. Antifungal chemotherapeutic agents are used in the treatment of central nervous system involvement and in the fulminant form of the disease.