Use of Off-Label Nasal Steroid Irrigations in Long-Term Management of Chronic Rhinosinusitis

Abstract

Objective: Chronic rhinosinusitis (CRS) is an inflammatory disease of the paranasal sinuses and mucosa. Topical nasal corticosteroids are a mainstay treatment for CRS by reducing sinonasal inflammation and improving mucociliary clearance. However, topical corticosteroids have limited paranasal distribution, and patient response to treatment has been variable in randomized controlled trials (RCT). Thus, there is significant interest in evaluating the efficacy of nasal steroids delivered by nasal irrigation in order to improve penetration and absorption of topical steroids into the sinonasal mucosa. In this review, we discuss the use of off-label nasal steroid irrigations in the management of CRS. Methods: A review of clinical trials evaluating the use of nasal steroid irrigations for CRS in the PubMed electronic database was performed. Results: Of the 12 clinical studies identified, 10 evaluated budesonide irrigations while the remaining 2 focused on mometasone. The overwhelming majority of studies for both budesonide and mometasone supported the use of nasal irrigations with corticosteroids over nasal corticosteroid sprays alone. However, the heterogeneity in study design, patient cohort, and volume of steroid irrigation limit the interpretations of these studies. Conclusions: Nasal irrigation with corticosteroids is beneficial and safe for the treatment of CRS. Future RCTs controlling for type of surgical intervention, CRS pheno- and endo-type, as well as dosing and duration of nasal corticosteroid irrigations are warranted.

Comparison of sinus distribution between nasal irrigation and nasal spray using fluorescein‐labelled in patients with chronic rhinosinusitis: A randomised clinical trial

“…Furthermore, sufficient therapy duration might help relieve inflammation at the OMU, maxillary and ethmoid sinuses, ultimately promoting the distribution of the drug into the most challenging parts, that is, the frontal and sphenoid sinuses. Fortunately, corticosteroid nasal irrigation showed no serious adverse effects, even in long‐term use 18–20 …”

“…Fortunately, corticosteroid nasal irrigation showed no serious adverse effects, even in long-term use. [18][19][20] The limitation of this study was that the sinus penetration of a solution can be influenced by multiple factors apart from the delivery technique, that is, the head position and the surgical status of the sinus cavity. In addition, symptomatic outcomes were not evaluated in our study and therefore further studies are required before adopting the approach as the standard of care.…”

Application of nasal irrigation in the treatment of chronic rhinosinusitis

“…There are also reviews on NI after sinus surgery for CRS [ 46 , 47 ]. Some believe that NI after sinus surgery is not beneficial [ 46 ], while others suggest that using local corticosteroids in irrigation can be a first-line medical treatment for postoperative CRS patients [ 47 ], which is safe and effective [ 48 ]. Therefore, further clinical trials with strong evidence are needed to confirm this.…”

“…There are also many inconsistent aspects, such as the dosage of irrigation ranging from 5 ml to 480 ml. It is recommended that randomized controlled trials in the future are necessary for CRS phenotypes, subtypes, and the dosage and duration of nasal corticosteroid irrigation [ 48 ]. Therefore, comparing the advantages and disadvantages of local corticosteroid irrigation treatment for CRS with other management schemes is still a field that needs further research [ 49 ].…”

Updates on treatment options in aspirin exacerbated respiratory disease

“…sinuses and therefore more effective at treating polyps, but no head-to-head trials have been performed for these two treatment options [30,31]. The published reports on the efficacy of budesonide as a nasal rinse have variable efficacy, but generally effective [30,[32][33][34]. This variability is likely due to the small number of studies, variable patient inclusion criteria, the amount of steroid used, and methods of performing the irrigation.…”