Antifungal therapy for eosinophilic fungal rhinosinusitis is still under investigation. Several preliminary trials have reported improvement in objective and subjective findings in patients with CRS, who were treated with nasal irrigation using amphotericin B (16,17). These patients were irrigated with 20 mL of amphotericin B (100 |g/mL) twice daily for up to 12 months. The authors report complete disappearance of nasal polyps in 35% to 39% of patients. These studies, however, lack control groups, randomization, and blinding. It is unclear whether the improvement is due to the antifungal agent or simply a nonspecific benefit associated with nasal irrigation. Significant benefit has been reported with the use of hypertonic saline alone. A prospective, double-blind, placebo-controlled investigation published by Weschta in 2004 failed to show benefit from amphotericin washes. In this trial, patients used 200 | L of amphotericin B in each nostril, at a concentration of 3 mg/mL, four times a day for eight weeks. A response was noted in only 2 of 28 patients, which was not significantly different from the control group (18). Another important observation from studies of ciliary beat frequency has shown that several antifungals, including amphotericin, clotrimazole, and itraconazole, have the potential for dose-dependent ciliotoxicity. Higher concentrations of amphotericin resulted in ciliary stasis within two hours of administration. This suggests that there may be undesirable repercussions of amphotericin irrigation (11). Oral antifungal therapy has also been studied. Kennedy conducted a multicenter trial of oral terbinafine for six weeks in patients with CRS. This prospective study was well done, adequately blinded, and randomized. It failed to show any benefit when compared to placebo even in patients with positive fungal cultures (19).
Eosinophil production, chemotaxis, and degranulation are inhibited by steroids. Therefore, topical steroids are attractive in that they may exert a local benefit without systemic side effects. Multiple studies have shown a modest decrease in polyp size and improvement in nasal airflow. The molecular effects of topical nasal steroids in patients with CRS and nasal polyposis have been evaluated by Burgel. He found that eight weeks of intranasal steroids improved nasal airflow and decreased polyp size, with a corresponding decrease in intraepithelial eosinophils. Mucin production, IL-8, and tumor necrosis factor-a levels, however, were unchanged (20).
Nasal irrigation with saline solution is a mainstay of treatment and should be performed in conjunction with topical nasal steroids. Irrigation is thought to reduce antigen load by removing airborne fungal elements deposited on the nasal mucus film. The current recommendations from the UCSD Nasal Dysfunction Clinic are twice daily, hypertonic, pulsatile irrigation. This is best delivered with a WaterPik®-type device. The Grossan Hydropulse is a commercially available device that performs well.
Endoscopic sinus surgery is an option for patients with CRS, who fail to respond to nasal irrigation, nasal steroids, and long-term antibiotic therapy. Patients with extensive nasal polyposis tend to have a more dramatic improvement in their symptoms. Surgery typically involves polypectomy with anterior ethmoidectomy and maxillary antrostomy. Patients with more extensive disease may require frontal sinus, posterior ethmoid, and sphenoid procedures. Postoperatively, patients are instructed to perform twice-daily nasal irrigation and use topical intranasal steroids. To reduce polyp recurrence, this regimen is continued indefinitely. If specific allergens are identified, environmental modifications and immunotherapy are recommended as appropriate.
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