Effectiveness of itraconazole in the management of refractory allergic fungal rhinosinusitis.

OBJECTIVES: Conventional management of allergic fungal rhinosinusitis (AFRS) after surgery consists of the use of steroids to immunomodulate the body's response to fungi. However, there are many side effects to prolonged steroid use, and some patients are unresponsive to standard treatment. The role of systemic antifungal drugs in AFRS is still largely unknown. This was a pilot study to evaluate the effectiveness of itraconazole, an oral antifungal drug, in the treatment of refractory AFRS. METHOD: Thirty-two patients with AFRS who had had surgery and were refractory to prednisone, steroid, and amphotericin B nasal sprays were treated with itraconazole for at least 3 months. They were evaluated with pre- and posttreatment endoscopic examinations, serum immunoglobulin E (IgE), and the 31-Item Rhinosinusitis Outcome Measure (RSOM-31) questionnaires. Monthly liver function tests were done to monitor for the hepatic side effects of itraconazole. RESULTS: Twelve cases had endoscopic improvement. Fifteen had no difference, and five had a worse endoscopic stage after 3 months. One patient had to stop treatment due to abnormal liver function tests. The mean pre- and posttreatment IgE levels were 581 microg/L and 766 microg/L, respectively. Subjectively, 9 patients (28%) reported a significant improvement, 9 (28%) had moderate improvements, and 14 (44%) reported little or no change. There was no correlation between the subjective and the endoscopic changes. CONCLUSION: Itraconazole may be useful as an adjunct in the management of AFRS. However, more studies, including a prospective randomized clinical trial, are required to determine if itraconazole is effective in the management of AFRS.

Effectiveness of intraoperative mitomycin C in maintaining the patency of a frontal sinusotomy: a preliminary report of a double-blind randomized placebo-controlled trial.

BACKGROUND: Postoperative scarring in the frontal recess is the most common cause of iatrogenic frontal sinusitis. Topical mitomycin-C (MMC) is an antifibroblastic agent that has been shown to reduce clinical scarring. This is a preliminary report of a double-blind, randomized, placebo-controlled trial using MMC to determine its effectiveness in reducing frontal recess stenosis after frontal sinusotomy. METHODS: All patients with chronic rhinosinusitis undergoing primary or revision bilateral image-guided endoscopic sinus surgery were enrolled. Patients requiring frontal sinus stents and those with allergic fungal sinusitis were excluded. After completion of the frontal sinusotomy, dimensions of the frontal recess were measured using curved Frazer suction diameters. A neuropattie soaked in 0.5 mg/mL of MMC was then placed into one frontal recess for 4 minutes in a randomized manner. A saline control was used for the other side. The primary surgeon was blinded to the medicated side intraoperatively and throughout the follow-up period. Measurements of the frontal recess were repeated at 1, 3, and 6 months. RESULTS: There was no difference in the degree of frontal recess stenosis between the MMC and control sides at 1, 3, and 6 months postoperatively for both primary and revision cases. CONCLUSION: One-time intraoperative topical MMC is not effective in reducing postoperative frontal recess stenosis in both primary and revision cases.

Acoustic rhinometric assessment of nasal obstruction after treatment with fluticasone propionate in patients with perennial rhinitis.

OBJECTIVE: To investigate the effect of fluticasone propionate (FP) on the symptom of nasal obstruction and to assess the correlation between the subjective visual analogue score (VAS) and the objective acoustic rhinometry (AR) measurements. METHODS: A prospective study of 45 consecutive patients, 30 males and 15 females with a mean age of 27 years (range: 16-59 years), with moderate/severe symptoms of perennial rhinitis who were treated by FP nasal spray for 4 weeks. AR and VAS were used to evaluate, compare and correlate the efficacy of FP nasal sprays. RESULTS: There was a significant improvement in the VAS post-treatment (3.9) compared with pre-treatment (6.3). There was also a significant increase in the nasal volume (V) and minimum cross-sectional area (MCA) after intranasal FP. Good correlation between the total MCA and total V was noted. Subjective improvements in symptoms did not correlate well with objective measurements as the correlation between VAS and AR was poor. CONCLUSION: Our study provides subjective and objective evidence on the efficacy of intranasal FP in improving nasal obstruction in perennial rhinitis. AR also proved to be a useful instrument in monitoring the effectiveness of medical therapy for perennial rhinitis.