Topical nasal treatment is considered the mainstay treatment for chronic rhinosinusitis (CRS). The authors reviewed the effectiveness of saline irrigation, topical corticosteroids, topical antibiotics and topical antifungals in the treatment of CRS. Large volume saline irrigation was found to be superior to low volume sprays, both in terms of irrigation of the sinuses and symptom relief. Patients must be advised to clean the irrigation devices regularly as bacterial colonisation of the devices has been described – there is no evidence however that the bacterial colonisation increases postoperative infections. The authors discussed different topical corticosteroids including the more recently available budesonide spray. The bioavailability of budesonide spray is high, at 40% to 50% while fluticasone and mometasone are lower at 1%. Low bioavailabilty intranasal steroid treatment is recommended, especially for patients with asthma who are being treated with steroid inhalers as well. Topical antibiotics are not recommended routinely. There is a role for topical antibiotics using mupirocin ointment, which could be mixed with normal saline as nasal irrigation to treat MRSA positive CRS exacerbations. Tobramycin spray could also be used to treat pseudomonas related to CRS while maintaining low serum levels. The use of topical antifungal is limited as well. While it is currently used in patients with fungal sinusitis, evidence of its efficacy is mixed – improvement in mucosal thickening is seen but it does not subjectively improve symptoms over placebo in CRS patients. In summary, the authors conclude that primary treatment in CRS patients include topical treatments using large volume saline irrigation in conjunction with corticosteroids while topical antibiotics and antifungals have a targeted but limited role. 

Topical drug therapies for chronic rhinosinusitis.
Luk LJ, DelGaudio JM.
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Wai Sum Cho

Queens Medical Centre, Nottingham, UK.

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