Combination Treatment Provides Short-term Endoscopic Relief in CRSwNP Subtype

Endoscopic scores improved in the short term for individuals who have aspirin-exacerbated respiratory disease (AERD)—a subtype of chronic rhinosinusitis with nasal polyposis (CRSwNP) characterized by a high recurrence rate, treatment resistance, and increased immunoglobulin E production vs aspirin-tolerant CRSwNP—following receipt of combination treatment.

A new retrospective cohort study investigated the effectiveness of culture-directed topical antibiotic treatment plus intranasal corticosteroids (INCs) among persons with this CRSwNP subtype, and the findings were published recently in Frontiers in Cellular and Infection Microbiology.

There were 26 patients in the control group (INC treatment only; twice-daily budesonide respule 0.5 mg/2 mL in 240 mL saline) and 18 in the study group (same INC treatment plus 4 weeks of topical antibiotic irrigation), both administered postoperatively. The 22-item Sino-Nasal Outcome Test (SNOT-22) and Lund-Kennedy scores (LKS) were used to gauge symptom improvement at 3 points: preoperatively, 4 weeks after endoscopic sinus surgery (ESS), and 4 to 6 months after ESS. The ESS had to occur from 2016 to 2021, and patients (mean [SD] age, 53 [14] years; 59.1%, female patients) needed to have a positive preoperative or intraoperative sinonasal culture.

“Identifying effective therapy for recalcitrant CRSwNP is a major challenge. Evidence on topical antibiotics use in CRSwNP is lacking,” the study authors wrote. “Current consensus guidelines recommend against its routine use, but recent reviews show some benefit when managing recalcitrant disease after ESS.”

The most common bacteria in the entire study cohort was Staphylococcus aureus in 43.2%, and 77.7% of those using a topical antibiotic were receiving tobramycin. Asthma, in 84.1%, was the most common comorbidity.

With higher SNOT-22 scores indicating worse symptoms—on a score scale from 0 to 110 for 22 items each rated 0 (no problem) to 5 (the worst)—statistically significant differences were not seen at any of the 3 evaluations between the groups:

• At the preoperative visit, the INCs-only group had a mean (SD) score of 57 (24.9) vs 54.5 (25) in the combination group
• At 4 weeks, the scores were 21.1 (18.6) and 19.5 (11.9), respectively
• At 4-6 months, the scores were 19.3 (11.8) and 20.3 (16.2)

However, these same numbers also show significant differences among the individual groups in mean SNOT-22 scores, the authors noted:

• INCs-only group: from 57 to 19.3 overall
• Combo group: from 54.5 to 19.5 overall

The differences in LKS also were not significant between the groups:

• At the preop visit, the INCs-only group had a score of 6.5 (2.8) vs 8.1 (3) in the combination group
• At 4 weeks, the scores were 4 (2) and 6 (3), respectively
• At 4 to 6 months, the scores were 3 (3) and 4(2)

Significant differences in LKS, however, were seen from the preoperative visit to the 4-week mark and from the preoperative visit to the 4- to 6-month mark within each treatment cohort:

• INCs-only group: 6.5 vs 4 at 4 weeks and 3 at 4 to 6 months
• Combination group: 8.1 vs 6 at 4 weeks and 4 at 4 to 6 months

The authors noted their data met the minimal clinically important difference (MCIS) threshold at the 2 follow-up visits in each group for both ESS indicators.

An additional linear regression analysis indicated that the use of topical antibiotics had a positive effect only on the 4-week LKS measure (β= 2.0; 95% CI, 0.43-3.7; P = .015) and there was no effect on either SNOT-22 or LKS from concurrent treatment with oral antibiotics at any of the evaluations.

“The addition of culture-directed topical antibiotic irrigation in the immediate postoperative period leads to a statistically significant short-term improvement in LKS compared to those treated with nasal steroid irrigation alone,” the authors concluded. “However, our study did not find a significant improvement in patient-reported symptoms measured by SNOT-22 when topical antibiotics were added to the postoperative treatment regimen compared to INCS alone.”

They suggest longer follow-up studies, with larger patient populations, for a more comprehensive evaluation of nasal polyps and sinus symptom recurrences, as well as how to sustain long-term improvement.

Reference

Martinez-Paredes JF, Choby G, Marino M, et al. Endoscopic outcomes in patients with AERD treated with topical antibiotics and intranasal corticosteroids. Front Cell Infect Microbiol. Published online July 22, 2022. doi:10.3389/fcimb.2022.812215