The most common anti-inflammatory agents are steroids. Budesonide (Pulmicort) can be obtained at most local pharmacies, although pre-certification issues for off label use can be a hindrance. There are a number of compounding pharmacies that will ship pre-packaged 2ml aliquots of most steroids directly to patients at home. These include mometasone and others. Concern over systemic absorption when using higher doses of steroids in irrigations has arisen. Recent studies have not shown any significant adrenal suppression and when taking into account that only 3% of irrigation volume is retained, the actual concentration of steroid exposure is similar to commonly used nasal steroid sprays (Harvey etal, OHNS 2009). The regimes used most often are budesonide (0.5mg-1.0mg) or mometasone (0.6mg) bid.

Antibiotics

MRSA is one of the toughest bugs to eradicate. I inform patients that Staph (and likely MRSA) can be a colonizing bacteria, especially if the culture swab gets contaminated when placing it into the sinuses, so clinical correlation with symptoms and visualization of purulence is always done. I typically use mupirocin for MRSA. It has good coverage and also appears to break up biofilms that make this bacteria more of a problem (Uren etal, Laryngoscope 2008). Pseudomonas is another tough bacteria which also forms biofilms. I typically use tobramycin when this is cultured, as fluoroquinolone resistance is becoming more common. I caution patients about the potential for ototoxicity with aminoglycosides, although this seems to be rare. Dosing for both of these antibiotics has not been thoroughly studied.

Antifungals

There have now been a number of placebo controlled trials investigating topical anti-fungal irrigations. The vast majority have failed to demonstrate any benefit. Patients must be informed that fungi are ubiquitous and studies show that most healthy patients have an average of 3 different species of fungi intheir nose. Again, any positive fungal cultures must interpreted in the context of the clinical picture of the patient.

Other agents

Patient scenarios 

Patient 2: This patient has failed multiple courses of oral antibiotics. Cultures demonstrate MRSA and CT to right demonstrates a patent maxillary antrostomy. I suspect this patient has biofilms playing a role. I perform aggressive office debridement of any purulence or crusting every 1-2 weeks. This is done in conjunction with topical antibiotics (typically mupirocin for MRSA) and surfactant based irrigations. Steroids can be added to irrigations if edema/polypoid mucosa is noted. In these cases, it is imperative to ensure a widely patent cavity (the maxillary in many cases) that is brought into communication with the natural os and does not allow mucus recirculation to play a role.
 

In summary, try to tailor your topical therapies to your patient. All patients need proper surgery resulting in widely patent cavities for access. Large volumes devices are most effective at drug delivery. The active agents you select depend upon the presence of polyps, bacterial infection and potential biofilm formers. This is an area of significant research in the Rhinology community and I'm certain new therapies will continue to emerge.

Thanks for all your support.

Rodney J. Schlosser, MD                                                                Professor and Director of Rhinology