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Antifungal nasal washes for chronic rhinosinusitis: What's therapeutic—the wash or the antifungal?

2003; Elsevier BV; Volume: 111; Issue: 5 Linguagem: Inglês

10.1067/mai.2003.1481

1097-6825

Berrylin J. Ferguson,

Respiratory and Cough-Related Research

Ponikau et al 1Ponikau J Sherris DA Kita H Kern EB Intranasal antifungal treatment and 51 patients with chronic rhinosinusitis.J Allergy Clin Immunol. 2002; 110: 862-866Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar report an impressive improvement, both objectively and subjectively, in patients with chronic rhinosinusitis (CRS). In the introduction to their article, they report that CRS is the most common chronic disease, having an impact on an estimated 37 million people per year in the United States (approximately 20% of the total population). In contrast, the patients who are the subject of their study universally had nasal polyps (90%) or polypoid changes by endoscopy (10% [5/51]); the reported prevalence of nasal polyps is much lower, ranging from 0.3% to 3.5%. 1Ponikau J Sherris DA Kita H Kern EB Intranasal antifungal treatment and 51 patients with chronic rhinosinusitis.J Allergy Clin Immunol. 2002; 110: 862-866Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar Eighty-eight percent of the patients in their study had undergone sinus surgery previously. The response of these patients to vigorous nasal washings might not be applicable to the larger pool of patients with symptoms of CRS who do not have surgically enlarged openings to the sinuses. In the article's Fig 3, there appear to be only 12, not 13, patients with data regarding changes in mucosal thickening of the maxillary sinus. Could the authors clarify this figure? As the authors point out, because of increased radiation risk and cost a posttreatment sinus computed tomography (CT) scan is usually not obtained. What were the indications for obtaining a sinus CT scan after the nasal washings in the 13 patients who did receive posttreatment sinus CT scans? The authors rightly assert that a placebo-controlled trial is required before efficacy of their study irrigation can be attributed to the inclusion of an antifungal agent. Whereas 75% of patients showed improvement in clinical symptoms in the study by Ponikau et al, 1Ponikau J Sherris DA Kita H Kern EB Intranasal antifungal treatment and 51 patients with chronic rhinosinusitis.J Allergy Clin Immunol. 2002; 110: 862-866Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar similar degrees of improvement have been reported in studies using only hypertonic saline solution. In a study of 211 patients with a variety of causes for sinonasal symptoms, daily nasal pulsatile irrigation with hypertonic saline solution resulted in statistically significant improvement in 23 of 30 nasal disease–specific measures and quality of life in comparison with what was seen in a control group without nasal symptoms. 2Prevalence of selected chronic conditions, USA. Vital and Health Statistics. Series 10, number 155. p. 25.Google Scholar Heatley et al 3Heatley DG McConnell KE Kille TL Leverson GE Nasal irrigation for the alleviation of sinonasal symptoms.Otolaryngol Head Neck Surg. 2001; 125: 44-48Crossref PubMed Scopus (131) Google Scholar reported that daily nasal hypertonic saline irrigation through use of a bulb syringe or nasal irrigation pot and daily reflexology massage were equally efficacious and resulted in improvement in the symptoms of chronic sinusitis in more than 70% of subjects. 3Heatley DG McConnell KE Kille TL Leverson GE Nasal irrigation for the alleviation of sinonasal symptoms.Otolaryngol Head Neck Surg. 2001; 125: 44-48Crossref PubMed Scopus (131) Google Scholar Medication usage was decreased in approximately one third of participants, regardless of the intervention. I am impressed with the inclusion in the study by Ponikau et al 1Ponikau J Sherris DA Kita H Kern EB Intranasal antifungal treatment and 51 patients with chronic rhinosinusitis.J Allergy Clin Immunol. 2002; 110: 862-866Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar of a great deal more detail and information on outcomes than was provided in other studies of nasal irrigation. However, I would like more information on how the authors assessed subjective improvement. Was a validated disease-specific or quality-of-life instrument used? Was it possible for the patients to indicate that any of their symptoms had worsened? I congratulate the authors on their inclusion of many of the criteria required for critical assessment of a study.