Recent cutting-edge research at the Mayo Clinic has introduced a new paradigm for the treatment of chronic rhinosinusitis (CRS). Clinical studies have demonstrated that topical antifungals are effective in treating and altering the disease progression of CRS. In addition to improving symptoms, topical antifungal therapies have demonstrated decreased mucosal thickening on endoscopic exam and CT scan (View image).

Antifungal drugs used in the treatment of CRS include:

• Amphotericin B
• Itraconazole
• Voriconazole

In clinical studies, topical antifungals have been used as follows:

• Amphotericin B: 100 mg/L of sterile water (up to 200 mg/L has been used)
• Itraconazole: 100 mg/L of sterile water
• Voriconazole: 1000 mg/L of normal saline

With the introduction of topical antifungal therapy, there remains a role for the traditional therapies in the treatment of CRS. Antibiotics are useful in treating acute bacterial infections that may result because of damage to the nasal epithelium. Use of a systemic corticosteroid may be desirable in patients with moderate-severe to very severe disease. In these patients, thickened, inflamed tissue may prevent the antifungal preparation from reaching the entire affected sinus. In studies, pretreatment with a systemic corticosteroid decreased the extent of inflammation and allowed for better distribution of the antifungal. Systemic corticosteroid options include a short course of 7 to 10 days, an extended taper of up to two weeks, or a one-time dose of an intramuscular formulation, such as triamcinolone dosed at 60 to 100 mg.

Sinus surgery has shown to be useful to remove obstructions and excess mucus from the frontal and maxillary sinus prior to initiating topical antifungal treatment. Intraoperative irrigation with an antifungal preparation has also been beneficial to reach the remote portions of the sinuses and to remove excess mucus. In addition, the access provided during surgical intervention provided an opportunity for distribution of the antifungal to the complete sinus area. Such thorough distribution is difficult for the patient to achieve using post-operative drug delivery.

In studies, following surgery, patients began irrigation with an antifungal preparation as soon as the treatment could be tolerated. This was generally three to seven days post-operatively. Dosing of the antifungal was 20 mL into each nostril given twice daily. Therapy was continued for a minimum of three months. Some patients responded sooner than three months, but patients with severe disease benefited from extended treatment of up to several years.