Full text of DOI:10.1097/00005537-200205000-00015

The Laryngoscope
Lippincott Williams & Wilkins, Inc., Philadelphia
© 2002 The American Laryngological,
Rhinological and Otological Society, Inc.
Intrasinus Administration of Topical
Budesonide to Allergic Patients With
Chronic Rhinosinusitis Following Surgery
Franc¸ois Lavigne, MD; Lisa Cameron, PhD; Paolo M. Renzi, MD, PhD; Jean Franc¸ois Planet, MD;
Pota Christodoulopoulos, MSc; Bouchaib Lamkioued, PhD; Qutayba Hamid, MD, PhD
Objective: Whether instillation into the maxillary
sinus of topical budesonide affected the immune re-
sponse and improved allergic patients with chronic rhi-
nosinusitis that had persistence of symptoms despite
appropriate surgical intervention was assessed. Study
Design: Double-blind placebo-controlled. Methods:
Twenty-six patients with allergy to house dust mites
who had previously had surgery and who had persis-
tent symptoms of disabling rhinorrhea or pressure-pain
resistant to oral antibiotics and intranasal corticoste-
roids were recruited. During the double-blind study,
patients instilled 256 ␮g budesonide daily or placebo
through an intubation device (maxillary antrum sinu-
sotomy tube) into one of the maxillary sinuses for 3
weeks before clinical assessment and a second biopsy.
Results: We found an improvement in the symptom
scores in 11 of the 13 patients who received budesonide;
we also found a decrease in CD-3 (P ؍ .02) and eosino-
phils (P ؍ .002), and a decrease in the density of cells
expressing interleukin-4 (P ؍ .0001) and interleukin-5
messenger RNA (P ؍ .006) after treatment. Conclusion:
Topical budesonide delivered through a maxillary an-
trum sinusotomy tube can control chronic rhinosinus-
itis that persists after surgery. Key Words: Chronic rhi-
apy.3 However, some patients with diffuse disease on com-
puted tomography (CT) scan do not benefit from these
surgical procedures and exhibit persistent mucosal dis-
ease, which leads to repetitive antibiotic treatment and
even surgical revisions.4
The phenotypic qualities of CRS are considered a
consequence of the inflammation that overwhelms the
nasal and sinus mucosa. This inflammation occurs in both
allergic and nonallergic patients, with the most notable
increase being in the number of eosinophils, and in aller-
gic individuals there is also an elevated number of T cells
and the type 2 T-helper-cell (Th2) cytokines, including
interleukin-4 (IL-4) and interleukin-5 (IL-5).5 Together,
these two cytokines mediate the development of the aller-
gic inflammatory response observed within respiratory
mucosa. Interleukin-4 influences activated naive T cells to
express predominantly Th2 cytokines; it facilitates eosin-
ophil infiltration by enhancing endothelial expression of
vascular cells adhesion molecules (VCAM)-1,6 the counter
ligand for very late antigen (VLA)-4 used by eosinophils
for endothelial transmigration7; and it induces B cells to
isotype switching in favor of immunoglobulin E (IgE).8
Interleukin-5 is the required cytokine for eosinophil dif-
ferentiation9 and also activates10 and enhances the sur-
vival of these cells.11,12
nosinusitis, maxillary sinus, budesonide, type
T-helper-cell cytokines, allergy.
2
Laryngoscope, 112:858–864, 2002
Topical corticosteroid treatment is well documented
as an effective method for reducing inflammation and
improving the symptoms of allergic rhinitis13 but is less
successful in patients with CRS.14 Indeed, we have previ-
ously demonstrated that intranasal administration of top-
ical corticosteroids can reduce the number of eosinophils
and T cells and the expression of Th2 cytokines IL-4, IL-5,
and interleukin-13 (IL-13) in patients with perennial
rhinitis.15
There are patients with persistent CRS who do not
respond to intranasal topical corticosteroids or antibiotic
treatment and show little improvement after surgery.16
We recently demonstrated that sinus mucosa readily ex-
posed to environmental air, the ethmoidal sinus mucosa,
was more inflamed than maxillary sinus mucosa.17 As
such, surgical intervention, which increases exposure of
INTRODUCTION
Chronic rhinosinusitis (CRS) is a disease of the nasal
and paranasal sinuses characterized by the symptoms of
facial pain, nasal obstruction, and rhinorrhea.1 Surgery,
involving the removal of ethmoidal tissue and middle me-
atus antrostomy,2 is indicated when recurrent infection
and clinical symptoms are not improved by medical ther-
From Centre Hospitalier Universitaire de Montre´al–Hoˆpital Noˆtre-
Dame (F.L., J.F.P., B.L.), Universite´ de Montre´al, and Meakins Christie
Laboratories (L.C., Q.H.), McGill University Montre´al, Que´bec, Canada.
Supported by Astra-Zeneca Canada Inc., and Fond de recherche en
sante´ du Que´bec.
Editor’s Note: This Manuscript was accepted for publication Decem-
ber 19, 2001.
Send Correspondence to Franc¸ois Lavigne, MD, 1100 Beaumont
Avenue, Mont-Royal, Que´bec, Montre´al, Canada H3P 3H5.
Laryngoscope 112: May 2002
858
Lavigne et al.: Budesonide for Chronic Rhinosinusitis

under the inferior turbinate on the lateral wall of the nose, to
provide anesthesia up to the level of its posterior attachment. A
Karl Storz canula with a distal lip was directed under the inferior
turbinate with endoscopic guidance and rotated to get to the
posterosuperior area of the inferior meatus because penetration
is easier at that level. The endoscope was removed, and a trocar
or a specially designed trephine was used to penetrate the max-
illary antrum. Once the canula was in place with the aid of
endoscopy and tissue resection if needed, the MAST was pushed
through, into the cavity, and the canula removed. In effect, this
technique is a sinus lavage procedure in which the tube is left in
place.
the maxillary sinus mucosa to environmental air, may
serve to increase mucosal inflammation and the need for
surgical revision.
Intubation and irrigation of the maxillary cavity have
been used for some time,18 and instillation of saline solu-
tion has been associated with increased levels of immuno-
globulin A (IgA), immunoglobulin G (IgG), complement
fractions 3 and 4 (C3 and C4), and a reduction in proteo-
lytic activity.19 In light of this, we proposed that intuba-
tion and instillation of topical corticosteroids directly into
the maxillary sinus might be more beneficial because it
allows for steroids to access the inflamed site. Indeed, we
demonstrate in the current study that instillation of top-
ical budesonide into the maxillary sinus of patients with
persistent CRS was successful in reducing both the sinus
inflammation and the clinical symptoms. Furthermore,
some of these patients were symptom free for up to 12
months after treatment with significant reduction in med-
ication needs for sinus and pulmonary disease. As such,
our results indicate that this route of administration holds
real potential as a method of treating patients with per-
sistent CRS.
Study Design and Tissue Collection
The maxillary sinus was intubated, and the patient received
a 3-week course of steroid or placebo treatment in which 256 ␮g
topical budesonide (five sprays of Rhinocort [Astra-Zeneca Can-
ada, Inc., Mississauga, Ontario, Canada], 100 ␮g/spray) in a 3-mL
syringe injected through a 19-gauge needle) or matched placebo
was instilled directly into the maxillary sinus using the MAST.
Follow-up visits were scheduled at 2 and 3 weeks. Biopsy speci-
mens were obtained from the most affected maxillary sinus at the
time of intubation and after the 3-week treatment period. The
Karl Storz flexible optical biopsy and grasping forceps with a
2.7-mm oblique telescope was used to gain access to the maxillary
sinus cavity either through the opened middle meatus or through
the canula passing under the inferior meatus into the sinus
cavity. Each tissue sample was bisected with a No. 11 blade and
processed for in situ hybridization or immunocytochemical study.
Patients with pollen sensitivity underwent intubation at a time
outside the respective pollen season.
PATIENTS AND METHODS
Patients
The current study was undertaken after approval by the
Ethics Committee of Notre Dame Hospital (Montreal, Quebec,
Canada). Patients were enrolled and followed for 1 year between
November 1995 and April 1998. Written, informed consent was
obtained in 29 nonsmoking patients with CRS, which was defined
as a clinical syndrome of rhinorrhea, congestion, and facial
pressure-pain lasting for more than 6 months and resistant to
medical therapy, including antibiotics, topical steroids, or oral
prednisone. In all patients, persistent CRS was confirmed by
nasosinusal endoscopy examination that showed diffuse bilateral
thickening or erythema in both the ethmoid and maxillary si-
nuses with obvious signs of inflammation (Fig. 1). The presence of
atopy was determined clinically by positive reaction on skin test
(wheal Ն3 mm) to house dust mite, as well as a panel of 11 other
common aeroallergens. Peripheral eosinophil counts with com-
plete blood cell counts were performed in all patients, and the
presence of specific IgE was determined by RAST testing in
patients with negative or small skin reactions. Nasal steroids
were withheld for 14 days and systemic steroids were witheld for
2 months withheld before the study. Patients with nasal polyposis
or immunodeficiency and individuals who required further sinus
surgery were excluded from the study.
Assessment of Clinical Response
Categorization of the patients into responders and nonre-
sponders to maxillary sinus irrigation and steroid administration
was performed using a total score based on questionnaires and
endoscopic evaluation. Patients were assessed before as well as 3
weeks and 6 to 12 months after intubation. The questionnaire
assessed all of the patient’s symptoms without focusing on the
side that was treated. The questionnaire focused on three major
symptoms: facial pressure or pain, nasal congestion, and obstruc-
tion and rhinorrhea, as assessed by the patient using an ordinal
scaled visual analogue score of 0 to 10 (0 ϭ no symptoms and 10
ϭ severe symptoms). At the 3-week visit videoendoscopy was
performed, providing an objective evaluation of the nasal, eth-
moidal, and maxillary sinus cavity. The endoscopic appearances
were quantified on a three-point basis for the presence of dis-
charge (0 ϭ none, 1 ϭ clear and thin, and 2 ϭ thick and purulent)
and mucosal status (0 ϭ normoplasia, 1 ϭ light hyperplasia with
no erythema, and 2 ϭ hyperplasia or obvious erythema). A total
score was calculated for each visual analogue scale and the en-
doscopic assessment. The patients were considered to have re-
sponded to intubation when they reported a digital analogue
score of less than 2.5 for all the symptom scores or an average
decrease of at least 50% from the initial score and when the
endoscopic score was 0 or 1 at 3 weeks after the intubation. The
follow-up period consisted of a visit at 3 to 6 months and at 1 year.
Intubation of Maxillary Sinus
Only one of the maxillary sinuses was intubated. The most
affected maxillary sinus identified during endoscopy was selected
for intubation. The maxillary antrum sinusotomy tube (MAST)
(Fig. 2) is a flexible tube that is used to provide access to the
maxillary sinus cavity and has an anchoring member at its distal
end. The curve of this distal end and the flanges conform to the
lateral wall of the nose and keep the flexible tube under the
inferior turbinate, leaving the airway passage free of obstruction.
When the proximal end is cut at the level of the nostril, it does not
show outside the nose, yet is still accessible to the patient for
self-irrigation (Fig. 3). Every MAST was installed with the pa-
tient under local anesthesia using 4% topical lidocaine and
adrenalin for 10 minutes before injecting 1 to 2 mL of 1% lido-
caine (1:100,000) at the anterior part of the inferior turbinate and
Immunocytochemistry
The cellular infiltrate was quantitated by performing alka-
line phosphatase–antialkaline phosphatase immunocytochemis-
try on sections of biopsy tissue obtained from the maxillary sinus,
as previously described.20 Mouse anti-human monoclonal anti-
body directed against CD4 and major basic protein (MBP) (kind
gift from Redwan Moqbel, PhD, University of Alberta, Edmonton,
Alberta, Canada) to detect T cells and eosinophils, respectively.
Laryngoscope 112: May 2002
Lavigne et al.: Budesonide for Chronic Rhinosinusitis
859

Fig. 1. Endoscopic images from a
2.7-mm, 30°, wide-angle telescope of
the mucosa of the right-side maxillary
sinus. (A) Erythema and hypertrophy
of the mucosa; (B) hypertrophy and
swelling of the mucosa; and (C) nor-
mal mucosa are evident.
Both primary antibodies, as well as the secondary rabbit anti-
mouse antibody and tertiary rat anti-rabbit antibody conjugated
to alkaline phosphatase antibody, were diluted in a commercially
available diluting buffer. Sections were incubated with the pri-
mary antibody at 4°C overnight and then with the secondary and
tertiary antibodies for 30 minutes each. The reaction was visual-
ized with Fast Red TR (Sigma Chemical Company, St. Louis, MO)
and alkaline phosphatase substrate. Using this method, positive
cells stain red.
In Situ Hybridization
Radiolabeled complementary RNA probes for IL-4 and IL-5
messenger RNA (mRNA) were generated by in vitro transcription
in the presence of 35S-conjugated UTP and T7 or SP6 RNA poly-
merases for sense and antisense probes. Tissue sections were
made permeable with 0.3% Triton X-100 and a 1-␮g/mL solution
of proteinase K at 37°C and were fixed in 4% paraformaldehyde.
A wash in 50% formamide in 2ϫ standard saline citrate (SSC) at
Fig. 2. The maxillary antrum sinusotomy tube (Hood Laboratories,
Pembroke, MA).
Fig. 3. The tube is accessible at the
nostril level for self-irrigation when the
patient sits in front of a mirror.
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860
Lavigne et al.: Budesonide for Chronic Rhinosinusitis

42°C was performed to equalize the tissues and increase adher-
ence to the slide. Sections were incubated overnight at 42°C with
1 ϫ 106 counts per minute per section of riboprobe. Washing after
hybridization was performed in decreasing concentrations of SSC
(4 ϫ SSC Ϫ 0.1 ϫ SSC) at 42°C. Excess probe was destroyed by
incubating with a 20-␮g/mL RNAse A solution at 42°C. Sections
were then dehydrated by washing in increasing concentrations of
ethanol. For autoradiography, slides were dipped in Amersham
LM-2 emulsion (Oakville, Ontario, Canada), stored at 4°C for a
period of 12 days, developed in Kodak D-19 (Eastman Kodak,
Toronto, Ontario, Canada), and counterstained with Mayer’s he-
matoxylin. Positive signal was identified as a discrete collection of
silver grains overlying the cell. Negative control experiments
using sense probes or RNAse A pretreatment, or both, was per-
formed to confirm probe specificity.
were only three smokers with 10, 15, and 19 pack/year
histories of smoking; two were responders to intubation,
and one was a nonresponder. A typical example of a CT
scan obtained before therapy is shown in Figure 4.
Adverse Effects
In general, the instillation of budesonide did not gen-
erate any irritation of the sinus cavity. In three patients
the tube fell out after manipulation during the self-
administered irrigation and was replaced the next day.
There were three cases of epistaxis; one required complete
packing of the nostril, and local application of Surgicel
(Ethicon, Inc., Johnson & Johnson, Somerville, NJ) was
sufficient for the other two cases. One of the two diabetic
patients had to increase insulin intake during treatment
to control glycemia. Five patients could not complete the
study. There was one case of Staphylococcus aureus infec-
tion with pus surrounding the tube after 1 week of the
study. Two patients had an asthma attack during intuba-
tion requiring steroid treatment, but one was reintro-
duced later into the study, after a sufficient washout pe-
riod. For three other cases, either the first or the second
biopsy was insufficient for analysis.
Quantification
Slides were counted in a blinded fashion using an Olympus
light microscope (Carson Group Inc., Markam, Ontario, Canada)
at 200ϫ magnification. The graticule was placed under the base-
ment membrane, and the number of positive cells were counted
and reported as the mean of the counts for at least six (range 6–8)
grids of 0.2 mm2 each. The within-observer coefficient of variation
for repeated counts of immunostaining was 8%, and for hybrid-
ized sections, less than 5%. Data are expressed as the median
(range) and analyzed using Wilcoxon’s signed-rank test. P values
of less than .05 were considered significant. Correlational analy-
sis was applied using Pearson’s correlation coefficient (SyStat,
version 7.1, SyStat Inc., Evanston, IL).
Clinical Response to Treatment
At the evaluation before intubation, patients selected
for the placebo and the steroid groups experienced a sim-
ilar degree of discomfort, which was assessed by general
score, pain, rhinorrhea, and congestion (Fig. 5). The effect
of budesonide compared with placebo treatment was as-
sessed using visual analogue scores, which demonstrated
that 11 of 13 patients receiving budesonide improved by
more than 50% for a period of 2 to 12 months (Fig. 6). In
the placebo group, 4 of 13 patients improved by more than
50%, but the reduction of symptoms was significantly less
important than with budesonide and the duration of im-
provement was less than 2 months, mainly during the
RESULTS
Patients
Twenty-four of the 29 patients who were recruited
completed the study. These patients had perennial rhini-
tis and persistent CRS but without nasal polyposis. Of the
29 patients, 18 were women and 11 were men with a mean
age of 46 Ϯ 10.7 years (mean Ϯ standard deviation). There
Fig. 4. Computed tomography scan of a patient with persistent
chronic sinusitis after ethmoidectomy and middle meatus antros-
tomy. Scan confirms the patency of the antrostomy and the persis-
tence of mucosal hypertrophy.
Fig. 5. Relative level of symptomatology on a scale of 1 to 10;
general discomfort and specific symptoms show that the two
groups were comparable before irrigation. Rhinorrhea was the most
inconvenient symptom for the patients.
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Lavigne et al.: Budesonide for Chronic Rhinosinusitis
861

Fig. 6. Results of the summation of symptom scores after placebo
and steroid therapy. The regression of symptoms was significantly
more important in the budesonide group.
intubation period. The post-treatment endoscopy con-
firmed that the appearance of the untreated side had not
improved. There was also a tendency to see a highlighting
of the mucosa during endoscopy confirming the presence
of an active inflammatory reaction with hypertrophy or
erythema of the mucosa lining the sinuses.
Assessment of Cell Density and Profile of
Cytokine Messenger RNA
The similarities between the two patient groups were
confirmed by the demonstration of no statistical difference
in the numbers of T cells and eosinophils within sections
of maxillary sinus mucosa obtained from the placebo (28
[17–41] and 11.5 [5–18], respectively) and steroid (32 [21–
42] and 16 [7–21], respectively [P Ͼ.05]) groups (Fig. 7)
before treatment. After 3 weeks, the number of T cells was
significantly reduced within sections of maxillary sinus
mucosa obtained from patients receiving budesonide com-
pared with pretreatment tissue (29 [16–35], P Ͻ.05), but
not within sections obtained from patients who received
placebo treatment (30 [25–37], P Ͼ.05). Similarly, there
were also significantly fewer eosinophils in the tissues of
steroid-treated patients (5 [3–11], P Ͻ.05) than in the
tissues of placebo-treated patients (12.5 [4–24], P Ͼ.05).
There were also cells expressing mRNA coding for IL-4
and IL-5 at baseline in similar numbers within the
steroid-treated (6.0 [2–9] and 11 [5–18]) and placebo-
treated (4.5 [2–11] and 10.75 [5–18], P Ͼ.05) groups (Fig.
8). However, within sections of sinus mucosa obtained
after the steroid treatment there were significantly fewer
cells expressing IL-4 (3.0 [0–7]) and IL-5 (4 [0–10]) mRNA
compared with pretreatment values (P Ͻ.05). This reduc-
tion was not observed within tissue obtained from patients
who were given a matched placebo (6.5 [3–11] and 11.0
[5–25], P Ͼ.05).
Fig. 7. T cells (A) and eosinophils (B) within sections of sinus
mucosal tissue obtained before (B) and after (A) 3 weeks of intrasi-
nus administration of 256 ␮g/mL budesonide or matched placebo.
DISCUSSION
This study assessed the efficacy of a new delivery
system for topical corticosteroids to the maxillary sinus in
patients with CRS. Our results demonstrate that a 21-day
treatment in which 256 ␮g budesonide was instilled di-
rectly into the maxillary sinus reduced eosinophilia and
reduction of the number of cells expressing mRNA for the
Th2 cytokines IL-4 and IL-5, and is associated with pro-
longed improvement in clinical symptoms.
Maxillary sinus intubation was introduced in North
America as a therapeutic approach by Jasbi and Ritter18
and has been mainly used for sinusitis in children. This
approach for chronic maxillary sinusitis in children used a
T-shaped tube with a relatively big lumen and a “T” shape
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Lavigne et al.: Budesonide for Chronic Rhinosinusitis

The increased requirement for insulin in one case
suggests a systemic absorption of budesonide when it is
delivered onto the inflamed mucosa of the sinus cavity.
Further studies on bioavailability should address this
question to determine the exact percentage of absorption.
The use of irrigation was supported by clinical experience
at Notre Dame Hospital since the 1960s, mainly for fron-
tal sinus empyema, and from the Swedish literature. Al-
though good results could be achieved in acute and sub-
acute sinusitis, our experience with CRS has been that
only temporary relief could be achieved from saline irri-
gation. Because of the similarities in Th2 cytokine expres-
sion seen in allergic rhinitis and CRS,5 we expected a
reduction in the synthesis of IL-4 and IL-5 mRNA by
intrasinus steroid application. At the onset of the current
study we did not expect a clinical response from therapy
because of unilateral application and the importance of
mucosal abnormalities that were seen during endoscopic
examination. The treatment duration of 21 days was de-
termined mainly because of our knowledge of the clinical
behavior of topical corticosteroids in allergic rhinitis13 and
the limited time period of 31 days for the use of the
intubation device in Canada.
Corticosteroids act through the inhibition of mRNA
synthesis21 and have been shown to effectively inhibit the
production of a number of proallergic mediators, including
leukotrienes, histamine and cytokines like IL-4 and IL-13,
that regulate IgE production,22 and IL-5, which modulates
eosinophil differentiation and survival within the tissues.8
Because of the reciprocal relationship between the expres-
sion of Th2 and Th1 cytokines, steroid treatment has been
associated with an increase in the expression of Th1 cyto-
kines.23 We have previously shown that the relative level
of Th2 cytokine expression within the nasal and sinus
mucosa of individuals with allergic rhinitis and sinusitis
is associated with an elevated number of lymphocytes and
eosinophils.17 In the present study, we show that cortico-
steroids delivered into the maxillary sinus cavity of pa-
tients with persistent allergic CRS could reduce the in-
flammatory process. This supports the assumption that
CRS is not simply an infectious disease but a complex
inflammatory process. The effect on regression of mucosal
hypertrophy in cases of persistent sinusitis even after
surgery support the hypothesis that some patients with
CRS could benefit from a mucosal therapy instead of
surgery.
The possibility of a systemic, instead of topical, effect
is not supported by our results. The endoscopic evaluation
was unchanged on the untreated side with obvious
changes of hypertrophy regression or disappearance of
erythema on the budesonide-treated side. At present, we
cannot explain why topical treatment influenced all the
sinuses on one side in some cases. There did not appear to
be an influence on the infundibulum and the drainage of
the maxillary sinus because the ethmoid labyrinth was
already disrupted at that level. There could possibly be an
influence on the ipsilateral fifth nerve, which would be
consistent with a previous study that examined neuroki-
nins, pain, and inflammation.24 In our experience, pa-
tients treated with oral prednisone need a longer period of
treatment for the same condition, sometimes as long as 6
Fig. 8. Number of cells expressing messenger RNA coding for
interleukin-4 (A) and interleukin-5 (B) within sections of sinus mu-
cosal tissue obtained instead of (B) and instead of (A) intrasinus
administration of 256 ␮g/mL budesonide or matched placebo.
that aligns the straight part of the tube toward the mid-
line of the nose and as such has a tendency to irritate the
nasal septum. In the present study, we designed a smaller
tube that travels along the lateral wall of the nose as a
delivery system, not for ventilation or drainage. The sta-
bility and tolerance of the tube were adequate because the
tube fell out only when the manipulations for irrigation
were excessive (3/24 cases) and no bleeding or irritation
occurred during the days after the insertion. This is most
likely attributable to the specific design of the tube, which
keeps it under the inferior turbinate and away from the
airway passage and nasal septum.
Laryngoscope 112: May 2002
Lavigne et al.: Budesonide for Chronic Rhinosinusitis
863

10. Lopez AF, Sanderson CJ, Gamble JR, Campbell HD, Young
IG, Vadas MA. Recombinant human interleukin 5 is a
selective activator of human eosinophil function. J Exp
Med 1988;167:219–224.
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interleukin-5 (IL-5) regulates the production of eosinophils
in human bone marrow cultures: comparison and interac-
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1504–1512.
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its homologues in human eosinophils: modulation by
interleukin-5. Am J Respir Cell Mol Biol 1999;20:720–728.
13. Naclerio RM, Mygind M. Intranasal steroids. In: Mygind N,
Naclerio RM, eds. Allergic and Non-Allergic Rhinitis: Clin-
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months. The influence of systemic corticosteroids on ho-
meostasis of the sinuses supports the use of a topical
preparation in this condition.
It has not yet been shown whether opening the sinus
cavities to the environment, a consequence of ethmoidec-
tomy and meatotomy, may negatively influence the out-
come of CRS in patients with IgE-mediated allergy. In-
deed, this surgical approach may not be the best
treatment for CRS in patients with perennial allergy. The
recurrence of symptoms in approximately half of the pa-
tients after 6 months to 1 year probably represents the
time needed for the return of the vicious circle of inflam-
mation associated with Th2 cytokine expression within the
sinus mucosa.
We have shown that a 21-day treatment of the sinus
cavity with budesonide instilled through a MAST tube can
control the clinical symptoms and the inflammatory pro-
cess involved in persistent sinusitis for up to 12 months
after treatment.
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