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Anti-Fungal Therapy to Treat Chronic Rhinosinusitis

Sleep Disorders | March 2, 2015 | Author: The Super Pharmacist

sleep, ENT

Anti-Fungal Therapy to Treat Chronic Rhinosinusitis

Rhinosinusitis is a condition affecting the nasal passages and airways causing a consistent 'runny nose' and nasal congestion. In some cases nasal polyps may develop. Nasal polyps are cellular growths within the nasal sinuses which can affect the ability to breathe through the nose. Some research indicates that chronic rhinosinusitis is an obstructive lung condition, or one that restricts pulmonary function by causing a blockage at some point in the airway. Chronic rhinosinusitis is typically regarded as rhinosinusitis that persists for twelve weeks or more, whereas acute rhinosinusitis has a duration of no more than twelve weeks.

Rhinosinusitis may be associated with infection by various types of micro-organisms (such as bacteria or viruses), or excessive reactions of the immune system and is significantly associated with the prevalence of biofilms. A biofilm is a 'collaboration' of various types of micro-organisms which build a scaffold-like structure in tissues such as mucous membranes of the nasal passages to improve their abiltiy to grow and propagate.

Chronic rhinosinusitis is associated with the release of cytokines, a class of immune-system molecules that may act to 'recruit' immune cells to an injured or infected part of the body. These release inflammatory chemicals that may cause pain and tissue damage as well as destroy micro-organisms such as bacteria. Cytokines may also affect the central nervous system, inducing behavioral changes and other disease symptoms.

Chronic rhinosinusitis may also be associated with additional symptoms such as anxiety, depression, fatigue, reduced appetite and with sleep disturbances. Sleep disturbance is influenced by nasal obstruction and possible immune system interactions.This can result in daytime drowsiness and poor sleep quality (e.g. frequently interrupted sleep, inadequate time spent in each stage of sleep and differences in overall sleep time compared to normal) due to their condition and contribute to decreased quality of life.

Reduced sleep quality in chronic rhinosinusitis may be increased by a number of factors, including a history of smoking, a pre-existing depressive disorder and female gender. Chronic rhinosinusitis may also affect sleep through its effects on snoring and airflow obstruction (or apnoea). This is affected by other unrelated factors such as body mass index, however.

Diagnosing rhinosinusitis

Chronic rhinosinusitis may be diagnosed or assessed using a number of methods. These include:

  • Patient assessment rating scales and questionnaires
  • Computed tomography
  • Nasal endoscopy
  • Microscopy (to quantify and assess microbiological growth)
  • Polyp biopsy, to detect immune cells associated with chronic rhinosinusitis

Treatment for chronic rhinosinusitis

There are many therapeutic options available for chronic rhinosinusitis. These include:

Antibiotics

These are antibacterial drugs often prescribed for respiratory conditions such as chronic rhinosinusitis. Antibiotics typically associated with the treatment of this condition include low-dose clarithromycin.

The drawback to using antibiotic therapy is the potential of the bacteria to become resistant to the antibiotic being used thus increasing the risk of the recurrence of chronic rhinosinusitis.

Antileukotrienes

Cysteinyl leukotrienes are a subclass of cytokines associated with the induction of rhinorrhoea (nasal running or dripping) and mucus formation. They may also affect sleep quality. Drugs that inhibit these molecules have been found to have moderate efficacy in treating chronic rhinosinusitis. Antileukotriene drugs include montelukast, pranlukast and zileuton.

Corticosteroids

These are a class of drugs similar in structure to natural hormones, associated with the effective reduction of inflammation. The use of steroid nasal sprays and other similar delivery systems is a common line of treatment for chronic rhinosinusitis9.

Surgery

Some procedures may be carried out to restore the structure of the nasal passages or improve their ability to function normally. This may also improve sleep apnoea and snoring. These may be accompanied by the implantation of small devices (or stents) which release a controlled dose of steroid medications to reduce inflammation. These have been shown to reduce complications such as the regrowth of polyps and also the need for oral steroids after surgery.

Chronic Rhinosinusitis and Anti-Fungal Therapy

Some researchers argue that chronic rhinosinusitis may be associated with another similar condition, allergic rhinitis. This is another disorder of the nasal passages in which inflammation and other immune reactions are caused by abnormal concentrations of a class of immune molecules called immunoglobins. These proteins may increase in number in response to a wide range of triggers, which include pollen and fungal spores.

Some analysis does not find any causational relationship between the two conditions, but there is some evidence to indicate the possibility of an allergic component in chronic rhinosinusitis. (Chronic rhinosinusitis is also associated with conditions in which immunoglobulins are deficient). Therefore, treatments that prevent the growth of fungi (micro-organisms that are similar in some ways to bacteria, and also have some properties found in plants) may address some cases of chronic rhinosinusitis.

Fungi comprise a wide range of microbial species, which may also be referred to as moulds or spores. Many of these are found in the environment and in the air, and can infiltrate the airways. Once established there, they may cause serious disorders by releasing toxins, and through physical obstruction with large growths. Fungal sinusitis is a discrete, serious condition in which timely and acute treatment, including surgery to remove growths, is often needed. There is evidence that allergic fungal rhinosinusitis is a condition distinct from chronic rhinosinusitis, and should be treated accordingly. This condition may be diagnosed by testing for fungi-specific immunoglobulins, and biopsies to assess the presence of fungal growth.

Fungal infection leads to the immune cell activity associated with chronic rhinosinusitis. Fungi may be eradicated with some classes of antibiotics, which may be administered orally, intravenously or topically. 

There are few clinical trials testing their effect in chronic rhinosinusitis. A double-blind trial randomised 64 patients with chronic rhinosinusitis without polyps to an antifungal antibiotic, amphotericin B, or a placebo in a nasal irrigation treatment for four weeks. Scores of a rhinosinusitis outcome assessment tool were significantly lower in the amphotericin B group after two weeks compared to the placebo group, but not after four weeks. In addition, there were no significant differences in the endoscopic tests for bacteria or fungi between the groups. Another trial randomised 30 patients to an amphotericin B or placebo nasal spray after a surgery to treat polyps. The patients were assessed with computer tomography, which found a slight but not significant improvement in the antibiotic group compared to the placebo group at a twelve-month follow-up. There were no significant differences between groups in symptom or life quality scores.

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