REVIEW ARTICLE Current Concepts in Topical Therapy for Chronic Sinonasal Disease Richard J. Harvey, MD, Alkis Psaltis, MD, Rodney J. Schlosser, MD, and Ian J. Witterick, MD ABSTRACT Introduction: There has been an explosion in the understanding of the mechanisms of chronic sinonasal inflammation. Multiple approaches to control and modify the inflammatory reaction in chronic rhinosinusitis have led to many new agents being introduced topically to the sinonasal cavities. This article aims to provide an evidence-based approach to the science behind topical management of sinonasal disease. Methods: The literature on delivery device, position, surgical state, and pharmaceutical and mechanical concepts of topical therapy to the paranasal sinuses is reviewed. Results: High-volume irrigation under positive pressure and in head-down positions is important for effective delivery and mechanical action of topical solutions. Unoperated paranasal sinuses appear to receive very limited topical therapy. Enhanced steroid therapy and surfactants appear to be the most promising pharmaceutical approaches. Future novel therapies may include enhancers of the innate immune system. The effect of antibiotic additives is difficult to establish as this might be treating a disease- modifying state rather than the underlying pathology. Conclusions: Topical therapies, applied after surgery, are likely to represent the mainstay of future management for chronic inflammatory rhinosinusitis. SOMMAIRE Introduction: La compre ´ hension des me ´ canismes de l’inflammation nasosinusale chronique a fait des pas de ge ´ ant. De nombreuses recherches visant a ` limiter et a ` modifier la re ´ action inflammatoire dans la rhinosinusite chronique ont mene ´ a ` l’e ´ laboration de nombreux nouveaux agents a ` application topique dans les cavite ´ s nasosinusales. L’article vise a ` pre ´ senter une approche fonde ´ e sur des donne ´ es probantes, a ` la science qui sous-tend le traitement topique des affections nasosinusales. Me ´ thode: Nous avons passe ´ en revue la documentation sur les dispositifs d’administration, la position de la te ˆ te, l’e ´ tat du traitement chirurgical ainsi que les principes pharmaceutiques et me ´ caniques du traitement topique des affections des sinus paranasaux. Re ´ sultats: Une irrigation a ` grand volume, sous pression positive, et la te ˆ te en position de ´ clive sont des facteurs importants d’une administration efficace et de l’action me ´ canique des solutions topiques. Il semble que les sinus paranasaux non ope ´ re ´ s soient tre `s peu soumis au traitement topique. L’ame ´ lioration du traitement par les ste ´ roı ¨des et les agents de surface seraient les deux voies les plus prometteuses de la pharmacothe ´ rapie. Les nouveaux traitements pourraient comprendre des stimulateurs du syste ` me immunitaire naturel. Enfin, l’effet de l’adjonction d’antibiotiques est difficile a `e ´ valuer e ´ tant donne ´ que ces me ´ dicaments pourraient agir sur un e ´ tat modifiant l’e ´ volution de la maladie pluto ˆ t que sur l’affection sous-jacente. Conclusions: Les traitements topiques postope ´ ratoires constitueront probablement, a ` l’avenir, la clef de vou ˆ te de la prise en charge de la rhinosinusite inflammatoire chronique. Key words: antibiotic, biofilm, endoscopic sinus surgery, irrigation, sinusitis, steroid, surfactant, topical Richard J. Harvey: Department of Otolaryngology/Skull Base Surgery, St Vincent’s Hospital, Darlinghurst, Sydney, NSW, Australia, and Department of Otolaryngology–Head and Neck Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia; Alkis Psaltis: Department of Otolaryngology–Head and Neck Surgery, Royal Adelaide Hospital, Adelaide, SA, Australia; Rodney J. Schlosser: Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina; Ian J. Witterick: Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario. Address reprint requests to: Richard J. Harvey, MD, Department of Otolaryngology/Skull Base Surgery, St Vincent’s Hospital, Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia; e-mail: richard@ richardharvey.com.au. DOI 10.2310/7070.2009.090161 # 2010 The Canadian Society of Otolaryngology-Head & Neck Surgery Journal of Otolaryngology-Head & Neck Surgery, Vol 39, No 3 (June), 2010: pp 217–231 217