ENT Surgeon at Ohio ENT & Allergy, Adam Spiess, MD talks about a new treatment for chronic sinusitis.
Interview conducted by Ivanhoe Broadcast News in 2022.
What is schronic sinusitis?
SPIESS: Sure. Chronic sinusitis is a period of three months where you are suffering from symptoms from inflammation and edema of the nasal cavity. I always say think of the nasal cavity like an office. There is a hallway divided into right and left hand sides by a wall called the nasal septum. On the side are structures called turbinates, which are like little hot dogs. And there are three on each side, inferiors, middles, and superiors. Next to the middle ones are doors that go into big rooms called the paranasal sinuses, and there’s eight sinuses. There are frontal which are above the eyes, ethmoids are between the eyes, maxillaries are below the eyes and above the teeth, and there are sphenoids between your ears. Rooms make a bunch of mucus and it drains out the doors into the hallway. When people get sinus trouble, so they get inflammation of the hallway and it blocks off the doors and causes these type of symptoms. So the treatment options are typically decongestants, nasal steroids, antihistamines if you truly have allergies, occasionally antibiotics for chronic infections, but mainly it’s more of an inflammatory problem and not necessarily an infectious problem.
For most people, is that enough? Will that solve the problem? Will that make them more comfortable?
SPIESS: Everyone’s a little bit different as far as their symptoms go. Everyone’s anatomy is little bit different as well. Some people do have anatomical obstructions as well. Typically nasociliar irrigations can help. But if that’s really bad, then we’ll arrange to get a CAT scan, look at the anatomy, and pursue a little bit further. But we try to maximize the medical therapy as best we can.
Polyps. Is that a problem that is caused by consistent sinusitis?
SPIESS: So polyps are basically a benign growth in the nasal cavity created by inflammation or edema. So chronic sinusitis can contribute to that, as well as bad allergies, those kind of things just cause additional swelling that will block off those doors. Sometimes gets so big they block off the breathing apparatus of the nose and can cause loss of smell and also taste because you can get airflow up to the high part of your nose called the olfactory cleft.
And polyps, if you have those, are they for the patient’s symptom less, do you sometimes have them in half?
SPIESS: You for sure don’t know that they’re there sometimes. People can have severe nasal congestion and you can see them on the nose but that’s pretty unusual. So typically you don’t know they’re there until you typically look in their nose with a camera or an endoscope or get a CAT scan that shows everything being blocked off or they lose their sense of smell which you can assume they may have some polyps on their nose because there’s some blockage in there as well.
You talked about medication that can certainly help. And along those lines, if you can describe for me the XHANCE, the delivery system. What’s new about it? How does it work?
SPIESS: So XHANCE uses an exhalation delivery apparatus and it is different because it delivers medications higher up in the nose. So what I typically say is a typical nasal spray like Nasacort or Flonase, Rhinocort, it’s like shooting a water pistol. You blow it in your nose and it goes straight back and down the back of your throat. It doesn’t go high up into your nose where that blockage is at. What XHANCE does, you blow into it and push down. And I always say it’s like blowing on flower. You blow on flower. It goes a big poof ball and delivers the medication higher up into the nose. So if we go back to the analogy as far as where those doors are at, the doors are higher up in the nose and not along the floor. So a sinus surgery changed about 25 years ago where the old days they used to make holes in the bottom part of the sinuses where the drainage pathway was, we thought it was going to drain like a typical collection of water, like a drain. But actually found out that the drainage is higher up in the nose and that’s where we do sinus surgery now. So the huge revolution with XHANCE is you’re actually getting the medications where we do surgery. So that’s why it works so much better than a typical sprays for these kind of problems.
How often would a patient have to have XHANCE deliver the medication? Isn’t a one and done, is it over a period of time? And how long before it starts to work and they notice a difference?
SPIESS: Everyone’s a little bit different. Again, everyone’s nature of the polyps is different. In general, I always say nasal polyps can be a long-term problem because it’s called the underlying factors like allergies. So sometimes when you get them under control, you keep a managed with the XHANCE. So we vary the dose sometimes where they’re really having troubles. We do two sprays twice a day. Then when they become more under control, we can go down to even one spray twice a day or one spray day. So we titrate that dose and it comes and goes. So not everyone is exactly the same. Sometimes with really bad polyps, we’ll add a course of oral steroids as well if that doesn’t cover and sometimes surgery is still warranted for really bad patients with polyps.
Does this replace surgery for some patients? Will this be effective enough where they can avoid surgery?
SPIESS: The answer is, I’ve had a lot of patients that have not had to have surgery, which typically we would have to have surgery in the past. And so for a portion of my patients, definitely can avoid surgery if they have a good response from it.
This is FDA approved for a certain indication, isn’t it? Can you tell me about that?
SPIESS: Correct.
Is there a clinical trial for other indications?
SPIESS: So currently it’s FDA approved for nasal polyposis. There also is a trial going on to having an approval for chronic sinusitis as well. There is no current treatment available for the treatment of chronic sinusitis, so this would be a unique medication for that problem.
So is there nothing right now?
SPIESS: There’s nothing currently. There’s no approved medication for chronic sinusitis.
So what do you do again?
SPIESS: So right now we do is symptomatic care. So we’ll do nasal saline, nasal steroids if they have allergies and antihistamines or Singulair. Sometimes steroids, sometimes antibiotics. But in general, there’s no definite treatment plan that’s approved for that problem.
Does the anatomy, just the fact that you’re breathing in and out, what kind of impact does that have on the medication? Is that helping move it through the system?
SPIESS: It can cause if you’re right, that delivery really depends on how much room there is inside the nose. So the more room you get, the better delivery it’s going to happen. And to your point, we still need to do surgery on these patients. And what I have found out that patients who have had prior surgery and then use XHANCE, they have a very, very good response to the XHANCE even more so because you’re right, the opening passage way is even more open so you can deliver medications further and higher up into the nose. So it has an additive effect on top of surgery as well.
Is this something that has to be done in a doctor’s office? It’s not something that patients can do at home?
SPIESS: Correct. Currently has to be written by a physician.
Does the physician have to do the application?
SPIESS: No. No. This isn’t due to home. Yeah. Just like using an over-the-counter nasal spray like phone intranasal core. It’s just a different delivery mechanism, so we just have to do a little bit different.
Can you talk to me a little bit about Cato?
Adam Spiess: Cato came to me because it’s referred by an allergist who is having troubles, allergies. He had really severe nasal congestion. He came to me and said, I can’t sleep at night because I can’t breathe through my nose. It really disrupting my life. He also said I can’t smell at all and this has been going on for a prolonged period of time. So he had already been through aggressive medical therapy with a very, very good allergist and came to me for further treatment options. So I had seen him in the office, noticed he had extensive nasal polyps, I put him on some XHANCE, got a CAT scan, and he had a really extensive nasal polyps as well as chronic sinusitis. So he did end up going through some sinus surgery to get some of the polyps out. And he’d been also managed with the XHANCE, but he has done exceedingly well. He has had no further nasal congestion, his sense of smell and taste has been resolved. He’s done great. His quality of life has improved dramatically.
Is it covered by insurance?
SPIESS: It is covered by insurance, not all insurances as far as we have to go through that process like other medications to get their approvals. Right now, we’re working with some specialty pharmacies to help with the carbomer and helping with their patients. Optinose has been very good as far as programs for my patients over the last several years. And in general, it’s been very, very well covered in those situations. But again, not by all. And it changes obviously day-by-day.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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