The Efficacy of MEDIHONEY® for Chronic Rhinosinusitis With Nasal Polyposis After Functional Endoscopic Sinus Surgery

In patients with refractory CRSwNP, functional endoscopic sinus surgery (FESS), is intended to restore physiologic sinus ventilation and drainage, which can facilitate the gradual resolution of mucosal disease. However, because FESS does not directly treat the underlying inflammatory disorder, a successful sinus surgery must be followed by medical maintenance therapy to control inflammatory processes.

The current mainstay of treatment of CRSwNP includes antibiotics and topical and systemic steroids. There is evidence that administration of systemic steroids in the postoperative period for patients who have polyps may have a significant impact on their postoperative course. However, the chance of significant side effects increases with the dose and duration of treatment and therefore the minimum dose necessary to control the disease should be given. Antibiotics also have their limited but documented side effects and can induce resistance.

A semi-natural product like manuka honey (brand name MEDIHONEY®), with antibacterial and anti-inflammatory properties, might prove as a useful alternative since it has no major adverse events documented in the literature, does not induce resistance and is effective against resistant pathogens common in this patient population.

This study is a prospective, randomized, pilot clinical trial that will determine if the use of MEDIHONEY® sinus rinses (alone or in combination with intranasal steroids) in the postoperative period enhances recovery and prevents polyp recurrence in patients after functional endoscopic sinus surgery (FESS), compared with the standard regimen of topical corticosteroid sinus rinses. The study will collect and compare subjective and objective efficacy assessments of both types of rinses.

• MEDIHONEY® (Device): MEDIHONEY® is a seminatural product with antibacterial and anti-inflammatory properties
• Budesonide (Drug): Topical steroid
• Normal saline sinus rinse (Drug): 8 oz or 4 oz of normal saline with NeilMed sinus rinse bottle
• Prednisone (Drug): Post-operatively, 40 mg daily for 7 days
• Endoscopic sinus surgery (Procedure): Endoscopic sinus surgery to debride polyps and establish adequate sinus drainage
• nasal saline spray (Drug): saline nasal mist every hour while awake

Primary outcomes

• Change in Lund-Kennedy Endoscopic Scores [119 days]: Characteristics of each sinonasal cavity are assessed endoscopically to provide a score based on polyp disease, mucosal edema/crusting/scarring and nasal secretions. A score is provided for the left and right. The scores are totaled to provide a number between 0 and 20. Polyps: 0 = absence of polyp; 1 = polyps in middle meatus only; 2 = polyps beyond middle meatus Edema: 0 = absent; 1 = mild; 2 = severe Discharge: 0 = no discharge; 1 = clear, thin discharge; 2 = thick, purulent discharge Scarring: 0 = absent; 1 = mild; 2 = severe Crusting: 0 = absent; 1 = mild; 2 = severe This scoring system has since been the instrument of choice to endoscopically evaluate outcomes of interventions in non-neoplastic sinonasal disease prospectively over time in research and clinical practice. The higher the score, the worse the outcome. Endoscopy scores from the 3 study groups are compared for the average unit change between baseline and day 119.

Secondary outcomes

• Nasal Drainage Cultures [35 days]: Nasal drainage cultures from the 3 study groups will be compared for the average percent change between a patient's positive intraoperative cultures compared to the patient's cultures at day 35.
• Change in Sinonasal Outcome Test (SNOT-22) Questionnaire Score [119 days]: The SNOT-22 consists of 22 questions; items 1 to 12 represent the physical problems associated with rhinosinusitis, items 13 to 18 represent the functional limitations, and items 20 to 22 represent the emotional consequences. Each question is scored by the patient from 0 (no problem) to 5 (the problem is as bad as it can be). The overall score can theoretically range from 0 to 110, with higher scores reflecting more severe quality of life impairment as subjectively reported by the patient. Overall SNOT-22 scores from the 3 study groups are compared for the average change in score from baseline to day 119.
• Change in SNOT-22 Nasal Symptom Scores [119 days]: The SNOT-22 consists of 22 questions; items 1 to 12 represent the physical problems associated with rhinosinusitis, items 13 to 18 represent the functional limitations, and items 20 to 22 represent the emotional consequences. Each question is scored by the patient from 0 (no problem) to 5 (the problem is as bad as it can be). The first seven questions relate to nasal symptoms. The nasal symptoms score is calculated by summing the scores for these first seven questions. The range is 0 to 35. Higher scores reflect more severe quality of life impairment as subjectively reported by the patient. The nasal symptom scores from the 3 study groups are compared for the average change in score from baseline to day 119.

Sex: All, ages: 18 Years to any

Inclusion Criteria:

1\. Age 18 years or older;

2\. Diagnosis of CRSwNP based on the following criteria:

* Pattern of symptoms:

  i. Symptoms present for ≥12 wk
* Symptoms for diagnosis: Requires ≥2 of the following symptoms:

  i. Anterior and/or posterior mucopurulent drainage; ii. Nasal obstruction; iii. Facial pain/pressure/fullness;
* Objective documentation: Requires both:

  1. Endoscopy to verify the presence of polyps in middle meatus and document presence of inflammation, such as discolored mucus or edema of middle meatus or ethmoid area; and
  2. Evidence of rhinosinusitis on imaging by CT (1 obvious polypoid tissue or sinus opacification and/or at least 2mm of mucosal thickening).
* Failed medical management (i.e. refractory CRSwNP) and eligible for FESS.

Exclusion Criteria:

1. Contraindications to oral prednisone or known hypersensitivity to any study medications;
2. Churg Strauss disorder;
3. abnormalities of mucociliary clearance (cystic fibrosis, primary ciliary dyskinesia and Young's syndrome);
4. Diagnosed immunodeficiency;
5. Aspirin-induced asthma (ASA) (aka Samter triad) (a triad of asthma, aspirin and NSAID sensitivity, and nasal/ethmoidal polyposis).

Participant flow

Outcome results

• Change in Lund-Kennedy Endoscopic Scores (Primary), Mean, score on a scale: Budesonide Rinse Group -8.0 +/- 3.1; MEDIHONEY® Rinse Alone Group -1.5 +/- 4.6; MEDIHONEY® and Budesonide Rinse Group -6.9 +/- 3.9
• Nasal Drainage Cultures (Secondary)
• Change in Sinonasal Outcome Test (SNOT-22) Questionnaire Score (Secondary), Mean, score on a scale: Budesonide Rinse Group -22.8 +/- 20.2; MEDIHONEY® Rinse Alone Group -15.3 +/- 27.4; MEDIHONEY® and Budesonide Rinse Group -25.6 +/- 16.9
• Change in SNOT-22 Nasal Symptom Scores (Secondary), Mean, score on a scale: Budesonide Rinse Group -10.0 +/- 7.0; MEDIHONEY® Rinse Alone Group -5.3 +/- 15.5; MEDIHONEY® and Budesonide Rinse Group -11.7 +/- 7.9

Adverse events

Time frame: Adverse event data was recorded in the form of a modified version of the Common Toxicity Criteria for Adverse Events (CTCAE). This was done at each visit from baseline (pre-surgery) to the 6th visit on day 182.

Other adverse events by term

Limitations and caveats: Limitations of this study include: non-blinded study, high drop-out rate in one study arm, and lack of quantitative data for sinus cultures.

• Study Protocol (PDF, 2016-07-06)
• Statistical Analysis Plan (PDF, 2018-11-19)

• Gary P Landrigan, MD, Principal investigator, University of Vermont Medical Center