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. 2024 Mar;14(3):660-667.
doi: 10.1002/alr.23248. Epub 2023 Aug 17.

Accessing the Eustachian tube: Conventional nasal spray vs. exhalation delivery system and the impact of targeted endoscopic sinus surgery on topical distribution patterns

Lucas G Axiotakis Jr  1 , Daniel B Spielman  1   2 , David A Gudis  1 , Nathan Yang  1 , Carol H Yan  3 , Zachary M Soler  4 , Joshua M Levy  2 , Nicholas R Rowan  5 , Alexandria L Irace  6 , Brandon J Vilarello  1 , Patricia T Jacobson  1 , Jonathan B Overdevest  1
Affiliations

Accessing the Eustachian tube: Conventional nasal spray vs. exhalation delivery system and the impact of targeted endoscopic sinus surgery on topical distribution patterns

Lucas G Axiotakis Jr et al. Int Forum Allergy Rhinol. 2024 Mar.

Abstract

Background: Eustachian tube dysfunction (ETD) may occur distinct from, or in conjunction with, chronic rhinosinusitis (CRS+ETD). Intranasal corticosteroid sprays are often prescribed for ETD, although ET distribution may be limited. To date, no anatomic studies compare nasopharynx (NP) distribution between conventional nasal sprays (NS) and exhalation delivery systems (EDS) after surgery. This study utilizes a cadaver model to examine topical NP delivery using EDS vs. NS before and after targeted endoscopic sinus surgery (ESS).

Methods: Sixteen sinonasal cavities were administered fluorescein solution via NS and EDS before and after maxillary antrostomy and anterior ethmoidectomy, followed by nasal endoscopy of the NP and ET orifice. Seven blinded experts submitted staining ratings of endoscopy images on a 0- to 3-point scale, with ratings averaged for analysis.

Results: Interrater reliability was excellent (intraclass correlation, 0.956). EDS was associated with significantly greater NP staining vs. NS in a pooled cohort of nonsurgical and ESS specimens (1.19 ± 0.81 vs. 0.78 ± 1.06; p = 0.043). Using a logistic regression model, EDS significantly outperformed NS in nonsurgical (odds ratio [OR], 3.49; 95% confidence interval [CI], 1.21-10.09; p = 0.021) and post-ESS (OR, 9.00; 95% CI, 1.95-41.5; p = 0.005) specimens, with the greatest relative staining observed for EDS after targeted ESS (OR, 18.99; 95% CI, 3.44-104.85; p = 0.001).

Conclusions: EDS is more effective than NS in topical delivery to the NP and ET orifices in cadavers. Targeted ESS may facilitate greater NP penetration by EDS compared with NS, with possible synergism after ESS for augmented delivery. These findings suggest a role for EDS delivery methods for ETD management and in CRS+ETD patients undergoing sinus surgery.

Keywords: eustachian tube; nasal sprays; paranasal sinus diseases.

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Conflict of interest statement

CONFLICT OF INTEREST STATEMENT

Study design, collection of data, and interpretation of findings were independently completed by the study authors. The authors have no financial conflicts of interest to disclose.

Figures

FIGURE 1
FIGURE 1
Endoscopic view of nasopharynx with representative range staining using nasal spray and the exhalation delivery system. Gradient corresponds to degree of staining.
FIGURE 2
FIGURE 2
Average nasopharynx staining ratings for individual cadaver sides by delivery method and surgical group. Each point represents an individual cadaver side. (A) Average nasal spray and exhalation delivery system nasopharynx staining across paired individual cadaver sides, after pooling of surgical groups. (B) Average nonsurgical and targeted endoscopic sinus surgery nasopharynx staining across paired individual cadaver sides, after pooling of delivery methods. Green boxes represent significant staining (>0.5 on average), whereas red boxes represent minimal staining. Horizontal solid and dashed lines reflect mean and median, respectively. The p values for statistical comparisons between pooled groups are included in each panel (Wilcoxon matched-pairs signed-rank test). Abbreviations: EDS, exhalation delivery system; ESS, endoscopic sinus surgery; NS, nasal spray.
See this image and copyright information in PMC

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