Challenges in topical therapy of chronic rhinosinusitis: The case of nasal drops application - A systematic review

Objective: Chronic rhinosinusitis (CRS) is a common health issue associated with a significant life quality impairment. Intranasal glucocorticoid is the treatment of choice both as initial therapy as well as after surgery. In contrast to nasal spray, liquid glucocorticoids in form of nasal drops have the advantage of reaching the middle and upper meatus. The efficiency of the glucocorticoid nasal drops is nevertheless strictly dependent on the head position they are being applied in. Several head positions have been described in the literature but no clear recommendation towards the best suited position exist to date. Methods: A systematic review was completed using the PubMed database. Journal articles assessing the effect of head position on intranasal drop fluid distribution, clinical effectiveness, or factors affecting patient compliance were included. Results: In total 15 publications meeting the inclusion criteria have been found, out of which 9 cover the effect of head position as a primary outcome using quantitative measures. Conclusions: The positions Lying Head Back, Lateral Head Low, and variations of those can be recommended equally at the moment. Evidence speaks against the use of the classic Head Back position because of poor clinical outcome, and against the position Head Down and Forward as initial therapeutic approach because of high discomfort. For the olfactory cleft, a new head position has been described (Kaiteki), although no comparisons to other positions exist to date. (C) 2020 Oto-Rhino-Laryngological Society of Japan Inc. Published by Elsevier B.V. All rights reserved.