What treatment is recommended for an 80-year-old patient with a mucus retention cyst and chronic rhinitis symptoms already on fluticasone (fluticasone) twice daily?

Treatment for 80-Year-Old with Mucus Retention Cyst and Chronic Rhinitis Symptoms on Fluticasone

For an 80-year-old patient with a mucus retention cyst and chronic rhinitis symptoms already on fluticasone twice daily, switching to a fluticasone nasal irrigation delivery method (400μg twice daily) is recommended to improve medication distribution to the affected areas. 1

Rationale for Treatment Modification

The current treatment with standard fluticasone spray is likely providing inadequate distribution to the affected sinus areas, particularly given:

• Presence of a mucus retention cyst suggests more significant disease
• Age-related changes in nasal anatomy may affect drug delivery
• Standard nasal sprays have limited penetration to sinus cavities

Recommended Treatment Algorithm

1. Primary Intervention: Change Delivery Method

   • Switch from standard fluticasone nasal spray to fluticasone nasal irrigation (400μg twice daily)
   • Irrigation provides better distribution to the sinus mucosa, especially around cysts and polyps 1
   • Evidence shows significantly greater improvement in nasal blockage, drainage, and endoscopy scores with irrigation compared to spray delivery 2

2. Adjunctive Treatments

   • Add isotonic saline irrigation once or twice daily (can be combined with the corticosteroid irrigation)
   • This improves mechanical clearance of mucus and inflammatory products 1
   • Consider a short 14-day course of oral prednisolone (starting at 25-30mg daily with tapering dose) if symptoms are severe 1

3. Dosing Considerations

   • The FDA-approved dosage for fluticasone is 200mcg daily (two 50-mcg sprays in each nostril once daily) 3
   • For elderly patients with significant symptoms, higher doses via irrigation may be more effective 2, 1
   • Once adequate control is achieved, consider reducing to maintenance therapy of 100mcg daily 3

Monitoring and Follow-up

• Evaluate response after 4-6 weeks of modified therapy
• Monitor for potential side effects:
  • Local irritation and epistaxis (occurs in approximately 11% of patients) 1
  • Systemic absorption is minimal with recommended doses but requires monitoring in elderly patients
  • Long-term use of intranasal corticosteroids at recommended doses has not shown significant impact on bone mineral density 2

Important Considerations and Pitfalls

• Avoid long-term use of decongestants - They provide only symptomatic relief and can cause rebound congestion with prolonged use 2
• Ensure proper irrigation technique - Improper technique may limit effectiveness
• Consider referral to an allergist/immunologist or ENT specialist if:
  • Symptoms persist despite 8-12 weeks of optimized medical therapy
  • The cyst enlarges or causes significant obstruction
  • There are complications such as recurrent sinusitis or significant quality of life impairment 2

This treatment approach prioritizes improved medication delivery to maximize symptom control and quality of life while minimizing potential adverse effects in an elderly patient.