Is fluticasone (fluticasone) nasal spray contraindicated in a patient status post (s/p) craniotomy 6 days ago?

Fluticasone Nasal Spray After Craniotomy

Fluticasone nasal spray is not contraindicated in patients 6 days after craniotomy, but should be used with caution and proper technique to minimize risk of intracranial complications. 1

Rationale and Considerations

The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS 2020) does not specifically contraindicate intranasal corticosteroids following craniotomy 1. However, several important factors must be considered:

1. Timing after surgery: At 6 days post-craniotomy, the patient is still in the early recovery phase, which requires careful consideration of medication administration techniques.

2. Risk of intracranial infection: Craniotomy creates a temporary disruption of the barrier between the external environment and the intracranial space. Risk factors for post-craniotomy intracranial infection include:

   • Surgical duration ≥4 hours
   • Intraoperative blood loss ≥400 ml
   • Male gender
   • Age ≤45 years 2

3. Administration technique: Proper technique is critical to prevent potential complications:

   • Use gentle pressure when administering the spray
   • Avoid forceful spraying that could theoretically introduce pressure changes
   • Direct spray away from the surgical site

Recommended Approach

1. Technique modification:

   • Use fluticasone nasal spray with gentle pressure
   • Avoid Valsalva maneuvers or forceful blowing of the nose for at least 6 weeks post-craniotomy 1
   • Consider having the patient tilt their head forward slightly during administration to minimize upward pressure

2. Dosing considerations:

   • Start with standard dosing (typically 1-2 sprays per nostril daily)
   • Monitor for any unusual symptoms (headache, clear nasal discharge, fever)

3. Alternative options if concerns remain:

   • Consider saline nasal irrigation with lower pressure as an alternative to manage nasal symptoms 3
   • If using saline irrigation, use isotonic solution with gentle pressure to avoid trauma

Benefits of Fluticasone Use

Fluticasone nasal spray has demonstrated efficacy in:

• Reducing sinus pain and pressure 4
• Managing nasal congestion 4
• Potentially helping manage post-craniotomy headache, which affects approximately 29% of patients by the second post-operative day 5

Safety Profile

• Studies have shown that even higher-dose fluticasone propionate irrigations (3 mg in 240 mL saline twice daily) did not result in systemic absorption concerns 6
• The localized nature of nasal spray administration minimizes systemic effects

Precautions and Monitoring

• Monitor for signs of infection (fever, increased headache, clear nasal discharge)
• Ensure proper technique is used consistently
• Consider antibiotic prophylaxis if there are signs of infection, as studies show reduced infection rates with prophylactic antibiotics after craniotomy 7

Conclusion

While fluticasone nasal spray is not specifically contraindicated after craniotomy, proper administration technique is essential to minimize any theoretical risk. The benefits of managing nasal symptoms likely outweigh potential risks when used correctly at the 6-day post-operative mark.