***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The delivery of nasal drugs specifically to the middle meatus is of critical importance in the medical treatment of rhinosinusitis . In this respect , topical nasal drug administration by drops has generally been perceived to be superior to nasal sprays , although there is a lack of evidence to support this notion . This study aims to compare the intranasal delivery of nasal sprays and drops to the middle meatus in vivo , using a novel quantitative method . A surgical patty was placed in the middle meatus . Radio-labelled topical nasal drops and aqueous sprays were administered in a st and ardized fashion in normal volunteers ( 10 nasal cavities ) . The subsequent absorption of administered radio-labelled saline on the patty was measured using a gamma counter . A r and omized prospect i ve crossover design was used for the study . The mean percentage ( range ) of absorbed administered saline on the swab was 8.7 ( 0.3 - 39.5 ) and 9.7 ( 0.03 - 20.4 ) for the spray and drop administration techniques respectively ( p = 0.8 ) . Thus , there is wide variation in the delivery of topical nasal drugs and the perceived superiority of nasal drop administration , in terms of delivery to the middle meatus , may be incorrect OBJECTIVE To compare intranasal distribution of saline solution delivered by three popular methods for nasal saline irrigation . STUDY DESIGN Prospect i ve , controlled comparison . METHODS Eight healthy adult volunteers received nasal irrigation with 40 mL of isotonic , nonionic contrast material immediately before having coronal computed tomography to visualize distribution of solution in the paranasal sinuses . For each study subject , three methods of irrigation were used : irrigation using positive-pressure irrigation , irrigation using negative-pressure irrigation , and irrigation using a nebulizer . For each subject , three-dimensional computer reconstructions of the irrigated paranasal sinus airspaces were used to compare contrast solution volume and distribution achieved by the three methods . RESULTS Of the three methods used , two methods , positive-pressure and negative-pressure irrigation , distributed contrast solution widely to ethmoid and maxillary sinuses , but distribution of contrast solution was more uniform using positive-pressure irrigation than using negative-pressure irrigation . The nebulization method distributed contrast solution poorly and result ed in a significantly lower volume of retained contrast solution ( P < .05 ) . CONCLUSION Judged solely on the basis of solution distribution in the nasal sinuses , nasal irrigation is effective when either positive-pressure or negative-pressure irrigation is used but is ineffective when a nebulizer is used The distribution of nasal drugs specifically to the middle meatus is of vital importance in the treatment of rhinosinusitis and nasal polyposis . It is widely assumed that the intranasal distribution is superior with nasal drops rather than spray delivery . However , a comparison of nasal spray and drop delivery specifically to this area has not been studied before . This study aims to compare semiquantitatively the intranasal distribution of nasal sprays and drops to the middle meatus in vivo . A novel method was used whereby a neurosurgical patty was placed in the middle meatus .  Topical nasal drops and aqueous sprays dyed with methylene blue ( 0.1 % v/v ) were administered in a st and ardized fashion in normal volunteers . The subsequent absorption of administered dye was classified on a four-point scale . A r and omized prospect i ve cross-over design was used for the study . We found that there was no difference in the delivery of nasal drug to the middle meatus between either method of drug administration ( P > 0.2 ) . The perceived superiority of nasal drops may therefore be as a result of the acknowledged systemic effect of betamethasone drops OBJECTIVES To compare the distribution patterns of topical medication delivery systems in the sinonasal region and upper respiratory tract after functional endoscopic sinus surgery . STUDY DESIGN Prospect i ve descriptive evaluation . METHODS Four topical delivery systems ( spray bottle , atomizer , nebulizer , and bulb syringe ) were studied . Using a dye solution as a marker , we independently applied the four topical delivery systems to a population of patients with chronic rhinosinusitis who had undergone functional endoscopic sinus surgery . The anatomic distributions were videotaped using flexible fiberoptic endoscopy . Three blinded observers independently rated the anatomic distribution of dye using a 4 point scale . Statistical analysis was performed using analysis of variance ( ANOVA ) and Dunn posttesting . RESULTS Seven participants completed the study . All participants had undergone bilateral maxillary antrostomies , bilateral total ethmoidectomies , and bilateral sphenoidotomies . Five sinonasal sites and the larynx were evaluated for dye deposition . Interobserver agreement reached 95.6 % . There was no statistical difference between the atomizer and spray bottle . The bulb syringe was statistically superior to the nebulizer in all sinonasal sites and statistically superior to the atomizer and spray bottle in the ethmoidal region . Dye was rarely seen within the larynx . CONCLUSIONS The delivery systems tested were shown to have significant differences in their capability to place dye in specific sinonasal areas . Because topical medications are commonly administered to postoperative patients , these differences may have important clinical implication OBJECTIVE To assess the effectiveness of three methods of nasal irrigation on distributing saline to the nasal cavity and paranasal sinuses . DESIGN : A prospect i ve , cross-over study . MATERIAL S AND METHODS Twelve subjects ( 9 patients with chronic sinusitis after functional endoscopic sinus surgery and 3 healthy controls ) underwent nasal irrigation with normal saline containing Technetium 99 m sulfur colloid . The distribution of radioactivity was assessed on each subject after three different irrigation techniques : metered nasal spray , nebulization with RinoFlow , and nasal douching while kneeling with the head on the floor . RESULTS The nasal cavity was well irrigated by all three techniques . Compared with the other two methods , douching was significantly more effective in penetrating the maxillary sinus ( P = .036 ) and frontal recess ( P = .003 ) . The sphenoid and frontal sinuses were poorly irrigated by all three techniques . CONCLUSION Nasal douches are more effective in distributing irrigation solution to the maxillary sinus and frontal recess . This should be the method of choice for irrigating these areas Topical corticosteroids are one of the main pillars in the treatment of nasal polyps . The exact topography of their intranasal deposition has not yet been adequately visualised . The intranasal distribution of a 1 % sodium fluorescein solution applied with original Pulmicort Topinasal ( budesonide ) metered pump bottles was analysed by videoendoscopy . The study group included eight healthy subjects and ten patients who had undergone endonasal sinus surgery . Videoendoscopy was performed in the study group within the first minute after application of the fluorescein solution . Additionally the deposition pattern of Pulmicort Topinasal was analyzed using a nasal model . The examination showed that the majority of the substance is deposited on the anterior portion of the nasal septum and the head of the inferior turbinate . Only a small fraction actually reaches the middle meatus . The distribution is improved by application during the decongested phase of the nasal cycle , after use of vasoconstricting nasal drops and maintaining a spraying angle of 45 degrees upwards . The development of new delivery techniques and systems could improve the efficacy of intranasally administered corticosteroids and reduce the complication rate Background Nasal douching is common practice in treatment of chronic sinusitis and after endoscopic sinus surgery . Current nasal delivery techniques show inconsistent sinus penetration . The aim of this study was to compare sinonasal penetration of nasal douching to an optimized nasal nebulizer in an operated cadaver model . Methods Fourteen preserved cadavers were used receiving complete sphenoethmoidectomies with a Draf III , wide maxillary antrostomy , or medial maxillectomy . Seven control cadavers received nasal douching with one st and ardized squeeze bilaterally of a 200-mL nasal irrigation bottle and seven intervention cadavers were nebulized with 3 minutes of the PARI sinus device bilaterally . Douching solutions were stained with methylene blue . Independent observers documented sinonasal anatomy , staining intensity , and percentage area covered by dye using st and ardized grading protocol s. Results Combined data showed a significant increase in intensity of stain ( 2.06 versus 0.26 , p < 0.001 ) , percentage of stain ( 49.96 % versus 4.19 % , p < 0.001 ) , and circumference stained ( 76.59 % versus 12.7 % , p < 0.001 ) with the plastic nasal irrigation squeeze bottle versus PARI device . Analysis of individual sinuses consistently showed significant increases in indices of nasal douching relative to nebulization . The PARI sinus nebulizer was noted to reach the ethmoids regularly ( 92 % incidence ) , whereas the other sinuses were not reached as regularly with incidences noted at frontal ( 43 % ) , maxillary ( 46 % ) , and sphenoid ( 54 % ) . This compares to 96 % of all sinuses being stained by the squeeze bottle . Conclusion In all measured indices , the nasal douching method with the squeeze bottle was superior to the PARI sinus nebulizer in highly dissected sinonasal cadaver models OBJECTIVE /HYPOTHESIS Endoscopic sinus surgery is an accepted treatment for medically recalcitrant chronic rhinosinusitis . Effective saline douching may improve long-term outcomes of chronic rhinosinusitis but is often impaired by postoperative ostial stenosis . The aim of this study is to determine a critical ostial size at which douching solution reliably enters the sinus cavities . STUDY DESIGN Prospect i ve study of consecutive patient cohort . METHODS Seventeen preoperative or well-healed postoperative endoscopic sinus surgery patients were irrigated with 5 mL blue food coloring mixed with 200 mL buffered saline from a squeeze bottle . The degree of sinus penetration , sinus ostial patency , and ostial size were endoscopically determined . RESULTS Sinuses penetrated by blue dye had a significantly larger minimal ostial dimension ( 7.31 mm ; 95 % confidence interval 5.54 - 9.08 ) than those that had no blue dye penetration ( 1.26 mm ; 95 % confidence interval 0.86 - 1.66 ) as determined by Student t test . Chi-square analysis showed that operated sinuses were more likely to be penetrated than nonoperated sinuses ( P = .0016 ) and obstructed sinuses ( P = .0325 ) . Logistic regression showed a 95 % probability of penetration when the minimum ostial dimension is 3.95 mm or greater . CONCLUSIONS Unoperated sinuses or cases with gross sinus ostial obstruction will not be reliably penetrated by sinus irrigant . A 3.95-mm ostial diameter seems to be the minimum size to guarantee penetration in paranasal sinuses to maximize the potential for topical sinus treatment BACKGROUND Delivery of powder formulations to the nose is an attractive alternative for many drugs and vaccines . This study compared the regional nasal deposition and clearance patterns of lactose powder delivered by the OptiNose powder device ( Opt-Powder ; OptiNose US Inc. , Yardley , PA , USA ) to that of liquid aerosol administered via a traditional h and -actuated liquid spray pump ( Rexam SP270 , Rexam Pharma , France ) . METHODS The study was an open-label , crossover design in seven healthy subjects ( five females , two males ) . The regional nasal deposition and clearance patterns of the Opt-Powder device were compared to a traditional liquid spray pump by dynamic gamma camera imaging after administration of either (99m)Tc-labeled lactose powder or liquid (99m)Tc- diethelyne triamine pentaacetic acid-aerosol . The gamma camera images were scaled and aligned with sagittal magnetic resonance images to identify nasal regions . Possible deposition of radiolabeled material in the lungs following both methods of delivery was also evaluated . RESULTS Both powder and spray were distributed to all of the nasal regions . The Opt-Powder device , however , achieved significantly larger initial deposition in the upper and middle posterior regions of the nose than spray ( upper posterior region ; Opt-Powder 18.3 % ± 11.5 vs. Spray 2.4 % ± 1.8 , p<0.02 ; sum of upper and middle posterior regions ; Opt-Powder 53.5 % ± 18.5 vs. Spray 15.7 % ± 13.8 , p<0.02 ) . The summed initial deposition to the lower anterior and posterior regions for spray was three times higher compared to Opt-Powder ( Opt-Powder 17.4 % ± 24.5 vs. Spray 59.4 % ± 18.2 , p<0.04 ) . OptiNose powder delivery result ed in more rapid overall nasal clearance . No lung deposition was observed . CONCLUSIONS The initial deposition following powder delivery was significantly larger in the ciliated mucosa of the upper and posterior nasal regions , whereas less was deposited in the lower regions . Overall nasal clearance of powder was slower initially , but due to retention in anterior nonciliated regions the overall nasal clearance after spray was slower The distribution of topical nasal sprays is suboptimal , the main obstruction to adequate delivery in normal 
    Output:
    
RESULTS Recommendations were made for : improved sinus delivery with high-volume devices and after st and ard sinus surgery .
Recommendations were made against low-volume delivery devices , such as drops , sprays , or simple nebulizers  as they do not reliably reach the sinuses .
If large-volume devices are not tolerated , low-volume devices are recommended using the lying head back or lateral head low positions to improve nasal cavity distribution to the middle meatus or olfactory cleft .
CONCLUSION Surgery , volume of device , head position , and nasal anatomy were shown to impact distribution to the sinuses .