Drug eluting stents in ent short note
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drug eluting stent sinusitis ENT
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PMID: 38459984
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PMID: 39529438
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PMID: 32845808
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drug eluting stent ENT sinus surgery Propel mometasone clinical review 2024
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Drug-Eluting Stents in ENT
Definition
Drug-eluting stents (DES) in ENT are bioabsorbable implants placed in the sinonasal cavity - most often in the ethmoid sinuses after functional endoscopic sinus surgery (FESS) - that provide mechanical support (stenting) while simultaneously releasing a pharmacological agent (usually mometasone furoate) locally over a defined period.
Background and Rationale
Chronic rhinosinusitis (CRS) is the primary indication. FESS alone is not a definitive treatment - polyp regrowth, scarring, adhesion formation, and middle turbinate lateralization remain major causes of surgical failure. Systemic steroids and nasal sprays have limited local bioavailability. DES addresses this by delivering high concentrations of anti-inflammatory drug directly to the surgical site while maintaining sinus patency mechanically.
Available Devices
| Device | Drug | Duration of Elution | Placement |
|---|---|---|---|
| Propel (Intersect ENT) | Mometasone furoate 370 mcg | ~30 days | Ethmoid sinus (post-ESS) |
| Propel Mini | Mometasone furoate 160 mcg | ~30 days | Frontal/sphenoethmoidal recess |
| Propel Contour | Mometasone furoate | ~30 days | Frontal sinus ostium |
| SINUVA | Mometasone furoate 1350 mcg | ~90 days | Ethmoid sinus (in-office, for recurrent polyps - avoids repeat surgery) |
All are bioabsorbable - they dissolve over weeks and do not need retrieval.
Mechanism of Action
- Mechanical: The expanded stent scaffold holds the ethmoid sinus walls apart, preventing adhesion and middle turbinate lateralization during the critical postoperative healing phase.
- Pharmacological: Mometasone furoate (a high-potency topical corticosteroid) elutes at the mucosal surface, reducing:
- Local eosinophilic inflammation
- Type 2 cytokine levels (IL-4, IL-5, IL-13, periostin)
- Polyp regrowth
- Mucosal edema and granulation tissue
Indications
- Post-FESS placement in CRS with nasal polyps (CRSwNP) - primary indication
- CRS without polyps with a high risk of adhesion
- SINUVA specifically: in-office treatment for recurrent nasal polyps in adults who have previously had ESS, to avoid revision surgery
- Olfactory dysfunction associated with CRSwNP (emerging indication - Zhang et al., 2025, PMID 39529438 showed significant improvement in olfactory VAS and T&T olfactometer scores)
Clinical Evidence
RCT data (Huang et al., 2022 - PMID 32845808): In 181 CRS patients undergoing ESS (intra-patient comparison, stent vs. Nasopore pack on contralateral side):
- Significantly reduced need for postoperative surgical intervention at day 30 (p < 0.0001)
- Significantly lower polyp formation at days 14, 30, and 90 (p < 0.0001)
- Fewer severe adhesions at day 90 (p = 0.0003)
- No device-related adverse events
Systematic review (Calvo-Henriquez et al., 2024 - PMID 38459984): Analyzed 29 studies, 3,012 patients treated with steroid-eluting bioabsorbable implants (SEBIs):
- Evidence supports post-ESS symptom control, improved healing, reduced polyp regrowth, and benefit as an in-office procedure to reduce need for revision ESS
- Data on cost-effectiveness remain limited
Advantages
- Targeted local drug delivery - avoids systemic steroid side effects
- Bioabsorbable - no removal procedure needed
- Addresses both mechanical (patency) and inflammatory (polyp/adhesion) failure modes
- SINUVA offers an office-based alternative to revision surgery
Limitations and Safety
- Cost: Substantially more expensive than conventional packing materials; cost-effectiveness data are still evolving
- Systemic steroid absorption: Mometasone furoate is detectable systemically but at low levels; no clinically significant adrenal suppression reported in trials
- Displacement/expulsion: Can occur, particularly in the immediate postoperative period
- Not definitive: DES reduces recurrence but does not cure underlying CRS - patients may still need long-term medical management
- Some questions remain unanswered per the 2024 systematic review - e.g., ideal patient selection, long-term outcomes beyond 90 days, and comparison with other steroid-impregnated resorbable materials
Summary
Drug-eluting stents represent a significant advance in post-FESS management of CRS, combining mechanical sinus patency with targeted mometasone delivery. The strongest evidence supports their use in CRSwNP to reduce polyp regrowth, adhesion, and the need for postoperative interventions. SINUVA extends this benefit to an office-based setting for recurrent polyps. Their routine adoption is limited mainly by cost, but evidence from multiple RCTs and systematic reviews supports their clinical effectiveness and safety profile.
Key References:
- Calvo-Henriquez et al., 2024 - Systematic Review, Eur Arch ORL (PMID 38459984)
- Huang et al., 2022 - RCT, ENT Journal (PMID 32845808)
- Zhang et al., 2025 - RCT on olfaction, ENT Journal (PMID 39529438)
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