Efficacy and safety of intranasal xylometazoline and ipratropium in patients with common cold

BACKGROUND

Many over-the-counter medications are available to treat common cold nasal symptoms, but patients may be unsure which one to use.

METHODS

This review assesses two widely used intranasal treatments for nasal congestion and rhinorrhea in the common cold: xylometazoline hydrochloride and ipratropium bromide.

RESULTS

Xylometazoline quickly and effectively relieves nasal congestion, while ipratropium is effective at reducing rhinorrhea. When used in combination, a novel approach to treatment, nasal congestion and rhinorrhea are treated simultaneously, providing effective relief from two of the most troublesome symptoms of the common cold Both drugs are well tolerated, with only mild to moderate, nasal-related side effects.

CONCLUSIONS

The efficacy and safety of the combination product suggest that it should be used first-line in the symptomatic relief of nasal congestion and rhinorrhea, before the use of oral treatments.

A systematic review of the nasal index and the significance of the shape and size of the nose in rhinology

BACKGROUND

There was great interest in the 19th and early 20th century in classifying human races as Caucasian, Asian African etc. according to nasal shape and size, and the nasal index was the most commonly used measurement to differentiate races.

OBJECTIVE OF REVIEW

To determine if there is any clinical relevance of the shape and size of the nose in relation to physiology, pathology and surgery.

TYPE OF REVIEW

Systematic review.

SEARCH STRATEGY

A structured search of PubMed was performed from 1966 to 2008 for each section of the review focusing on the ethnic variations in nasal index, the effect of climate of nasal shape, ethic variations of nasal physiology and racial predilection for sinonasal pathology.

RESULTS

Nasal proportions do vary between ethnic groups but the size and shape of the nose does not define Caucasian, Asian and African races respectively. Anthropologists agree that the nasal variations are due to man's adaptation to the environment. However, this theory remains to be proven. Published data on nasal physiology have not shown significant differences between the ethnic groups despite obvious differences in nasal proportions. There is no evidence of ethnic specific predilection to disease due to anatomical variation, physiological vulnerability or genetic susceptibility. Rhinology research is often confounded by classifying populations according to race, as racial characteristics are not based on any scientific principles and the nasal index may be a more reliable discriminator. The only area in which the size and shape of the nose is of relevance is in aesthetic and reconstruction surgery.

CONCLUSIONS

Nasal proportions are important aesthetically but appear to have little relevance to the rhinologist.

Central mechanisms IV: conscious control of cough and the placebo effect

Early animal experiments on cough developed the concept that cough was an involuntary reflex controlled from areas in the brainstem and that cough could be inhibited by centrally acting medicines such as codeine. Studies on the voluntary control of cough, the urge to cough and the placebo effect of cough medicines have demonstrated that human cough is more complex than a brainstem reflex. The efficacy and mechanism of action of centrally acting cough medicines such as codeine and dextromethorphan is now in dispute, and codeine is no longer accepted as a gold-standard antitussive. This review puts forward a cough model that includes three types of cough: (1) reflex cough, caused by the presence of food or fluid in the airway--this type of cough is not under conscious control and can occur in the unconscious subject during general anaesthesia; (2) voluntary cough--under conscious control that is abolished with general anaesthesia; (3) cough in response to sensation of airway irritation--this type of cough causes an urge to cough that initiates voluntary cough and may only be present in the conscious subject. The review proposes that human cough associated with respiratory disease is under conscious control and is mainly related to a sensation of airway irritation and an urge to cough (type 3). The review discusses the summation of sensory input from the airway in a brainstem integrator that reaches a threshold to cause reflex cough. Subthreshold conditions in the cough integrator may be perceived as an urge to cough that is under voluntary control. The cough model presented in the review has implications for the development of cough medicines as it indicates that the older view of cough medicines acting in the brainstem area to inhibit the cough reflex may need to be revised to include conscious control of cough as an important mechanism of cough in man.

The effects of a hot drink on nasal airflow and symptoms of common cold and flu

Hot drinks are a common treatment for common cold and flu but there are no studies reported in the scientific and clinical literature on this mode of treatment. This study investigated the effects of a hot fruit drink on objective and subjective measures of nasal airflow, and on subjective scores for common cold/flu symptoms in 30 subjects suffering from common cold/flu. The results demonstrate that the hot drink had no effect on objective measurement of nasal airflow but it did cause a significant improvement in subjective measures of nasal airflow. The hot drink provided immediate and sustained relief from symptoms of runny nose, cough, sneezing, sore throat, chilliness and tiredness, whereas the same drink at room temperature only provided relief from symptoms of runny nose, cough and sneezing. The effects of the drinks are discussed in terms of a placebo effect and physiological effects on salivation and airway secretions. In conclusion the results support the folklore that a hot tasty drink is a beneficial treatment for relief of most symptoms of common cold and flu.

Postnasal drip syndrome. Two hundred years of controversy between UK and USA

This review discusses the trans-Atlantic controversy concerning Post Nasal Drip Syndrome (PNDS). PNDS was described as a common condition in the UK in the nineteenth century and was so extraordinarily prevalent in the USA that it was called 'American catarrh'. American chest physicians adopted PNDS as the most common cause of chronic cough. A relationship between PNDS and chronic cough was not accepted by UK chest physicians, who preferred to use the term 'rhinosinusitis' instead of PNDS. In the USA the diagnosis of PNDS was linked to a response to therapy with a sedating antihistamine and decongestant, but UK physicians doubted if this was a specific therapy and did not accept the therapy as diagnostic for PNDS. In 2006 the American College of Chest Physicians replaced the term PNDS with upper airway cough syndrome and some UK otolaryngologists proposed that PNDS should be replaced with rhinosinusitis. PNDS is now being replaced with more general descriptions of upper airway disease and a causal link with chronic cough is now disputed. PNDS may be caused by a mucus hypersecretory phenotype that develops following chronic exposure of the respiratory tract to particulate matter, allergens, irritants and pathogens. Current research on treating excessive airway mucus in the lower airways may be applicable to PNDS.

Do chronic changes in nasal airflow have any physiological or pathological effect on the nose and paranasal sinuses? A systematic review

.A reduction in nasal airflow associated with anatomical defects of the nose such as nasal septal deviation has been proposed to cause nasal pathology. . The majority of animal experiments where one nasal passage is surgically closed over several months report only minor changes in the histology of the nasal epithelium and no rhinitis or sinusitis. .Complete abolition of nasal airflow associated with laryngectomy or the treatment of atrophic rhinitis is not associated with the development of rhinitis or sinusitis. . Radiological studies have shown a lack of association between the degree of nasal septal deviation and evidence of rhinosinusitis. .Such studies provide evidence that reduced nasal airflow causes no significant nasal disease. . There is no convincing evidence that a reduction in nasal airflow is a causative factor for rhinitis or sinusitis.

Assessment of subjective scales for selection of patients for nasal septal surgery

OBJECTIVE

To investigate the use of subjective measures to assist the surgeon in patient selection for septal surgery.

STUDY DESIGN

Prospective, observational. Approved by local ethics committee.

SETTING

ENT outpatient department, University Hospital of Wales.

PARTICIPANTS

Forty-six participants on the waiting list for septal surgery for nasal obstruction.

MAIN OUTCOME MEASURE

Measurement of nasal partitioning of airflow by rhinospirometer (GM Instruments, Scotland), subjective scales, and investigator's assessment of septal deviation.

RESULTS

The subjective scores, and investigator's assessment of septal deviation, were compared with the rhinospirometer objective measurements for correlation, sensitivity and specificity. The rhinospirometry results showed that 20% of the patients on the waiting list had objective measures of partitioning of nasal airflow within a normal range for healthy subjects. The ordinal scale proved to be more useful than the visual analogue scale for patient selection. The subjective scores of airflow partitioning from the double ordinal scale correlated well with the rhinospirometry measurements (r = 0.8). The ordinal scale also had a sensitivity of 81% and a specificity of 60%. The investigator's subjective assessment of septal deviation had a high sensitivity at around 100% but had a lower specificity (30%).

CONCLUSIONS

The use of a subjective ordinal scale to measure partitioning of airflow greatly increased the specificity of patient selection and it is proposed that this scale may be useful to the surgeon when assessing patients for septal surgery.

Chronic inferior turbinate enlargement and the implications for surgical intervention

Nasal obstruction due to chronic enlargement of the inferior turbinate is a common problem for the ENT surgeon. This review will discuss the pathology of 'bilateral' and 'unilateral' turbinate enlargement associated with chronic rhinitis and nasal septal deviation, and focus on the structural changes in the turbinates. Cellular hyperplasia, tissue oedema and vascular congestion all contribute to turbinate enlargement, but there is some evidence that bony enlargement is associated with unilateral turbinate enlargement. There is no evidence for cellular hypertrophy despite the common use of the term 'turbinate hypertrophy' and this term should be replaced with the more correct term of 'turbinate enlargement'. The underlying pathology of turbinate enlargement has important implications for the surgical management of nasal obstruction.

Efficacy of a paracetamol-pseudoephedrine combination for treatment of nasal congestion and pain-related symptoms in upper respiratory tract infection

OBJECTIVE

This study compared the efficacy of 1000 mg of paracetamol combined with 60 mg of pseudoephedrine, with that of either paracetamol or pseudoephedrine alone and placebo for the treatment of symptomatic URTI.

RESEARCH DESIGN AND METHODS

A double-blind, parallel group study was performed on 305 patients with URTI (nasal airflow resistance [NAR] of > 0.25 Pa cm3 s and a global pain score of at least moderate intensity). NAR and pain relief/intensity scores were measured over 4 h after initial dose. Patients then dosed up to three times daily for 3 days and recorded nasal congestion and pain intensity scores.

MAIN OUTCOME MEASURES

Nasal airflow conductance (NAC) and pain relief after the initial dose were primary objectives. NAC was calculated from NAR. Pain relief was measured on a 5-point verbal rating scale (VRS) and pain intensity and nasal congestion on a 4-point VRS. Data were analysed using analysis of covariance. Safety was assessed by adverse events.

RESULTS

A single dose of the combination was superior to paracetamol and placebo for NAC (p = 0.0001) and was superior to pseudoephedrine and placebo for pain relief (p < or = 0.048). Multiple doses of the combination were also superior to paracetamol and placebo for decongestion (p < or = 0.021) and were superior to pseudoephedrine and placebo for pain reduction (p < or = 0.0057). All treatments were well tolerated.

CONCLUSIONS

The combination treatment provided a greater decongestant effect than either paracetamol or placebo and better pain relief than either pseudoephedrine or placebo. The additive effect of the combination was apparent for both single and multiple doses.

Understanding submucosal electrosurgery for the treatment of nasal turbinate enlargement

The surgical management of inferior turbinate enlargement is controversial. Submucosal electrosurgical techniques for turbinate reduction include conventional diathermy, radiofrequency tissue reduction and coblation. All electrosurgical techniques use radiofrequency electricity to damage turbinate tissue but differ in the control and delivery of energy. This review will examine the history of submucosal electrosurgery and clarify the various techniques. This review will also examine the evidence for the efficacy and safety of electrosurgery for the treatment of nasal turbinate enlargement, and will make a case that no progress will be made in clinical trials on the safety and efficacy unless there is standardisation of equipment and techniques in nasal electrosurgery.

Efficacy and safety of over-the-counter analgesics in the treatment of common cold and flu

RATIONALE

Common cold and flu are the most common human illnesses, and over-the-counter (OTC) analgesics are widely used to treat the pain and fever symptoms. Despite the every day use of these analgesic there is little information available in the literature on the efficacy and safety of these medicines in treating colds and flu symptoms. The aim of this review was to determine the safety and efficacy of the analgesics, aspirin, paracetamol and aspirin for the treatment of colds and flu.

METHODS

Electronic databases and a personal database were searched and the information retrieved together with information from relevant textbooks has been integrated in the review.

RESULTS

The literature search established that there is relatively little information on the use of analgesics in treating colds and flu and that much of the safety and efficacy data must be related to other pain and fever models. The review establishes that aspirin, paracetamol and ibuprofen are safe in OTC doses and that there is no evidence for any difference between the medicines as regards efficacy and safety for treatment of colds and flu (except in certain cases such as the use of aspirin in feverish children). There is also no evidence that these medicines prolong the course of colds and flu by any effect on the immune system or by reducing fever.

CONCLUSION

Despite the lack of clinical data on the safety and efficacy of analgesics for the treatment of colds and flu symptoms a case can be made that these medicines are safe and effective for treatment of these common illnesses.

Evidence for correlation of objective and subjective measures of nasal airflow in patients with common cold

OBJECTIVES

To utilize posterior rhinomanometry and conductance, as units of measurement, to further investigate the relationship between subjective and objective measures of nasal airflow.

DESIGN

A prospective, observational study.

SETTING

Common Cold Research Centre.

PARTICIPANTS

Sixty healthy volunteers from the staff and student population of Cardiff University with an upper respiratory tract infection.

MAIN OUTCOMES MEASURES

To determine correlations between visual analogue scores (VAS) and posterior rhinomanometry for total, unilateral, high and low conductance groups.

RESULTS

No correlation was found between total VAS and total conductance (r = 0.17, P = 0.10). A substantially significant correlation was found between unilateral VAS and unilateral conductance (rho = 0.50, P < 0.001). The unilateral VAS and conductance were highly correlated for the low total conductance group (rho = 0.61, P < 0.001).

CONCLUSIONS

Posterior rhinomanometry allows actual measurement of the combined and unilateral conductance of nasal passages. The units of conductance, as opposed to resistance, allow totally obstructed nasal passages to be included in analysis. Visual analogue scores and conductance correlate strongly in unilateral measures for participants with a low total nasal conductance. Posterior rhinomanometry and units of conductance are recommended for future studies investigating the relationship between objective and subjective measures of nasal airflow.

Nasal congestion: mechanisms, measurement and medications. Core information for the clinician

The article provides the clinician with core information about the aetiology and treatment of nasal congestion and discusses nasal blood vessels, autonomic nerves, nasal cycle, effects of posture, subjective sensation of congestion, objective assessments of congestion and medical and surgical treatments.

Cough induced by airway vibration as a model of airway hyperreactivity in patients with acute upper respiratory tract infection

Patients with acute upper respiratory tract infection (URTI) have been shown to be hyperreactive to inhaled tussigens such as citric acid and capsaicin, and the authors propose that this may be due to an increased sensitivity of airway receptors that mediate cough. In recent studies we have demonstrated that cough may be induced by vibration of the airway at the level of the throat or chest in patients with URTI but that the same stimuli induce little or no cough in healthy subjects. The difference between the patients with URTI and healthy subjects in their response to airway vibration may be explained on the basis of hyperreactivity of airway sensory receptors. We propose that the model of cough induced by airway vibration may be useful for studies on the pathophysiology and pharmacology of airway hyperreactivity in acute cough. The airway vibration model of cough may have some advantages over inhaled tussigens as the stimulus is easily controlled and the method is safe for use in children.

Efficacy of fusafungine in acute rhinopharyngitis: a pooled analysis

Upper respiratory tract infections are generally mild but they are associated with an enormous loss in productivity. Treatment consists of reduction of local symptoms e.g. local inflammation and prevention of potential superinfections. Besides its bacteriostatic activity against most micro-organisms involved in respiratory tract infections fusafungine displays original anti-inflammatory properties. To optimise nasal and throat deposition, a new fusafungine oro-nasal spray using HFA 134a was developed and its efficacy was evaluated in patients with acute rhinopharyngitis based on improvement of significant nasal symptoms. Three randomised double-blind placebo-controlled parallel-group studies with identical objectives design and dosage were performed and results were pooled for a better evaluation of treatment effect (532 patients). The percentage of responders (patients with nasal symptom score improvement from Day 0 to Day 4) was 61.5 +/- 2.9% with fusafungine vs 46.8 +/- 3.1% with placebo (p=0.009) with an odds ratio of 1.8 (p=0.01) in favour of fusafungine. The nasal symptom score distribution at Day 4 showed an odds ratio of 1.56 (p=0.011) also in favour of fusafungine. For patients treated early (onset of symptoms 1 pounds day) the percentage of responders was 65.9 +/- 4.1% with fusafungine vs 38.3 +/- 4.0% with placebo (p=0.022) with an odds ratio of 3.08 (p=0.033) in favour of fusafungine. Therefore fusafungine through its dual bacteriostatic and original anti-inflammatory properties is an effective treatment of acute rhinopharyngitis especially when administered early.