Antihistamines for treating rhinosinusitis: systematic review and meta-analysis of randomised controlled studies

Dental management of Kartagener syndrome: A case report

BACKGROUND

Kartagener syndrome (KS) is recognized as an inherited, autosomal recessive disorder characterized by a combination of chronic sinusitis, bronchiectasis, and situs inversus. It affects one in 12,500-50,000 live births worldwide.

AIM

This paper aims to discuss the dental management of patients diagnosed with KS.

CASE REPORT

A 31-year-old male with KS manifests by impaired cilia motility which increases the risk of a frequent lung infection. The dental examination revealed that the patient required comprehensive oral hygiene care which included patient education and nonsurgical periodontal therapy under local anesthesia.

CONCLUSIONS

Dental care providers should ask affected patients with KS about their signs and symptoms of cardiac and pulmonary disease and seek consultation with their attending physician regarding these health concerns before the initiation of general anesthesia and perhaps conscious sedation administration. Patients with KS with emerging cardiac and/or respiratory impairment should be referred promptly for medical assessment.

Intranasal corticosteroids reduced acute rhinosinusitis in children with allergic rhinitis: A nested case-control study

BACKGROUND

Children with allergic rhinitis (AR) have substantially more acute rhinosinusitis than children without AR. We evaluated whether intranasal corticosteroids (INCS), second-generation antihistamines (SGH), and/or intranasal antihistamines (INH) for AR affect acute rhinosinusitis in children with AR aged 2-18 years.

METHODS

By using the National Health Research Institutes Database 2005 of Taiwan, a cohort of patients with AR aged 2-18 years treated with AR medications between 2002 and 2018 was made, within which a nested case-control study was performed. Risk settings for acute rhinosinusitis cases matched controls for age, sex, and comorbidities. Current users of INCS, INH, and/or SGH were compared with remote and recent users of any AR medications and current users of INCS with and without SGH were compared with current users of SGH.

RESULTS

Current users of SGH and/or INCS had a higher risk of acute rhinosinusitis than remote users of AR drugs, and current users of SGH had a higher risk of acute rhinosinusitis than recent users; however, no difference in the risk of acute rhinosinusitis was found between current users of INCS and recent users of AR drugs. Current users of INCS with and without SGH had a lower risk of acute rhinosinusitis than current users of SGH alone.

CONCLUSIONS

Treatment of INCS with and without SGH diminished the risk of acute rhinosinusitis compared with treatment using SGH alone. Adequate INCS treatment for patients with AR is important to reduce the incidence of acute rhinosinusitis.

Rhinorrhea and increased chloride secretion through the CFTR chloride channel-a systematic review

PURPOSE

Allergic and non-allergic rhinorrhea in the forms of acute or chronic rhinosinusitis can mean a watery nasal discharge that is disabling. Primary objective was to review the evidence supporting the hypothesis that rhinorrhea is due to increased chloride secretion through the CFTR chloride channel.

METHODS

The structure of the evidence review followed the EQUATOR Reporting Guidelines. Databases searched from inception to February 2022 included Pubmed, EMBASE and the Cochrane library using keywords "Rhinorrhea", "chloride", "chloride channel", "CFTR" and "randomized controlled trial". Quality assessment was according to the Oxford Centre for Evidence-based Medicine.

RESULTS

49 articles were included. They included randomized controlled trials out of which subsets of data with the outcome of rhinorrhea on 6038 participants were analysed and in vitro and animal studies. The review revealed that drugs, which activate CFTR are associated with rhinorrhea. Viruses, which cause rhinorrhea like rhinovirus were found to activate CFTR. The chloride concentration in nasal fluid showed an increase in patients with viral upper respiratory tract infection. Increased hydrostatic tissue pressure, which is an activator of CFTR was observed in allergic upper airway inflammation. In this condition exhaled breath condensate chlorine concentration was found to be significantly increased. Drugs, which can reduce CFTR function including steroids, anti-histamines, sympathomimetic and anticholinergic drugs reduced rhinorrhea in randomized controlled trials.

CONCLUSIONS

A model of CFTR activation-mediated rhinorrhea explains the effectiveness of anticholinergic, sympathomimetic, anti-histamine and steroid drugs in reducing rhinorrhea and opens up avenues for further improvement of treatment by already known specific CFTR inhibitors.

Intranasal Anticholinergics for Treatment of Chronic Rhinitis: Systematic Review and Meta-Analysis

OBJECTIVE

Topical intranasal anticholinergics are commonly prescribed for the relief of chronic rhinitis and associated symptoms, warranting thorough assessment of the supporting evidence. The present study aimed to evaluate the safety and efficacy of anticholinergic nasal sprays in the management of allergic and non-allergic rhinitis symptom severity and duration.

METHODS

A search encompassing the Cochrane Library, PubMed/MEDLINE, and Scopus databases was conducted. Primary studies describing rhinorrhea, nasal congestion, and/or postnasal drip outcomes in rhinitis patients treated with an anticholinergic spray were included for review.

RESULTS

The search yielded 1,029 unique abstracts, of which 12 studies (n = 2,024) met inclusion criteria for qualitative synthesis and 9 (n = 1,920) for meta-analysis. Median follow-up was 4 weeks and ipratropium bromide was the most extensively trialed anticholinergic. Compared to placebo, anticholinergic treatment was demonstrated to significantly reduce rhinorrhea severity scores (standardized mean difference [95% CI] = -0.77 [-1.20, -0.35]; -0.43 [-0.72, -0.13]) and duration (-0.62 [-0.95, -0.30]; -0.29 [-0.47, -0.10]) in allergic and non-allergic rhinitis patients respectively. Benefit was less consistent for nasal congestion, postnasal drip, and sneezing symptoms. Reported adverse effects included nasal mucosa dryness or irritation, epistaxis, headaches, and pharyngitis, though comparison to placebo found significantly greater risk for epistaxis only (risk ratio [95% CI] = 2.19 [1.22, 3.93]).

CONCLUSION

Albeit treating other symptoms with less benefit, anticholinergic nasal sprays appear to be safe and efficacious in reducing rhinorrhea severity and duration in both rhinitis etiologies. This evidence supports their continued use in the treatment of rhinitis-associated rhinorrhea.

LEVEL OF EVIDENCE

1 Laryngoscope, 133:722-731, 2023.

Assessment of the Prevalence of the Use of Nasal Decongestants Among the General Population in Saudi Arabia

Background A topical nasal decongestant (NDC) is widely prescribed in ENT practice and used as self-medication because it is available over the counter, which makes it an easily accessible medication. Due to its common and long-term use, it is associated with serious nasal complications. It is commonly self-administrated in many otolaryngology diseases like the common cold, sinusitis, and acute or chronic rhinitis. The long-term usage of nasal decongestants is associated with significantly increased side effects. Aim To assess the prevalence of the usage of nasal decongestants among the general population in Saudi Arabia ad the pattern of its use. Methodology A questionnaire-based, cross-sectional survey was applied to level all available populations in Saudi Arabia. Participants with ages aged 10 to 60 years old in Saudi Arabia were invited to participate in the survey. Data were collected from participants using a predesigned online questionnaire. The questionnaire included the participant's demographic data, NDC use, and pattern of use. The questionnaire was uploaded online by researchers and their friends using social media platforms. Results A total of 1456 participants completed the study questionnaire. Participants ages ranged from 10 to 60 years with a mean age of 26.9 ± 12.4 years old. Exact 585 (40.2%) participants were males and 1270 (87.2%) were from urban regions. A total of 657 (45.1%) respondents reported using nasal decongestants while 799 (54.9%) did not use NDC. As for the duration of use, 70.8% used NDC for less than five days and 13.5% used it for 5-15 days. The most reported causes of using NDC were nasal obstruction (62.7%) and common cold (25.7%). Conclusions In conclusion, the study revealed that the frequency of using nasal decongestants was common (45.1%) in the study. More efforts should be paid to improve public awareness regarding indications, duration of use, and method of using nasal decongestants to avoid rebound reactions that may affect patients' daily life activities.

Effects of large volume, isotonic nasal saline irrigation for acute rhinosinusitis: a randomized controlled study

BACKGROUND

The purpose of this study was to compare the effects of nasal saline irrigation (large volume, positive pressure isotonic saline) in addition to standard treatment in patients with acute rhinosinusitis (ARS).

METHODS

This parallel, randomized controlled trial was conducted at a tertiary hospital. The adult patients with ARS (age ≥18 years) were randomly assigned to two groups. The irrigation group received 0.9% saline irrigation twice daily, using a 250-ml squeeze bottle, in addition to standard treatment. The no-irrigation group received standard treatment only. Patients were evaluated at baseline, 1 week, and 2 weeks. The quality of life, rhinologic subscore, symptom score, endoscopy score, and cure rate were compared.

RESULTS

Sixty-one patients (30: irrigation, 31: no-irrigation) were enrolled. There were 17 males and 44 females. The mean age was 41.06 years. Although both groups showed improvements, the improvement of each outcome was not different between the groups. Subgroup analysis by ARS subtype showed benefits of irrigation in the common cold subgroup; the improvements that were greater than control included: rhinologic subscore, intergroup mean difference -4.15 [95% confidence interval (CI), -7.49, -0.80] at 1 week and -5.23 [95% CI, -9.69, -0.78] at 2 weeks; combined symptom score -5.35 [95% CI, -10.55, -0.14] at 1 week and -8.02 [95%CI, -14.36, -1.70] at 2 weeks.

CONCLUSION

The add-on isotonic nasal saline irrigation using a large volume, positive pressure device did not add benefits equally for all ARS patients. The benefits of irrigation on quality of life and nasal symptoms were only observed in the common cold patient subgroup.

Effects of H1 antihistamine addition to intranasal corticosteroid for allergic rhinitis: a systematic review and meta-analysis

BACKGROUND

A combination of H1 antihistamine (AH) with intranasal corticosteroid (INCS) is commonly prescribed to patients with allergic rhinitis (AR) who have an inadequate response to monotherapy. In this systematic review we aimed to determine the effects of AH combined with INCS (AH-INCS) for treating AR.

METHODS

Literature searches were performed using Medline and Embase. Randomized, controlled trials that studied the effects of AH-INCS vs INCS monotherapy for treating patients with AR were included. The primary outcomes were total nasal symptom scores, total ocular symptom scores, and disease-specific quality of life. The secondary outcomes were objective tests for nasal patency and adverse events.

RESULTS

Sixteen studies (4026 patients) met the inclusion criteria. Compared with INCS, AH-INCS decreased total nasal symptom scores (standardized mean difference [SMD], -0.13; 95% confidence interval [CI], -0.19 to -0.06; p < 0.001; 10 trials, 3348 patients) and total ocular symptom scores (SMD, -0.12, 95% CI, -0.20 to -0.04; p = 0.003; 6 trials, 2378 patients). Subgroup analysis indicated no benefit with the oral AH-INCS combination but did show benefit with intranasal AH-INCS (SMD, -0.18; 95% CI, -0.27 to -0.09; p < 0.001). There were no significant differences with regard to disease-specific quality of life (SMD, -0.07; 95% CI, -0.16 to 0.02; p = 0.12; 6 trials, 1981 patients), nasal inspiratory flow (MD, -0.03 L/min; 95% CI, -0.57 to 0.50; p = 0.91; 1 trial, 54 patients), or adverse events.

CONCLUSION

Intranasal AH-INCS has benefit over INCS on nasal and ocular symptom improvement for treating AR. Oral AH-INCS is not recommended.