Clinical study and literature review of nasal irrigation

The effect of diluted 1% baby shampoo on biofilm reduction in chronic rhinosinusitis with nasal polyposis

Background

Biofilm has been identified as the contributing factor for refractory chronic rhinosinusitis with nasal polyposis (CRSwNP). Nasal douching using baby shampoo was thought to be effective in patients with CRSwNP. We aimed to study the in-vitro reduction of biofilm using diluted 1% baby shampoo.

Methods

Sixty nasal polyps taken from patients who met the inclusion and exclusion criteria were sent for histopathological examination using haematoxylin and eosin staining. Another portion of the same samples was sent for tissue culture and tissue culture plate assay to identify S. aureus and P. aeruginosa and determine their biofilm forming capacity. The efficacy of diluted 1% baby shampoo versus normal saline was tested on the biofilm in vitro where the optical density readings were compared pre- and post-treatment.

Results

The prevalence of biofilm in patients with CRSwNP is 21.7%. Thirteen samples were positive for biofilm; P. aeruginosa 23% (n = 3), S. aureus 15% (n = 2), no bacterial growth 54% (n = 7) and others 8% (n = 1). Biofilm formation was significant in both S. aureus and P. aeruginosa (p < 0.001) whilst a significant reduction of biofilm was seen in diluted 1% baby shampoo (p = 0.043).

Conclusion

In conclusion, diluted 1% baby shampoo is an effective treatment in the reduction of biofilm for CRSwNP.

Atrophic Rhinitis Secondary to an Infection of Unusual Bacteria: A Case Report and Literature Review

Clinically, atrophic rhinitis (AR) is well recognized. We present the case of a patient diagnosed with AR. Sphingomonas paucimobilis, an uncommon bacterial pathogen, has been isolated in nasal cultures. This study discusses the microorganisms, causing AR. According to previous research, these infections have been associated with significant morbidity and mortality. Due to the limited knowledge on the disease, the diagnosis is frequently delayed. Thus, frequent monitoring and treatment are needed to avoid complications. This rare type of infection should be suspected in patients presenting with nasal blockage, including those from non-endemic areas.

Practices and Techniques of Jal Neti Across Indian Institutions: A Cross-sectional Study

Background

Nasal irrigation, including the traditional practice of Jal Neti, is increasingly used as an adjunctive treatment for various sinonasal disorders. It enhances mucociliary clearance, reduces mucus contact with irritants, and helps alleviate sinonasal symptoms. Despite its benefits, the practices and techniques vary widely across yoga traditions, necessitating a systematic examination of these differences.

Methods

This cross-sectional observational study was conducted at nine renowned yoga and naturopathy institutes in India to document and analyze the diverse practices of Jal Neti. Data were collected through direct interviews with experts, observations, and a review of institutional practices. Parameters studied included water source, purification methods, salt type and measurement, water temperature, and quality testing.

Results

The study revealed significant variations in Jal Neti practices among institutions, influenced by expertise, philosophy, and environmental factors. Water sources ranged from municipal to natural sources such as dams and ground water with purification methods including reverse osmosis and chlorination. Water temperatures varied seasonally, and salt types included rock, sea, and iodized salts, with measurement techniques often subjective. The pH, total dissolved solids, and salinity levels differed, reflecting the influence of local water characteristics. Although consistent water quality testing was observed, the frequency and parameters varied, affecting practice safety and effectiveness.

Conclusion

Jal Neti practices across major Indian yoga institutes exhibit significant diversity in methods, reflecting the individualistic yet systematic nature of this ancient technique. These findings highlight the need for standardized guidelines to ensure safety and efficacy, especially concerning water quality and salt concentration. The clinical relevance of these findings lies in the potential for improving the safety and effectiveness of Jal Neti for sinonasal disorders. Variations in salt types, concentrations, and water temperatures could influence mucosal irritation, symptom relief, and overall therapeutic outcomes. Standardizing these parameters could enhance the consistency and reliability, ensuring better patient outcomes in both traditional and clinical settings.

Effectiveness of hypertonic saline irrigation following functional endoscopic sinus surgery: a systematic review and meta-analysis

OBJECTIVES

This study aimed to clarify the impact of hypertonic solutions on various outcomes, including persistence or reduction of nasal crusts, polypoid edema, and postoperative inflammatory symptoms.

METHODS

We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials for studies comparing hypertonic with isotonic saline irrigation after FESS in adult patients with Chronic Rhinosinusitis (CRS). Outcomes were polypoid mucosa, nasal crusts, and variation from the baseline of Sino-Nasal Outcome Test (SNOT) 20/22 and Visual Analog Scale (VAS). For statistical analysis, we used RevMan 5.4.1, and assessed heterogeneity with I2 statistics.

RESULTS

We included a total of 479 patients from 7 studies. In the hypertonic saline group, there was a reduction in the nasal crust Risk Ratio (RR) (RR = 0.65; 95% CI 0.49 to 0.87; p = 0.004; I2 = 0%) after 30-45 days and severe crusts at 14-21 days (RR = 0.59; 95% CI 0.38 to 0.91; p = 0.02; I2 = 0%). Additionally, the persistence of polypoid mucosa was lower in the intervention arm (RR = 0.53; 95% CI 0.43 to 0.65; p < 0.00001; I2 = 0%) after 14-21 days. In the symptomatic evaluation hypertonic saline group showed an improvement in postoperative symptoms by a VAS Mean Difference (MD) (MD = -5; 95% CI -5.77 to -4.24; p < 0.00001; I2 = 0%) and a SNOT 20/22 Standard Mean Difference (SMD) (SMD = -1.65; 95% CI -2.7 to -0.61; p = 0.002; I2 = 93%) reduction from baseline in 30-45 days after the surgery.

CONCLUSION

Hypertonic saline showed a superior improvement in postoperative evaluation by means of nasal crusting, mucosal healing aspect, and nasal inflammatory symptoms compared with isotonic saline irrigation.

Mast Cells in Allergic and Non-Allergic Upper Airways Diseases: Sentinel in the Watchtower

Mast cells are immune system cells with the most disparate functions, but are also among the least understood. Mast cells are implicated in several known pathological processes, tissue homeostasis, and wound repair. However, they owe their notoriety to allergic diseases, of which they represent the effector cell par excellence. In both allergic and not upper airway pathologies, mast cells play a key role. Exploring the mechanisms through which these cells carry out their physiological and pathological function may help us give a new perspective on existing therapies and identify new ones. A focus will be placed on non-allergic rhinitis, a poorly recognized and often neglected condition with complex management, where the role of the mast cell is crucial in the pathogenetic, clinical, and prognostic aspects.

Saline nebulizers in treatment of bronchiolitis

Introduction

This study was conducted to assess the response to treatment and compare the effects of nebulized normal saline 0.9% and hypertonic saline 3% in the management of acute bronchiolitis, a condition associated with multiple complications in pediatric patients.

Materials and Methods

In this clinical trial, a total of 60 children diagnosed with viral bronchiolitis in the autumn and winter of 2018 at Ali Asghar Children's Hospital's emergency department were enrolled. The cohort consisted of 30 children in the control group treated with normal saline 0.9% nebulization and 30 in the treatment group treated with 3% hypertonic saline nebulization. Demographic variables, symptom onset duration, and initial heart and respiratory rates were recorded. Disease severity was assessed using the Respiratory Distress Assessment Index (RDAI). Data were analyzed using SPSS software.

Results

Following treatment, both groups exhibited significant improvements in vital signs (respiratory rate, heart rate, and oxygen saturation) and RDAI scores (P value < 0.001). However, there was no statistically significant difference in the degree of improvement in vital signs and RDAI scores between the two treatment groups (P value > 0.05). The mean hospital stay duration did not significantly differ between the groups (P value = 0.16).

Conclusion

Nebulized hypertonic saline and normal saline both effectively ameliorated symptoms in children with bronchiolitis. The absence of a significant difference between these treatments suggests that either can be recommended for use in the pediatric population experiencing acute bronchiolitis symptoms.

Therapeutic Management of Primary Atrophic Rhinitis (Ozene): About 4 Cases

Objective: To study the clinical characteristics and therapeutic means of primary atrophic rhinitis. Method: We present 4 cases of atrophic rhinitis caused by Klebsiella ozaenae observed in our hospital over a period of 5 years. Results: All patients presented the clinical triad: mucosal atrophy, presence of crusts, and cacosmia. Treatment was medical in 3 patients and surgical in 1 patient. We used rifampicin and sulfamethoxazole as antibiotics as well as trimethoprim for a period of 4 months. The surgical treatment consisted of recalibration of the nasal cavities by placing 2 silicone sticks in the subperiosteum. The evolution was marked by obstruction and cacosmia in 3 out of 4 patients. Conclusion: The treatment of primary atrophic rhinitis poses a problem for the clinician in terms of means and therapeutic effectiveness given that it is a chronic pathology requiring regular monitoring.

Double Blinded Randomized Controlled Trial Comparing Budesonide and Saline Nasal Rinses in the Post-operative Management of Chronic Rhinosinusitis

Post-operative management of chronic rhinosinusitis is very crucial for outcomes following surgery, Normal saline nasal irrigation and steroid spray form the standard treatment of care in this period. However nasal irrigation may not be adequate and spray is usually started after 2 weeks of surgery which in any case does not deliver optimum dosage of drug to the paranasal sinus mucosa. Budesonide nasal irrigation in a high-volume low-pressure system could be the solution for a better outcome. A double blinded randomized control trial with 88 patients in 2 groups of 44 each received normal saline or Budesonide nasal irrigation (0.5 mg in 200 ml) twice daily. Patients were followed up at 2 weeks post-operatively and 3 months, a SNOT 22 and Lund Kennedy Endoscopic scores were assessed for subjective and objective assessment. Subset analysis of only CRS patients (55) were done, and results presented. Patient reported subjective score at 3 months post operatively, SNOT22 was significantly (p < 0.0001) improved with the use of Budesonide irrigation (26.69 ± 2.92) as compared to Normal saline (30.54 ± 2.81) and objective assessment score, LKES was significantly (p = 0.0031) better in Budesonide group (4.06 + 0.74) in comparison to Normal saline in the saline (4.50 + 0.67) respectively. The mean scores 3 months post op visit was significantly lower for both subjective SNOT (p < 0.001) and objective score LKES (p < 0.0001) in Budesonide groups. Budesonide nasal irrigation with positive pressure high volume device has better patient benefits and wound healing when compared to normal saline irrigation in the post-operative management of chronic rhinosinusitis.

Necessary Factors for Efficient Frontal Sinus Irrigation After Endoscopic Sinus Surgery: A Systematic Review

OBJECTIVE

The frontal sinus remains a challenging site for irrigation due to its position relative to the nostril and ethmoid sinus. This study aims to summarize the necessary factors for efficient irrigation of the frontal sinus after endoscopic sinus surgery (ESS) among patients with chronic rhinosinusitis (CRS).

METHODS

Using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic literature review was conducted on PubMed, Scopus, and Cochrane databases to identify studies assessing the effect of frontal sinus irrigation in patients with CRS, cadaver models, or 3D-printed models of the sinonasal cavity after ESS.

RESULTS

Of the initial 206 abstracts reviewed, 18 full-text articles were included. The degree of the frontal sinus ostium opening after ESS was found to be associated with the efficacy of frontal sinus irrigation. More extensive frontal sinus surgeries tended to increase frontal sinus penetration. A Draf IIA procedure was identified as the minimum standard to achieve sufficient irrigation in the frontal sinus. Due to decreased backpressure in the nasal passage, increasing septectomy in Draf III did not significantly improve irrigation delivery. Squeeze bottles achieved significantly higher irrigation flow in the frontal sinus than syringes and pulsating devices. Large-volume irrigation devices provided better irrigation for the frontal sinus by entering or flushing the entire frontal sinus. The head position influenced the frontal sinus irrigation by altering the ostia position relative to fluid flow and vertical height of the frontal sinus during irrigation. While the vertex down head position was likely to enhance frontal sinus irrigation, the comfort of the head position and patient compliance should be considered.

CONCLUSION

Elements for optimization of frontal sinus irrigation are a minimum of a Draf IlA procedure for frontal sinus dissection, use of large-volume irrigation, and vertex down head positioning. Developing comfortable head positions with high frontal sinus irrigation efficiency would increase patient compliance and improve outcomes.

LEVEL OF EVIDENCE

NA.

Sinonasal Irrigation After Endoscopic Sinus surgery - Past to Present and Future

Functional endoscopic sinus surgery (FESS) is the gold standard treatment for medically refractive chronic rhinosinusitis, aimed at removing diseased tissue and improving natural sinus drainage and aeration. Irrigation of the sinuses has been known to improve sinus mucosal health and is an essential adjunct to surgery. There are a number of methods, devices, and solutions available which are used for nasal irrigation. Neti Pot, squeeze bottle, syringe, rubber bulb and commercially available nasal sprays are some of the simpler used devices used for douching. Electric devices like flosser, Hydropulse and the Navage nasal irrigation systems are available but it's not clear if they provide any advantage over the other methods. We use and propose a gravitational pressure-pulsed device which provides adequate volume and force without the need for external pressure. Salt with sodium bicarbonate is the most used solution base. Hypertonic saline has been described to be more efficacious compared to isotonic saline. Additives such as sodium hypochlorite, antibiotics, corticosteroids, manuka honey and xylitol have proven to be beneficial. Large volume positive pressure irrigations have proven to be beneficial. Optimal position for irrigation varies for low or high-volume irrigation systems. Patient education regarding precautions and disinfection of the device is a must.

Yogic Neti-Kriya Using Povidone Iodine: Can it have a Preventive Role Against SARS-CoV-2 Infection Gateway?

During this COVID-19 pandemic, except steroid, none of the therapeutic measures have showed any evidence of efficacy. Traditionally jala-neti using lukewarm salted water remains a yogic way of maintaining upper airway hygiene. Saline irrigation decreases the concentration of inflammatory mediators (e.g. histamine, leukotriene etc.) in nasal secretions, reduces the severity and frequency of sinusitis, reduce need of antibiotic therapy and restores competency of nasal mucosa. Jala-neti is an integral part of six cleansing techniques of yogic kriyas practised in India since thousands of years. Jala-neti can clean the upper airways, prevents colonization of infectious agents, removes foreign bodies, prevents stasis of mucous and subsequently enhances the drainage of paranasal sinuses and maintain health. Regular practice of Jala neti improves nasal symptoms and overall health status of patients with sinusitis. Jala-neti sample can even be used for COVID-19 diagnosis. Povidone iodine (PVP-I) has been utilized as a time tested antimicrobial agent with broad spectrum coverage against wide range of bacteria and viruses. Anti-SARS-CoV-2 action of PVP-I was seen at a concentration as low as 0.45%. PVP-I is generally well tolerated upto 5%, however nasal ciliotoxicity is reported at this concentration, however, this toxicity is not reported with lower concentrations(1.25% and 0.5%). So, theoretically, by using neti-kriya with povidone iodine (0.5-1%) as irrigation solution can combine and enhance the protection against COVID-19 and this can be an important armor in the fight against COVID-19. However, this hypothesis needs to be validated in real life clinical trial scenario before implementing.

Serum level and clinical significance of vitamin E in pregnant women with allergic rhinitis

BACKGROUND

Allergic rhinitis is a frequent disorder during pregnancy, while in children it is triggered by significantly lower serum vitamin E level. This research aimed to investigate whether serum vitamin E level exhibited clinical significance in pregnant women with allergic rhinitis.

METHODS

In this study, 37 pregnant women with allergic rhinitis and 35 healthy pregnant women were recruited. Allergic rhinitis severity was analyzed by the Total Nasal Symptom Score (TNSS) questionnaire. Blood samples were collected to evaluate serum vitamin E, interleukin (IL), and total IgE levels.

RESULTS

In pregnant women with allergic rhinitis, serum level of vitamin E was significantly lower than in healthy pregnant women. Serum vitamin E level in pregnant women with allergic rhinitis showed a negative correlation with TNSS, IL-13, IL-4, and total IgE levels.

CONCLUSION

In conclusion, this research has demonstrated that pregnant women with allergic rhinitis showed significantly lower serum level of vitamin E. The decreased vitamin E showed a correlation with the pathogenesis of allergic rhinitis in pregnant women.

Optimal Device and Regimen of Nasal Saline Treatment for Sinonasal Diseases: Systematic Review

Objective

This review aimed to systematically determine the optimal nasal saline regimen for different types of sinonasal diseases.

Data Sources

PubMed, Embase, SCOPUS, Cochrane Library, Web of Science, ClinicalTrials.gov. The last search was on December 6, 2021.

Review Methods

Study selection was done by 2 independent authors. Randomized controlled trials and meta-analyses were included. The effects of nasal saline treatment through various devices, saline tonicities, and buffer statuses were evaluated in patients with allergic and nonallergic rhinitis, acute and chronic rhinosinusitis (CRS), CRS with cystic fibrosis, and postoperative care, including septoplasty/turbinoplasty and endoscopic sinus surgery.

Results

Sixty-nine studies were included: 10 meta-analyses and 59 randomized controlled trials. For allergic rhinitis, large-volume devices (≥60 mL) were effective for treating adults, while low-volume devices (5-59 mL) were effective for children. Isotonic saline was preferred over hypertonic saline due to fewer adverse events. For acute rhinosinusitis, saline irrigation was beneficial in children, but it was an option for adults. Large-volume devices were more effective, especially in the common cold subgroup. For CRS, large-volume devices were effective for adults, but saline drop was the only regimen that had available data in children. Buffered isotonic saline was more tolerable than nonbuffered or hypertonic saline. The data for CRS with cystic fibrosis and nonallergic rhinitis were limited. For postoperative care, buffered isotonic saline delivered by large-volume devices was effective.

Conclusion

Nasal saline treatment is recommended for treating most sinonasal diseases. Optimal delivery methods for each condition should be considered to achieve therapeutic effects of saline treatment.

Impact of Patient Guidance Handouts on Outcomes of FESS

Post-operative care in FESS is an important aspect. Nasal saline irrigation and Nasal steroid spray are highly recommended worldwide in post-operative protocol after endoscopic sinus surgery. Hence patients compliance for both these procedures becomes a deciding factor for outcomes following FESS and there is not much evidence in literature regarding the same. The present study was conducted to evaluate the role of giving patients pictorial handouts regarding nasal saline irrigations and various positions of using nasal steroid spray in improving outcomes of FESS. It was a randomised control study.46post operative patients of FESS were randomised into two groups. Group A patients were verbally explained and practically demonstrated the technique of nasal saline irrigation and nasal steroid spray in the language best understood and by showing them the relevant images. Group B patients were also verbally explained as well as practically demonstrated the above mentioned procedure but were also given pictorial handouts (depicting in detail the positions of nasal saline irrigation and steroid spray} which were explained and handed over to them at the time of discharge. The patients were evaluated a 1st, 2nd 3rd and 4th post-operative week for compliance of both the procedures and its effect on post-operative cavity. In the present study there were 21 females versus 25 males. The average male: female ratio in group A was 1.3 versus 1 in group B. The mean age was 35.5652 ± 4.595 in group B versus 33.1739 ± 4.438 in group A. The average compliance over three weeks was 2.5765 ± 0.207 in Group B as compared to 1.4935 ± 0.27 in Group A. The t score for the difference in compliance between two groups was 15.2691. The two-tailed P value was less than 0.0001. The average Lund and Kennedy endoscopic appearance score for crusting was 1.75 ± 0.532, 1.217 ± 0.6, 0.696 ± 0.703 for Group A in post-operative follow up during week 1, 2 and 3 respectively as compared to 1.45 ± 0.59, 0.304 ± 0.47, 0.826 ± 0.49 for Group B. The P value was < 0.05 for the difference in both groups for all three weeks. The average Lund and Kennedy score for edema and other parameters has been enumerated in Table 1. 11/23 followed correct method for nasal saline irrigation in Group A as compared to 20/23 in Group B. 18/23 used nasal steroidal spray in all positions compared to only 9/23 in Group A. 3/23 in group B had polypoidal mucosa at frontal recess area at 1 month post-operative as compared to 16/23. Overall their was a negative correlation between the compliance of nasal saline irrigation with edema, crusting and discharge. The respective R score was -0.5311, -0.25296 and -0.19889 respectively. The pictorial handouts definitely improved compliance and hence outcomes in our study. We recommend this practice in routine to all our fellow rhinologists.

COVID-19 and its impact on cancer, HIV, and mentally ill patients

Severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) and its disease, COVID-19 is a global pandemic creating an unprecedented medical as well economic havoc across the world. Despite the wide spread global infection rates, the death rate is low for COVID-19. However, COVID-19 patients with other comorbid conditions face severe health complications irrespective of their gender or age. As the management of COVID-19 patients is taking up health resources, it is getting difficult to treat patients suffering from other dreadful diseases like cancer, HIV, and mental health issues. In this chapter, we discuss the effects of COVID-19 and management of cancer patients of main cancer subtypes (e.g., breast, lung, blood cancers), and patients affected with HIV and mental health issues. Finally, we also add a perspective on Ayurvedic treatment and its efficacy on COVID-19 patients.

Comparing the efficacy of sinus irrigation with traditional Caldwell-Luc procedure following odontogenic cyst surgery involving the maxillary sinus

A large maxillary odontogenic cyst could intrude into the maxillary sinus. The traditional approach following surgery for such a cyst is the Caldwell-Luc procedure. However, the traditional CDL procedure is associated with more complications and damage of the sinus mucosa. The purpose of this study was to assess a new method with easier operation, which not only prevented postoperative infection but also caused less damage to the maxillary sinus mucosa. A large odontogenic cyst in the maxillary sinus of 40 patients was diagnosed through radiographic imaging and postoperative histopathology. Twenty patients were treated with maxillary sinus saline irrigation after surgery, while 20 patients underwent the traditional Caldwell-Luc procedure. The therapeutic efficacy was evaluated by clinical examination and radiographic imaging; the longest follow-up was 36 months. The postoperative reaction was evaluated. There was a statistically significant difference in facial swelling, visual analog scale (VAS) and temperature elevation between the 2 groups. Sinus irrigation following large odontogenic cyst surgery involving the maxillary sinus can serve as an alternative to standard CDL and has the advantages of fewer complications, reduced trauma, restoration of the mucosa and more satisfactory results.

Efficacy and Safety of Sea Salt-Derived Physiological Saline Nasal Spray as Add-On Therapy in Patients with Acute Upper Respiratory Infection: A Multicenter Retrospective Cohort Study

Background

The purpose of this study was to assess the effects of seawater on nasal congestion and runny nose symptoms in adults with an acute upper respiratory infection (URI).

Material/Methods

This was a multicenter retrospective cohort trial of patients with acute URI and symptoms of nasal congestion and runny nose. The patients were assigned to 2 groups and were administered regular non-drug supportive treatment or supportive treatment with nasal irrigation with sea salt-derived physiological saline. The primary efficacy endpoint was the effective rate (percentage of patients with ≥30% symptom score reduction from baseline for nasal congestion and runny nose).

Results

In total, 144 patients were enrolled, including 72 in each group, and 143 patients completed the study. Both groups had similar demographics and vital signs. The effective rates for nasal congestion and runny nose were significantly increased in the seawater group compared with patients in the control group (87.3% vs 59.7% for nasal congestion; 85.9% vs 61.1% for runny nose; both P<0.001). In addition, the 2 groups showed markedly different degrees of patient symptom score improvement in sleep quality and appetite (both P<0.01), but not in cough and fatigue (both P>0.05). There were no adverse events in either group.

Conclusions

The sea salt-derived physiological saline nasal spray device satisfactorily improved nasal congestion, runny nose, sleep quality, and appetite in adults with URI, with no adverse effects.

Comparison of Intranasal Steroid Application Using Nasal Saline Irrigation and a Mucosal Atomization Device to Treat Chronic Rhinosinusitis

Introduction: Chronic rhinosinusitis (CRS) is a disease that can significantly reduce patients' quality of life (QoL). Intranasal steroid therapy is the most commonly used treatment for CRS. There are many evaluation tools dedicated to assessing CRS patients' QoL, but none of them evaluates QoL during local steroid therapy. Mucosal atomization devices (MADs) and nasal saline irrigation (NSI) are effective and safe methods of applying intranasal steroids for CRS patients. Materials and Methods: The sample population for this prospective study comprised 43 CRS patients. Following endoscopic sinus surgery, all participants received intranasal steroids administered via an MAD, followed by NSI for 1.5 months. Each participant completed the SNOT-22 (22-item Sino-Nasal Outcomes Test) score and a new questionnaire, the Complementary Topical Nasal Drug Delivery Questionnaire (the Complementary Questionnaire), at the end of 3 months of intranasal steroid therapy. Results: The patients' responses in both the SNOT-22 score and the Complementary Questionnaire revealed significant differences in their adverse experiences. The patients who received intranasal steroid treatment using NSI experienced more frequently delayed nasal drainage, higher frequency of ear symptoms, and facial pain/pressure, while those whose therapy was administered using an MAD reported complaints such as nasal irritation, nasal dryness, and postnasal drip with unpleasant taste/smell. Conclusion: We used the Complementary Questionnaire as an effective tool for assessment of the QoL of CRS patients. The SNOT-22 score and the Complementary Questionnaire make it possible to select an intranasal applicator tailored to a CRS patient's specific complaints.

Effect of surgery, delivery device and head position on sinus irrigant penetration in a cadaver model

OBJECTIVE

The extent of surgery, the type of device used and head position may influence nasal irrigation. The aim of this study was to determine the effectiveness of topical irrigant delivery to the paranasal sinuses according to these factors.

METHOD

Four cadaveric heads underwent four stepwise endoscopic dissections. Irrigations were evaluated after every stage using different delivery devices (squeeze-bottle, gravity-dependent device and syringe) in two head positions (nose-to-sink and vertex down). Irrigant penetration into each sinus was estimated using a four-point scale.

RESULTS

A significant positive effect of surgery was demonstrated for each sinus as well as for the delivery device. High-volume irrigant devices are more effective, and the head position plays a significant role in irrigant distribution to the frontal sinus.

CONCLUSION

This study further confirms the efficacy of high-volume irrigant devices. A vertex down position during the irrigation could improve delivery to the frontal sinus, and the widening of the ostia increases irrigant access to the sinuses.

The use of integrative therapy based on Yoga and Ayurveda in the treatment of a high-risk case of COVID-19/SARS-CoV-2 with multiple comorbidities: a case report

Background

We report a high-risk case of a coronavirus disease 19 (COVID-19)-positive patient with comorbidities including diabetes mellitus (DM), hypertension (HTN), hypothyroidism and chronic kidney disease (CKD), treated successfully using an integrative therapy plan based on Ayurveda and Yoga, along with government-mandated compulsory modern western medicine (MWM) treatment. Recently, some evidence has been emerging on the use of Ayurveda for treatment of COVID-19. The classical texts of Ayurvedic medicine such as Charaka Samhita and Sushruta Samhita contain descriptions of pandemics of similar proportions and describe them as Janapadoddhvansa, meaning the destruction of communities, along with their causes and treatment.

Case presentation

The case reported herein is a 55-year-old man from Delhi, India, with confirmed (tested) COVID-19, who first took MWM for 7 days before seeking integrative therapy. The patient has comorbidities including DM, HTN, hypothyroidism and CKD and had developed symptoms including fever (which was resolved by the time integrative therapy was started), sore throat, dry cough, body aches, weakness, bad taste and smell, and heaviness in the abdomen. Based on the patient’s symptoms and comorbidities, a treatment plan including Ayurvedic medicines, Yoga protocol, dietary recommendations and lifestyle modifications was prescribed by a registered Ayurveda doctor and a Yoga consultant. The patient started experiencing improvement in all the symptoms within 2 days after starting the treatment; he reported approximately \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$75\%$$\end{document}75% relief from the symptoms after 5 days, and almost complete relief within 9 days. Also, the blood sugar levels (both fasting blood sugar [FBS] and postprandial blood sugar [PPBS]) exhibited significant improvement after 5 days, and decreased to within the normal range within 12 days. Besides relief in symptoms, the patient’s real-time reverse transcription polymerase chain reaction (RT-PCR) test done on the 19th day returned negative results.

Conclusions

Integrative therapy was found to be effective in mitigating the symptoms of COVID-19 in this patient with multiple comorbidities. Moreover, a significant improvement in blood sugar levels (not under control with modern medicine) was also achieved. Integrative therapy based on the classical texts of Ayurveda and Yoga may offer a promising and scalable treatment option for COVID-19 patients. A case series or a suitably designed randomized controlled trial is needed to assess its efficacy.

Inhalations with Brine Solution from the 'Wieliczka' Salt Mine Diminish Airway Hyperreactivity and Inflammation in a Murine Model of Non-Atopic Asthma

Inhalations with brine solutions are old but underestimated add-ons to pharmacological treatments of inflammatory lung diseases. Although widely used, not all features underlying their action on the respiratory system have been explored. The aim of the present study was to elucidate the mechanism of the beneficial action of inhalations of brine solution from the 'Wieliczka' Salt Mine, a Polish health resort, in a murine model of non-atopic asthma. Asthma was induced in BALB/c mice by skin sensitization with dinitrofluorobenzene followed by an intratracheal challenge of cognate hapten. All animals underwent 12 inhalation sessions with brine solution, pure water or physiological saline. Control mice were not inhaled. We found that brine inhalations reduced, as compared to non-inhaled mice, the typical asthma-related symptoms, like airway hyperreactivity (AHR), the infiltration of pro-inflammatory cells into the bronchial tree, and the inflammation of the airways at the level of pro-inflammatory cytokines IL-1α, IL-1β and IL-6. The level of the anti-inflammatory IL-10 was elevated in brine-inhaled mice. Inhalations with pure water increased AHR, whereas saline had no influence, either on AHR or cytokine concentrations. These observations indicate that inhalations with a brine solution from the 'Wieliczka' Salt Mine diminish the asthma-related symptoms, mostly by reducing the inflammatory status and by decreasing AHR.

Efficacy of nasal irrigation with hypertonic saline on chronic rhinosinusitis: systematic review and meta-analysis

Introduction

Currently, several different concentrations of saline are recommended for use in nasal irrigation. Increasing studies show that nasal irrigation with hypertonic saline is more effective than traditional saline in the treatment of rhinosinusitis, but there have been few systematic analyses of the effect of nasal irrigation with hypertonic saline on chronic rhinosinusitis.

Objective

We sought to compare the effects of hypertonic saline and isotonic saline in the treatment of rhinosinusitis in order to provide a reference for clinical nasal irrigation for chronic rhinosinusitis treatment.

Methods

Medline, cochrane library, EMBASE, PubMed, Chinese biomedical journal database, China national knowledge infrastructure, Wanfang database, and other databases were searched, and the searching was supplemented by manual searches for relevant references to treatment of rhinosinusitis by saline nasal irrigation. The last retrieval date was March 2018. The included studies were evaluated for quality, and data were extracted for meta-analysis using RevMan 5.3.

Results

Seven studies were included. Effects favoring hypertonic saline on nasal symptoms were greater in 4 subgroups. These were (1) patients with nasal secretion (SMD = 1.52; 95% CI: 1.04, 2.00; p < 0.01), (2) patients with congestion (SMD = 1.52; 95% CI: 1.04, 2.00; p < 0.01), (3) patients with headache (SMD = 0.82; 95% CI: 0.38, 1.26; p < 0.01), (4) patients with overall symptomatic relief (SMD = 1.63; 95% CI: 0.83, 2.44; p < 0.01). However, no difference was shown in smell improvement (SMD = 0.47; 95% CI: −0.65, 1.59; p = 0.41) and radiologic scores improvement (SMD = 2.44; 95% CI: -3.14, 8.02; p < 0.01). Besides, hypertonic saline showed greater improvement in mucociliary clearance time scores than did the isotonic saline group (SMD = 1.19; 95% CI: 0.78, 1.60; p < 0.01). Hypertonic saline brought greater minor adverse effects.

Conclusion

Compared with isotonic saline, hypertonic saline nasal irrigation for the treatment of chronic rhinosinusitis is significantly more effective and has mild side effects in improving nasal symptoms and ciliary movement, but there is no significant difference in imaging findings and smell improvement. Although hypertonic saline is worthy of widespread use in clinical practice, it is still necessary to further study the exact manner and concentration of nasal irrigation.

Budesonide vs Saline Nasal Irrigation in Allergic Rhinitis: A Randomized Placebo-Controlled Trial

Objectives

Budesonide nasal irrigation is currently widely used in the treatment of chronic sinusitis typically following endoscopic sinus surgery to improve inflammatory control. Its application in treatment of allergic rhinitis has not been previously studied. This study assesses the subjective and clinical response to budesonide buffered hypertonic saline nasal irrigation and hypertonic saline nasal irrigation in patients with allergic rhinitis.

Study Design

This is a prospective, single-center, double-blind, randomized placebo-controlled trial.

Setting

Tertiary care hospital.

Subjects and Methods

Fifty-two patients diagnosed with allergic rhinitis were randomized into 2 groups to receive either buffered hypertonic saline nasal irrigation with a placebo respule or buffered hypertonic saline nasal irrigation with a budesonide respule. Patients were assessed at baseline and 4 weeks subjectively using the Sino-Nasal Outcome Test–22 (SNOT-22) questionnaire and visual analog scale (VAS). Clinical assessment was done using the modified Lund-Kennedy score.

Results

The average SNOT-22, VAS, and modified Lund-Kennedy scores improved in both groups ( P < .001). The budesonide irrigation group was found to have significantly better improvement than the saline nasal irrigation group with the SNOT-22 scores ( P = .012) and VAS scores ( P = .007). However, the difference in the clinical response between the 2 groups was not significant ( P = .268).

Conclusion

This study adds evidence to the use of saline nasal irrigation in allergic rhinitis but also demonstrates efficacy of the addition of budesonide to irrigations. Budesonide nasal irrigation thus appears to be a viable treatment option for allergic rhinitis.

Nasal Irrigation as Treatment in Sinonasal Symptoms Relief: A Review of Its Efficacy and Clinical Applications

Nasal irrigations have been used for centuries without any scientific data to determine its efficacy. Despite their widespread use, much confusion exist about the mechanism of action, preparation, indications and therapeutic advantage of nasal irrigations. Anecdotal evidence and poorly controlled studies add to the confusion. Recent evidence provides strong scientific justification of the benefits and advantages of using nasal irrigations in sinonasal symptoms relief. The present review of the evidence based literature highlights its efficacy and clinical applications.

Efficacy of 3% hypertonic saline in bronchiolitis: A meta-analysis

A meta-analysis was performed to analyze the efficacy of 3% hypertonic saline (HS) in bronchiolitis. Pubmed and MEDLINE databases were searched for relevant articles. A total of 2 authors selected the articles according to the inclusion criteria and then data were carefully extracted. Weighted mean difference (WMD) with 95% confidence interval (95% CI) values were used to pool continuous data, including length of stay and clinical severity score (CSS). Relative risk (RR) with 95% CI was calculated to determine the association between 3% HS and re-admission. The pooled data revealed that infants treated with 3% HS exhibited shorter durations of hospitalization compared with those treated with normal saline (NS; WMD=-0.43; 95% CI=-0.70, -0.15). Subgroup analysis examining the combination of HS or NS with additional medication demonstrated that 3% HS with epinephrine significantly decreased the length of hospital stay, with a WMD=-0.62 (95% CI=-0.90, -0.33). The results indicated a lower CSS score in the 3% HS group compared with the NS group (SMD=-0.80; 95% CI=-1.06, -0.54). The pooled outcome indicated a beneficial effect of 3% HS on decreasing re-admission rates compared with NS (RR=0.93; 95% CI=0.70, 1.23). No potential publication bias was observed (Begg's, P=0.133; Egger's, P=0.576). In conclusion, 3% HS was demonstrated to be a more successful therapy compared with NS for infants with bronchiolitis.

[Complications and side effects of conservative treatment of rhinological diseases]

BACKGROUND

The spectrum of rhinological diseases is wide, as is that of their drug-based treatment. Only 1272 compounds coded R01 (nasal preparations) are listed in the ATC group (Anatomical Therapeutic Chemical Classification). Conservative therapy of rhinological diseases additionally includes systemic (often oral) application of corticosteroids, antibiotics and immunomodulators.

OBJECTIVE

The aim of this paper is to outline possible complications of medication (subdivided into classes of ingredients) commonly used to treat rhinological diseases in hospitals. Useful therapeutic and preventive measures will be presented.

MATERIALS AND METHODS

Based on the expert information in the current pharmacological drug index (ATC) for the R01 group as well as literature research in the PubMed, Cochrane Library and MEDLINE databases, medication used for the treatment of rhinological diseases was analysed in terms of side effects and their frequency.

RESULTS

Common side effects of intranasally applied medication are local irritations, burning, dryness and epistaxis. Orally or intravenously applied rhinological medication can affect the organs and lead to side effects such as cardiac dysrhythmia or alterations of the blood count. It is recommended that the therapeutic be selected on an individual basis and that the patient be thoroughly informed about possible side effects.

CONCLUSION

Particularly when treating children or pregnant or breastfeeding women, the indications of all nasal preparations should be checked carefully. The huge variety of rhinologicals enables an optimal individual selection on the basis of consideration of known side effects.

Double-blind, randomised controlled trial on the efficacy of saline nasal irrigation with sodium hyaluronate after endoscopic sinus surgery

Objective

There is a growing interest in sodium hyaluronate for the clinical management of patients who undergo functional endoscopic sinus surgery for chronic rhinosinusitis, because of the mucosal regenerative properties of this macromolecule. However, its role in post-operative care is still debated. This study aimed to evaluate the effect of sodium hyaluronate administered via nasal irrigation with saline, in the post-operative period, after functional endoscopic sinus surgery.

Methods

A multicentric, prospective, randomised, double-blind, parallel group study was conducted on 56 consecutive patients who underwent functional endoscopic sinus surgery for chronic rhinosinusitis without polyps. Group 1 received the standard therapy of normal saline; group 2 received saline plus sodium hyaluronate.

Results

Both objective and subjective measurements, in terms of endoscopic appearance and patient-reported satisfaction, were significantly better in group 2 compared to group 1.

Conclusion

Sodium hyaluronate may be a useful adjunct to nasal saline irrigation in the early post-operative period following functional endoscopic sinus surgery.

Clinical Guidelines on Chronic Rhinosinusitis in Children

PURPOSE OF REVIEW

Pediatric chronic rhinosinusitis (CRS) is a prevalent problem that can elude diagnosis. In addition, given the burgeoning interest in pediatric sinonasal disease, treatment modalities are constantly evolving.

RECENT FINDINGS

The diagnosis of pediatric CRS is primarily based on clinical history and signs supported by objective findings (i.e., nasal endoscopy and/or computed tomography (CT) imaging). Cultures are indicated in patients who have not responded to medical therapy or have significant comorbidities. Nasal saline irrigation, nasal saline spray, and oral antibiotics are currently recommended for initial medical management. In children with CRS who have failed medical therapy, a stepwise approach to surgical intervention can lead to significant improvements in quality of life. This review provides an overview of the current guidelines and recent literature regarding the diagnosis, microbiology, and treatment options of CRS in the pediatric population.

A review on the therapeutic effects of NetiKriya with special reference to JalaNeti

Neti kriya is an integral part of shatkarmas/the six cleansing techniques that form the most important aspect of hatha yoga. Neti helps in preventing and managing upper respiratory tract diseases. An attempt is being made to collate and review articles that highlight the therapeutic effects of neti kriya. Databases like PubMed (January 1980–April 2016), Scopus and Ayush Portal were searched. We used keywords like jala neti, neti kriya, neti combined with terms such as yoga, sinusitis, rhinitis, common cold, vision, snoring, nasopharyngeal carcinoma and mental health for the search. As only a few results were obtained, we reviewed relevant studies with saline nasal irrigation. Evidence emerging from this review suggests that neti offers manifold benefits and relief from the antibiotic grip. Most studies support the role of neti in treating sinusitis, rhinosinusitis, allergic conditions and in improving vision. Jala neti has a significant role in improving the presence of mind and intelligence. We identified that it can be applied in mitigating post irradiation rhinosinusitis in nasopharyngeal carcinoma. However, randomized control trials must be conducted to substantiate the therapeutic efficacy of this simple cost-effective, non-pharmacological mode of treatment.

Effects of early postoperative nasal decongestant on symptom relief after septoplasty

BACKGROUND

A randomized, prospective, double-blinded clinical study was conducted at a single, tertiary referral center. The aim of the study was to evaluate the effects of nasal decongestant use in the early postoperative period after septoplasty.

METHODS

After septoplasty, patients who met the study inclusion criteria were randomized into 2 groups to receive either physiologic saline irrigation (saline group) or physiologic saline irrigation plus oxymetazoline hydrochloride 0.05% nasal spray (saline+oxymetazoline group). Visual analog scale (VAS) scores for bleeding, pain, and nasal crusting; Nasal Obstruction Symptom Evaluation (NOSE) scores; and rhinomanometric measurements were assessed pre- and postoperatively.

RESULTS

The VAS scores for bleeding and nasal crusting of patients in the saline+oxymetazoline group were significantly lower compared with the saline group (p < 0.005). VAS scores for pain were similar between the groups (p > 0.05). Total nasal resistance and NOSE scores of patients in the saline+oxymetazoline group were significantly lower than in saline group after surgery (p < 0.005).

CONCLUSION

The use of nasal decongestant sprays in the very early postoperative period is beneficial to reduce the postsurgical nasal crusting and bleeding symptoms and also for decreasing nasal resistance in this edematous period.

Saline irrigation for allergic rhinitis

BACKGROUND

Allergic rhinitis is a common condition affecting both adults and children. Patients experience symptoms of nasal obstruction, rhinorrhoea, sneezing and nasal itching, which may affect their quality of life.Nasal irrigation with saline (salty water), also known as nasal douching, washing or lavage, is a procedure that rinses the nasal cavity with isotonic or hypertonic saline solutions. It can be performed with low positive pressure from a spray, pump or squirt bottle, with a nebuliser or with gravity-based pressure in which the person instils saline into one nostril and allows it to drain out of the other. Saline solutions are available over the counter and can be used alone or as an adjunct to other therapies.

OBJECTIVES

To evaluate the effects of nasal saline irrigation in people with allergic rhinitis.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the ENT Trials Register; CENTRAL; Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 November 2017.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing nasal saline irrigation, delivered by any means and with any volume, tonicity and alkalinity, with (a) no nasal saline irrigation or (b) other pharmacological treatments in adults and children with allergic rhinitis. We included studies comparing nasal saline versus no saline, where all participants also received pharmacological treatment (intranasal corticosteroids or oral antihistamines).

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Primary outcomes were patient-reported disease severity and a common adverse effect - epistaxis. Secondary outcomes were disease-specific health-related quality of life (HRQL), individual symptom scores, general HRQL, the adverse effects of local irritation or discomfort, ear symptoms (pain or pressure) and nasal endoscopy scores. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included 14 studies (747 participants). The studies included children (seven studies, 499 participants) and adults (seven studies, 248 participants). No studies reported outcomes beyond three months follow-up. Saline volumes ranged from 'very low' to 'high' volume. Where stated, studies used either hypertonic or isotonic saline solution.Nasal saline versus no saline treatmentAll seven studies (112 adults; 332 children) evaluating this comparison used different scoring systems for patient-reported disease severity, so we pooled the data using the standardised mean difference (SMD). Saline irrigation may improve patient-reported disease severity compared with no saline at up to four weeks (SMD -1.32, 95% confidence interval (CI) -1.84 to -0.81; 407 participants; 6 studies; low quality) and between four weeks and three months (SMD -1.44, 95% CI -2.39 to -0.48; 167 participants; 5 studies; low quality). Although the evidence was low quality the SMD values at both time points are considered large effect sizes. Subgroup analysis showed the improvement in both adults and children. Subgroup analyses for volume and tonicity were inconclusive due to heterogeneity.Two studies reported methods for recording adverse effects and five studies mentioned them. Two studies (240 children) reported no adverse effects (epistaxis or local discomfort) in either group and three only reported no adverse effects in the saline group.One study (48 children) reported disease-specific HRQL using a modified RCQ-36 scale. It was uncertain whether there was a difference between the groups at any of the specified time points (very low quality). No other secondary outcomes were reported.Nasal saline versus no saline with adjuvant use of intranasal steroids or oral antihistamines Three studies (40 adults; 79 children) compared saline with intranasal steroids versus intranasal steroids alone; one study (14 adults) compared saline with oral antihistamines versus oral antihistamines alone. It is uncertain if there is a difference in patient-reported disease severity at up to four weeks (SMD -0.60, 95% CI -1.34 to 0.15; 32 participants; 2 studies; very low quality) or from four weeks to three months (SMD -0.32, 95% CI -0.85 to 0.21; 58 participants; 2 studies; very low quality). Although none of the studies reported methods for recording adverse effects, three mentioned them: one study (40 adults; adjuvant intranasal steroids) reported no adverse effects (epistaxis or local discomfort) in either group; the other two only reported no adverse effects in the saline group.It is uncertain if saline irrigation in addition to pharmacological treatment improved disease-specific HRQL at four weeks to three months, compared with pharmacological treatment alone (SMD -1.26, 95% CI -2.47 to -0.05; 54 participants; 2 studies; very low quality). No other secondary outcomes were reported.Nasal saline versus intranasal steroidsIt is uncertain if there was a difference in patient-reported disease severity between nasal saline and intranasal steroids at up to four weeks (MD 1.06, 95% CI -1.65 to 3.77; 14 participants; 1 study), or between four weeks and three months (SMD 1.26, 95% CI -0.92 to 3.43; 97 participants; 3 studies), or indisease-specific HRQL between four weeks and three months (SMD 0.01, 95% CI -0.73 to 0.75; 83 participants; 2 studies). Only one study reported methods for recording adverse effects although three studies mentioned them. One (21 participants) reported two withdrawals due to adverse effects but did not describe these or state which group. Three studies reported no adverse effects (epistaxis or local discomfort) with saline, although one study reported that 27% of participants experienced local discomfort with steroid use. No other secondary outcomes were reported.

AUTHORS' CONCLUSIONS

Saline irrigation may reduce patient-reported disease severity compared with no saline irrigation at up to three months in both adults and children with allergic rhinitis, with no reported adverse effects. No data were available for any outcomes beyond three months. The overall quality of evidence was low or very low. The included studies were generally small and used a range of different outcome measures to report disease severity scores, with unclear validation. This review did not include direct comparisons of saline types (e.g. different volume, tonicity).Since saline irrigation could provide a cheap, safe and acceptable alternative to intranasal steroids and antihistamines further high-quality, adequately powered research in this area is warranted.

Medical Management and Diagnosis of Chronic Rhinosinusitis: A Survey of Treatment Patterns by United States Otolaryngologists

Background

This study was performed to identify current patterns of diagnostic criteria and medical treatment for chronic rhinosinusitis (CRS) by otolaryngologists in the United States.

Methods

A 15-item survey was mailed to a random sample of 200 members of the American Academy of Otolaryngology–Head and Neck Surgery; statistical analysis was performed.

Results

The overall response rate was 40.0%. Of respondents, 73% defined CRS as lasting >12 weeks. Seventy-three percent also believed radiological imaging was necessary for definitive diagnosis, but only 30% believed nasal endoscopy was necessary. Regarding treatment, respondents reported use of oral antibiotics (94%) and nasal corticosteroids (94%) as part of maximum medical management; oral decongestants, oral mucoevacuants, and allergy testing were used only by about one-half of the respondents, and less frequently topical decongestants (38%), oral corticosteroids (36%), and oral antihistamines (27%) were used. Oral corticosteroids were more likely to be used by specialists that self-classified as rhinologists than by other otolaryngologists (p = 0.005), but rhinologists were less likely to use radiological imaging (p = 0.04) as a diagnostic criterion. Pediatric otolaryngologists used allergy testing in medical management more frequently than other otolaryngologists (p < 0.001). Overall, the basis for choice of maximal medical management was personal clinical experience (74%), rather than clinical research results or expert recommendations.

Conclusion

We had a fairly small sample of returned surveys; therefore, our findings may not be generalizable to the entire population of U.S. otolaryngologists. Nevertheless, in our survey, U.S. otolaryngologists agree on the use of oral antibiotics and nasal corticosteroids as part of maximal medical management for CRS but do not agree on other adjuvant therapies or on the use of endoscopy as a diagnostic criterion.

Effects of Saline Sprays on Symptoms after Endoscopic Sinus Surgery

Background

Topical saline is commonly recommended after endoscopic sinus surgery. The efficacy in this situation has never been shown.

Methods

We performed a controlled clinical trial to determine the effect of saline sprays on symptoms after endoscopic sinus surgery. Patients were randomized to receive normal saline (NS; n = 20), buffered hypertonic saline (HS; n = 20), or no spray (n = 20). A questionnaire measured symptoms of nasal obstruction, discharge, pain, headache, and trouble sleeping. Daily pain medication usage was recorded.

Results

Symptom scores over the first 5 postoperative days showed higher nasal discharge scores in the HS group. Day-by-day comparisons showed that the HS group reported significantly higher pain scores during some postoperative days. The NS group showed similar scores to control.

Conclusion

NS and HS sprays do not have a beneficial effect on symptoms compared with no treatment. HS sprays enhanced nasal drainage and pain. Our results do not support prescribing saline sprays early after sinus surgery but do not exclude the use of topical saline in other forms or for other uses, although they may be used for other intentions.

Evidence-Based Recommendations for Antimicrobial Nasal Washes in Chronic Rhinosinusitis

Background

Chronic rhinosinusitis (CRS) refractory to medical and surgical therapy is a difficult problem for patients and physicians. Topical antimicrobial nasal irrigations are commonly used for treatment with great variation in methodology and without clear scientific support for current treatment formulations. The purpose of this study was to develop a scientific rationale for creating standardized recommendations for clinical practice in the use of topical antimicrobial washes for CRS.

Methods

An extensive review of basic science and clinical literature on the treatment of CRS with topical antimicrobial washes was completed. Pharmacokinetics of and organism susceptibility to appropriate topically applied antimicrobial agents were reviewed.

Results

The most common organisms associated with CRS were identified. The relevant pharmacokinetics of drugs targeted at these organisms are presented. Susceptibility breakpoints set by the National Committee for Clinical Laboratory Standards are identified to help establish the most effective concentration of the identified drugs. Recommendations for agent selection, agent concentration, length of treatment, dosing schedule, and methods of irrigation are presented.

Conclusion

Antimicrobial nasal washes provide a potentially effective treatment for the growing population of patients who remain symptomatic after appropriate medical and surgical intervention. This study establishes the basic principles supporting this treatment option and offers rational, evidence-based treatment guidelines. The study has identified additional areas that need to be investigated before prospective clinical trials can be effectively undertaken.

'Well, it literally stops me from having a life when it's really bad': a nested qualitative interview study of patient views on the use of self-management treatments for the management of recurrent sinusitis (SNIFS trial)

OBJECTIVE

To explore the experience and perceptions of illness, the decision to consult a general practitioner and the use of self-management approaches for chronic or recurrent sinusitis.

DESIGN

Qualitative semistructured interview study.

SETTING

UK primary care.

PARTICIPANTS

32 participants who had been participating in the 'SNIFS' (Steam inhalation and Nasal Irrigation For recurrent Sinusitis) trial in the South of England.

METHOD

Thematic analysis of semistructured telephone interviews.

RESULTS

Participants often reported dramatic impact on both activities and their quality of life. Participants were aware of both antibiotic side effects and resistance, but if they had previously been prescribed antibiotics, many patients believed that they would be necessary for the future treatment of sinusitis. Participants used self-help treatments for short and limited periods of time only. In the context of the trial, steam inhalation used for recurrent sinusitis was described as acceptable but is seen as having limited effectiveness. Nasal irrigation was viewed as acceptable and beneficial by more patients. However, some participants reported that they would not use the treatment again due to the uncomfortable side effects they experienced, which outweighed any symptom relief, which may have resulted had they continued.

CONCLUSIONS

Steam inhalation is acceptable but seen as having limited effectiveness. Nasal irrigation is generally acceptable and beneficial for symptoms, but detailed information on the correct procedure and potential benefits of persisting may increase acceptability and adherence in those patients who find it uncomfortable.

TRIAL REGISTRATION NUMBER

ISRCTN 88204146.

Caregivers' education vs rhinopharyngeal clearance in children with upper respiratory infections: impact on children's health outcomes

Upper Respiratory Tract Infections (URTI) are very common in children having no effective pharmacological treatment. This study aimed to compare the effect of caregivers' health education regarding children's respiratory infections and the effect of a rhinopharyngeal clearance protocol in children with URTI. A factorial trial was conducted in 138 children up to 3 years, attending day-care centres. Children were distributed into four groups: control group (CG) (n = 38); education group (EG) (n = 34); intervention group (IG) (n = 35); and education and intervention group (E + IG) (n = 31). A Diary of Records was kept by caregivers during 1 month. There were significant differences between groups concerning: Lower Respiratory Tract Infections (CG = 29.4%; EG = 10.7%; IG = 3.8%; E + IG = 0.0%; p = 0.014); acute otitis media (CG = 32.4%; EG = 7.1%; IG = 11.5%; E + IG = 7.7%; p = 0.014); medical consultations (CG = 70.6%; EG = 42.9%; IG = 38.5%; E + IG = 30.8%; p = 0.021); antibiotics (CG = 44.1%; EG = 7.1%; IG = 23.1%; E + IG = 15.4%; p = 0.006); days missed from day-care (CG = 55 days; EG = 22 days; IG = 14 days; E + IG = 6 days; p = 0.020); days missed from employment (CG = 31 days; EG = 20 days; IG = 5 days; E + IG = 1 day; p = 0.021); and nasal clearance techniques (CG = 41.4%; EG = 78.6%; IG = 57.7%; E + IG = 84.6%; p = 0.011).

CONCLUSION

This study showed that the most positive impact on children's health outcomes occurred when combining health education of caregivers, regarding children's respiratory infections, with a rhinopharyngeal clearance protocol in children with URTI. What is Known: • Upper Respiratory Tract Infections are very common in children but still do not have an effective pharmacological treatment. • This generates a great burden of disease for the child and families, increasing the use of antibiotics. What is New: • This study is the first one that aims to analyze the effects of caregivers' health education in comparison to non-pharmacological intervention in acute respiratory infections in children. • It shows a positive impact on children's health outcomes, empowering caregivers regarding their child's health and reducing the burden of disease, medical consultations and the use of antibiotics.

Assessing the ideal microwave duration for disinfection of sinus irrigation bottles-A quantitative study

OBJECTIVES

Saline irrigation of the nasal cavity and paranasal sinuses has a recognised role in the management of chronic rhinosinusitis. However, bacterial recontamination of irrigation bottles through backflow from the sinonasal cavity is a concern in recurrent sinus cavity infections. While patients are encouraged to clean the irrigation bottles regularly, there remains significant concern that the use of contaminated bottles may perpetuate chronic rhinosinusitis. This study assesses the optimal microwave duration to achieve decontamination for each irrigation bottle component part (reservoir, tube and nozzle) using a standard, commercially available microwave. In addition, the irrigation fluid was also tested for contamination after each microwave cycle.

STUDY DESIGN

Laboratory-based experimental study.

PARTICIPANTS

No patients were involved in this study.

MAIN OUTCOME MEASURES

The percentage in vitro decontamination of the bottles' components was determined following 30, 60, 90, 120, 150 seconds of microwave cycles.

RESULTS

Complete decontamination of the bottles was not achieved at any of the tested microwave cycles. Levels of decontamination differed for the different bottle components, and the greatest degree of decontamination for all bottle components occurred at 90 seconds. Although higher levels of decontamination were observed at microwave durations exceeding 90 seconds, this was at the expense of thermal degradation and deformation of the reservoir plastic component of the irrigation bottle. Similarly, lowest contamination of irrigation fluid was observed at 120 seconds.

CONCLUSIONS

This study highlights the importance of establishing precise decontamination procedures and recommends a microwave cycle of 90 seconds for optimal decontamination.

Isotonic saline nasal irrigation in clinical practice: a literature review

Abstract Introduction: Nasal instillation of saline solution has been used as part of the treatment of patients with upper respiratory tract diseases. Despite its use for a number of years, factors such as the amount of saline solution to be used, degree of salinity, method and frequency of application have yet to be fully explained. Objective: Review the reported outcomes of saline nasal irrigation in adults with allergic rhinitis, acute or chronic sinusitis and after functional endoscopic sinus surgery (FESS), and provide evidence to assist physiotherapists in decision making in clinical practice. Methods: A search was conducted of the Pubmed and Cochrane Library databases between 2007 and 2014. A combination of the following descriptors was used as a search strategy: nasal irrigation, nasal lavage, rhinitis, sinusitis, saline, saline solution. Results: Eight clinical trials were included, analyzed according to participant diagnosis. Conclusion: The evidence found was heterogeneous, but contributed to elucidating uncertainties regarding the use of nasal lavage in the clinical practice of physical therapy, such as the protocols used.

The in vitro mucolytic effect of xylitol and dornase alfa on chronic rhinosinusitis mucus

BACKGROUND

The overproduction and stagnation of purulent mucus impair mucociliary clearance and exacerbate the symptoms of chronic rhinosinusitis (CRS). There is a clinical need for effective topical mucolytic agents to facilitate removal of mucus and improve postoperative outcomes.

METHODS

The effects of xylitol (5%) and dornase alfa (1 mg/mL) on mucus and mucus crusts were investigated. Viscoelasticity and viscosity of wet mucus derived from 30 CRS patients was measured with a plate rheometer. Postoperative dried mucus crust dissolution was measured by examining peripheral transparency, central transparency, and border definition of treated crust samples from 17 CRS patients.

RESULTS

Xylitol and dornase alfa reduced wet mucus viscoelasticity at a frequency of 0.1 Hz significantly more than the saline control. Treatments also produced significantly lower viscosities than saline at a shear rate of 10 and 100 seconds^-1 . Xylitol and dornase alfa significantly decreased mucus crust border definition relative to saline.

CONCLUSION

Xylitol and dornase alfa may be efficacious mucolytics, encouraging the breakdown of postoperative mucus crusts and the reduction of viscoelasticity and viscosity of wet mucus. In vivo study is required to evaluate the potential of these agents in treating recalcitrant CRS.

Nasal Irrigation: An Imprecisely Defined Medical Procedure

Nasal irrigation (NI) is an old practice of upper respiratory tract care that likely originated in the Ayurvedic medical tradition. It is used alone or in association with other therapies in several conditions—including chronic rhinosinusitis and allergic rhinitis—and to treat and prevent upper respiratory tract infections, especially in children. However, despite it being largely prescribed in everyday clinical practice, NI is not included or is only briefly mentioned by experts in the guidelines for treatment of upper respiratory tract diseases. In this review, present knowledge about NI and its relevance in clinical practice is discussed to assist physicians in understanding the available evidence and the potential use of this medical intervention. Analysis of the literature showed that NI seems to be effective in the treatment of several acute and chronic sinonasal conditions. However, although in recent years several new studies have been performed, most of the studies that have evaluated NI have relevant methodologic problems. Only multicenter studies enrolling a great number of subjects can solve the problem of the real relevance of NI, and these studies are urgently needed. Methods for performing NI have to be standardized to determine which solutions, devices and durations of treatment are adequate to obtain favorable results. This seems particularly important for children that suffer a great number of sinonasal problems and might benefit significantly from an inexpensive and simple preventive and therapeutic measure such as NI.

An algorithm recommendation for the pharmacological management of allergic rhinitis in the UK: a consensus statement from an expert panel

Allergic rhinitis is a frequent presenting problem in primary care in the UK, and has increased in prevalence over the last 30 years. When symptomatic, patients report significant reduction in their quality of life and impairment in school and work performance. Achieving adequate symptom control is pivotal to successful allergic rhinitis management, and relies mostly on pharmacotherapy. While it is recognised that most mild-moderate allergic rhinitis symptoms can be managed successfully in primary care, important gaps in general practitioner training in relation to allergic rhinitis have been identified. With the availability of new effective combination therapies, such as the novel intranasal formulation of azelastine hydrochloride and fluticasone propionate in a single device (Dymista®; Meda), the majority of allergic rhinitis symptoms can be treated in the primary care setting. The primary objective of this consensus statement is to improve diagnosis and treatment of allergic rhinitis in primary care, and offer guidance on appropriate referral of difficult-to-treat patients into secondary care. The guidance provided herein outlines a sequential treatment pathway for allergic rhinitis in primary care that incorporates a considered approach to improve the management of allergic rhinitis symptoms and improve compliance and patient satisfaction with therapy. Adherence with this care pathway has the potential to limit the cost of providing effective allergic rhinitis management in the UK by avoiding unnecessary treatments and investigations, and avoiding the need for costly referrals to secondary care in the majority of allergic rhinitis cases. The fundamentals presented in this consensus article should apply in most health-care settings.

Low-concentration hypochlorous acid nasal irrigation for chronic sinonasal symptoms: a prospective randomized placebo-controlled study

Low-concentration hypochlorous acid (HOCl) is an endogenous antibacterial and antiviral agent. The purpose of this study was to evaluate the effectiveness of HOCl irrigation in patients with chronic rhinosinusitis (CRS) refractory to medical therapy. Forty-three adult patients (mean age 45.5 years) were enrolled in this study. They were randomly chosen to receive nasal irrigation with either low-concentration HOCl generated by a Salicid device (n = 21), or a placebo (saline; n = 22) for 8 weeks. The outcome measures were scores on the 20-Item SinoNasal Outcome Test (SNOT-20), rhinosinusitis disability index (RSDI), nasal endoscopic score, and bacterial cultures. The SNOT-20 scores were significantly lower in the HOCl group than in the placebo group after 2 weeks of treatment (p < 0.05) and remained lower after 4 weeks of treatment. With respect to the RSDI scores, there was a significant improvement in the HOCl group at 1 week after treatment and in both groups at 2 weeks after treatment (p < 0.05). There were no significant differences in the endoscopic scores between the two groups after the treatment. The bacterial culture rates were lower in the HOCl group than in the placebo group after 4 weeks of treatment, but this was not significant (p > 0.05). Our results showed that low-concentration HOCl irrigation resulted in a greater improvement in CRS symptoms as compared to saline irrigation.

Effects of nasal saline lavage on pediatric sinusitis symptoms and disease-specific quality of life: a case series of 10 patients

We conducted a prospective study to assess (1) the effects of daily nasal irrigation in children with chronic sinonasal symptoms and (2) the impact that treatment had on disease-specific quality of life as assessed by a validated instrument, the five-item Sinus and Nasal Quality of Life Survey (SN-5), and by an overall nasal quality-of-life (NQL) score based on a 10-point faces scale. Our patient population was made up of 10 children-7 girls and 3 boys, aged 3 to 9 years (mean: 6.1)-who had presented with symptoms of chronic rhinosinusitis for more than 3 months and who had not responded to previous medical management. Patients were administered nasal saline lavage daily for 1 month. These patients and/or their caregivers completed an SN-5 questionnaire upon entry into the study and at the completion of treatment. At study's end, a comparison of pre- and post-treatment scores with paired Student t tests showed that the mean total SN-5 score improved significantly over baseline, falling 45% from 21.4 to 11.7 (p = 0.0002). Moreover, significant overall improvement was seen in each of the five subcategories of the SN-5 survey (p = 0.0009 to 0.038). The NQL scores also improved significantly from 4.7 to 7.7 (p = 0.0034). Compliance with nasal lavage was generally good among the 10 patients, as 8 of them used at least 75% of the recommended quantity of saline at least once a day. During a follow-up period that ranged from 2 to 23 months (mean: 10.4), only 1 patient required an adenoidectomy for symptom control. The results of this pilot study suggest that nasal saline lavage may significantly alleviate chronic sinonasal symptoms and improve disease-specific quality of life in children with symptoms of chronic rhinosinusitis.

Comparison between the use of saline and seawater for nasal obstruction in children under 2 years of age with acute upper respiratory infection

BACKGROUND/AIM

The effectiveness of isotonic and hypertonic saline solutions used to open the nasal passage and improve clinical symptoms was compared in children under 2 years of age admitted with the common cold.

MATERIALS AND METHODS

The study was performed as a randomized, prospective, and double-blind study. The study included 109 children. The children using saline (0.9%) and seawater (2.3%) as nasal drops (the patient group) and the control group (in which nasal drops were not administered) were compared. Seventy-four patients received nasal drops from package A (seawater) in single days and from package B (physiological saline) in double days.

RESULTS

The mean age of the patients was 9.0 ± 3.9 months and the numbers of boys and girls were 65 (59.6%) and 44 (40.4%), respectively. There was no significant difference between Groups A and B in terms of nasal congestion (P > 0.05). However, a significant difference was found between the control group and Groups A and B (P < 0.05).

CONCLUSION

Relief was seen in nasal congestion, weakness, sleep quality, and nutrition with the use of both saline and seawater in children with the common cold. Seawater or saline drops may be added to standard treatment protocols.

WITHDRAWN: Nasal saline irrigations for the symptoms of chronic rhinosinusitis

Review withdrawn from Issue 4, 2016. Review replaced by 'Saline irrigation for chronic rhinosinusitis' (Chong 2016).

The editorial group responsible for this previously published document have withdrawn it from publication.