Safety and effectiveness of a drug-loaded haemostatic sponge in chronic rhinosinusitis: a randomized, controlled, double-blind study

Some cases of chronic rhinosinusitis (CRS) require surgical treatment and postoperative nasal packing, but bleeding and adhesion are common complications after nasal surgery. Biodegradable drug-loaded implants hold great therapeutic options for the treatment of CRS, but little data are available regarding the safety and efficacy of a novel drug-loaded haemostatic sponge (DLHS) in the sinus. The aim of this study was to investigate the safety and efficacy of DLHS in the sinus. We conducted a prospective, randomized, controlled, double-blind clinical trial. In this clinical trial, 49 patients were enrolled and randomly divided into 2 groups: group A (n = 25) had the DLHS containing 1 mg budesonide and 0.67 mg sodium hyaluronate placed into the sinus, and group B (n = 24) had the Nasopore placed after ESS. Endoscopic follow-up was performed for 12 weeks, and the findings were classified using the discharge, inflammation, polyps/oedema (DIP) endoscopic appearance scores. All patients completed questionnaires to evaluate their sinonasal symptoms by using the sinonasal outcome test-22 (SNOT-22) Chinese version and visual analogue scale (VAS). Serum cortisol concentration in group A was measured prior to surgery and at days 1, 3, 7, and 14 after nasal surgery. Comparing group A and group B, at 2 weeks, no significant differences were observed in either objective or subjective parameters. The mean value of VAS for rhinorrhoea and DIP for oedema and the mean value of nasal adhesion were significantly lower in Group A than in Group B at 6 and 12 weeks, but a significant difference did not occur in SNOT-22 and VAS for dysosmia between the two groups at 6 and 12 weeks. The mean serum cortisol concentrations in group A at the follow-up were within normal limits without remarkable fluctuations. This study demonstrates the safety and efficacy of a novel biodegradable DLHS with the possibility of being used in CRS patients, and this sponge may reduce inflammation and minimize adhesions via controlled local drug delivery without measurable systemic exposure.

Challenges in Nasal Cartilage Tissue Engineering to Restore the Shape and Function of the Nose

The repair of nasal septal cartilage is a key challenge in cosmetic and functional surgery of the nose, as it determines its shape and its respiratory function. Supporting the dorsum of the nose is essential for both the prevention of nasal obstruction and the restoration of the nose structure. Most surgical procedures to repair or modify the nasal septum focus on restoring the external aspect of the nose by placing a graft under the skin, without considering respiratory concerns. Tissue engineering offers a more satisfactory approach, in which both the structural and biological roles of the nose are restored. To achieve this goal, nasal cartilage engineering research has led to the development of scaffolds capable of accommodating cartilaginous extracellular matrix-producing cells, possessing mechanical properties close to those of the nasal septum, and retaining their structure after implantation in vivo. The combination of a non-resorbable core structure with suitable mechanical properties and a biocompatible hydrogel loaded with autologous chondrocytes or mesenchymal stem cells is a promising strategy. However, the stability and immunotolerance of these implants are crucial parameters to be monitored over the long term after in vivo implantation, to definitively assess the success of nasal cartilage tissue engineering. Here, we review the tissue engineering methods to repair nasal cartilage, focusing on the type and mechanical characteristics of the biomaterials; cell and implantation strategy; and the outcome with regard to cartilage repair.

[Fundamentals and practice of the application of nasal packing in sinonasal surgery]

BACKGROUND AND OBJECTIVES

This paper presents an overview on nasal packing materials which are available in Germany. The current literature is analyzed whether there are robust criteria regarding use nasal packing after sinonasal surgery, whether there are fundamental and proven advantages or disadvantages of products, and what this means in clinical practice.

MATERIALS AND METHODS

Selective literature analysis using the PubMed database (key words "nasal packing", "nasal tamponade", "nasal surgery", "sinonasal surgery", or "sinus surgery"), corresponding text books and resulting secondary literature.

RESULTS AND CONCLUSIONS

Because of systematic methodological shortcomings, the literature does not help in the decision-making about which nasal packing should be used after which kind of sinonasal surgery. In fact, individual approaches for the many different clinical scenarios are recommended. In principle, nasal packing aims in hemostasis, should promote wound healing, and should not result in secondary morbidity. Nasal packing materials should be smooth (non-absorbable materials), inert (absorbable materials), and should not exert excessive pressure. Using non-absorbable packing entails the risk of potentially lethal aspiration and ingestion. For safety reasons inpatient control is recommended as long as this packing is in situ. With other, uncritical packing materials and in patients with special conditions, outpatient control could be justified.

Maximizing Postoperative Recovery: The Role of Functional Biomaterials as Nasal Packs-A Comprehensive Systematic Review without Meta-Analysis (SWiM)

Numerous biomaterials have been developed over the years to enhance the outcomes of endoscopic sinus surgery (ESS) for patients with chronic rhinosinusitis. These products are specifically designed to prevent postoperative bleeding, optimize wound healing, and reduce inflammation. However, there is no singular material on the market that can be deemed the optimal material for the nasal pack. We systematically reviewed the available evidence to assess the functional biomaterial efficacy after ESS in prospective studies. The search was performed using predetermined inclusion and exclusion criteria, and 31 articles were identified in PubMed, Scopus, and Web of Science. The Cochrane risk-of-bias tool for randomized trials (RoB 2) was used to assess each study's risk of bias. The studies were critically analyzed and categorized into types of biomaterial and functional properties, according to synthesis without meta-analysis (SWiM) guidelines. Despite the heterogeneity between studies, it was observed that chitosan, gelatin, hyaluronic acid, and starch-derived materials exhibit better endoscopic scores and significant potential for use in nasal packing. The published data support the idea that applying a nasal pack after ESS improves wound healing and patient-reported outcomes.

Self-Cross-Linked Hyaluronic Acid Hydrogel in Endonasal Endoscopic Dacryocystorhinostomy: A Randomized, Controlled Trial

PURPOSE

To investigate whether self-cross-linked HA hydrogel fill stimulates wound mucosal regeneration and its epithelialization around the ostia to improve long-term ostial patency in endonasal endoscopic dacryocystorhinostomy (En-DCR).

METHODS

One hundred and ninety-two patients with unilateral primary chronic dacryocystitis (PCD) were randomized divided into 2 groups: group A (the HA hydrogel group) and group B (the control group). All patients underwent En-DCR. The HA hydrogel group received HA hydrogel filling the ostium at the end of the surgery and the control group received no treatment. The mucosal epithelialization of the wound, the formation of granulation, the formation of scars, and the success rate of ostial patency were compared.

RESULTS

Our study included 82 patients in group A and 79 patients in group B. At the 2-week follow up, 74 patients (90.2%) in the group A had a healed ostium with a lining of intact epithelial mucosa. It was higher when compared with 56 patients (70.9%) in group B (X2 = 9.698, P < 0.05). At the 12-month follow up, Granulation were present in 7.3% of patients in group A which was significantly lower than the 19.0% of patients in group B (X2 = 4.831, P < 0.05). No statistical difference was found with scars formation between 2 groups (X2 = 1.607, P = 0.205). The success rate of ostial patency was 89.0% (73/82) in group A and 77.2% (61/79) in group B. The success rate was much higher in group A than group B (X2 = 4.02, P < 0.05).

CONCLUSION

Self-cross-linked HA hydrogel may enhance the success rate of En-DCR for PCD by promoting mucosal epithelial healing and preventing excessive granulation.

The postoperative outcomes of patients with chronic rhinosinusitis with nasal polyps by sustained released steroid from hyaluronic acid gel

PURPOSE

The self-crosslinked hyaluronic acid (scHA) and steroids are considered as efficient factors for postoperative management after chronic rhinosinusitis (CRS) nasal surgery. This randomized clinical trial is designed to investigate the efficacy and potential of scHA gel as a topical drug sustained release carrier for steroid of budesonide.

METHODS

The study is performed with 30 patients of chronic rhinosinusitis with nasal polyps (CRSwNP) who underwent functional endoscopic sinus surgery (FESS). The single application of scHA was assessed in the control patient group for postoperative recovery. In the treatment patient group, the combination of scHA/budesonide was applied for postoperative management. The patients are followed up in 2 weeks, 4 weeks and 12 weeks after surgery.

RESULTS

The combination of scHA/budesonide results in better endoscopic scoring and mucus evaluation than the single scHA application.

CONCLUSION

The results indicate that the combination of scHA/budesonide is a valuable treatment for the FESS postoperative management and implies the potential of scHA gel as a topical drug sustained release scaffold.

Evaluation of Hemostatic Behavior of Micro and Nano Gelatin/Silica Hybrid in Severe Bleeding

Background:

The pH variation of the injury site is an important factor in the failure of styptic and its structural damage. In this study, the behaviour of a gelatin-silica hybrid in severe bleeding was evaluated under different pH values. On the other hand, the effect of the hybrid particle size, which is one of the key physical properties of the hybrid, has been studied in rapid control of haemostasis. </P><P> Method: The hybrid haemostatic behaviour varied drastically by changing the particle size, so that the hybrid containing SiO2 with the average particle size of about 1 micro-meter (Hyb Gel-MSiO2) demonstrated very poor ability in platelet adhesion in neutral pH, about 24%. Also, the aPTT was not shorter than the normal time, whereas reduction of the particle size beyond a certain limit (with nanometer SiO2 for Hyb Gel-NSiO2) led to both increasing platelet adhesion to 32% and very considerable reduction of aPTT. </P><P> Results: Alignment of all results showed that the particle size reduction improves the haemostatic behaviour of the hybrid toward its best performance by controlling excessive bleeding. By changing the pH for a certain particle size, structural integrity, and thereby the hybrid haemostatic behaviour changed dramatically. Therefore, the nano-hybrid showed the most blood absorption (around 470%) in natural pH and acceded to a coherent structure. The results demonstrated that in alkaline or acidic environment, the hybrid haemostatic behaviour was limited. Based on the results of this study, it was found that changes in the hybrid behaviour in acidic pH were much more drastic than in alkaline pH, and also the hybrid with the optimum particle size (Hyb Gel-NSiO2) can maintain the structural integrity with rapid haemostasis (<3 seconds). </P><P> Conclusion: Based on the objective that the pH at the injury site change to the alkaline side, the resulting hybrid has an excellent ability to control excessive bleeding and can be proposed for further in vivo studies as a novel styptic.</P>

In vitro analysis of growth patterns of invasive fungal species on commonly used endonasal hemostatic agents

OBJECTIVE

Previous studies have not examined the potential role of endonasal hemostatic agents in facilitating growth of fungal species. We aim to determine the possibility of these to serve as a nutrient source for fungal growth.

METHODS

Cultures of Aspergillus, Fusarium, and Mucor were harvested and placed in solution in sterile saline at standardized high and low concentrations. Thrombin gelatin matrix, carboxyl methylcelluose, and potato starch derivative agents were prepared following manufacturer instructions and applied to two separate Petri dishes per agent. Each substrate was then inoculated with either high or low concentrations of fungal species. Negative and positive control plates with each organism were included. Dishes were sealed, incubated, and examined daily for fourteen days for microscopic and macroscopic growth.

RESULTS

Thrombin gelatin matrix was relatively resilient to growth, although Fusarium growth was noted on all packing material by day three. Carboxyl methylcellulose also supported growth of high-concentration Mucor appreciated on day five. The potato starch derivative supported fulminant growth of all fungal species.

CONCLUSIONS

Endonasal hemostatic agents may be nutrient sources that facilitate growth of fungal species. This may be a consideration in a surgeon's decision to use a hemostatic agent. Prompt initial post-operative debridement may be warranted in select patients. Our findings serve as a model for further testing of fungal growth on other hemostatic materials. Future studies are needed to confirm the clinical significance of these findings in vivo.

Multiple bioabsorbable corticosteroid-eluting stent placement with associated skull base injury

Bioabsorbable corticosteroid-eluting sinus stents (BCES) are used to optimize healing after sinus surgery. We report a patient with BCES placed through a dural defect. A 70 year old underwent sinus surgery. Postoperatively, the patient developed mental status changes. The patient was taken to the operating room and eight BCES were identified, with one extending through the skull base. The stents were extracted and the defect was repaired. The patient recovered well. This is the first significant complication associated with BCES. Thorough review of preoperative imaging, understanding of skull base anatomy, and careful use of BCES are critical for safety. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1494-1496, 2019.

Efficacy of hyaluronic acid and hydroxyethyl starch in preventing adhesion following endoscopic sinus surgery

Adhesion is a major complication of endoscopic sinus surgery that may lead to recurrence of chronic rhinosinusitis, necessitating revision surgery. The purpose of this study was to evaluate the effect of hyaluronic acid and hydroxyethyl starch (HA-HES) relative to hyaluronic acid and carboxymethylcellulose (HA-CMC) with regard to anti-adhesion effect. In this multi-center, prospective, single-blind, randomized controlled study, 77 consecutive patients who underwent bilateral endoscopic sinus surgery were enrolled between March 2014 and March 2015. HA-HES and HA-CMC were applied to randomly assigned ethmoidectomized cavities after the removal of middle meatal packing. At the 1st, 2nd and 4th weeks after surgery, the presence and grades of adhesion, edema, and infection were, respectively, examined via endoscopy by a blinded assessor. The incidence and grades of adhesion at the 2-week follow-up were significantly less in the HA-CMC group than in the HA-HES group (p < 0.05). However, with the exception of week 2, there were no significant differences in the incidence or grades of adhesion, edema, and infection between the two groups. When the primary endpoint-the presence of adhesion at the 4-week follow-up-was compared between two groups, the incidence of adhesion in HA-HES group at the 4-week follow-up was 32% and in HA-CMC was 41.3%, indicating that HA-HES was not inferior to HA-CMC in terms of anti-adhesive effect. No severe adverse reactions were noted during the study period. In conclusion, HA-HES is a safe substitutional anti-adhesion agent that has equivalent effect as HA-CMC after endoscopic sinus surgery.

Evaluation of a steroid releasing sinus implant for the treatment of patients undergoing frontal sinus surgery for chronic rhinosinusitis

INTRODUCTION

Management of the frontal sinus places great demands on the otolaryngologist. Given that the fronto-ethmoidal region is susceptible to recurrent inflammation, scarring, and stenosis, maintaining long-term patency of the frontal sinus is a difficult challenge. Oral and topical anti-inflammatory therapy, post-operative stenting, and 'home-brew' drug elution have been used for the treatment of the frontal sinus with mixed success. Recently an implant has been approved for post-operative placement into the frontal recess. This implant provides reliable and consistent steroid drug elution to address inflammation of the frontal recess secondary to chronic sinusitis. Areas covered: This review discusses the development and application of steroid eluting implants in the postoperative care of patients with chronic frontal sinusitis. All randomized controlled trials evaluating steroid eluting implants are discussed. Relevant supporting material discussing background, economics, safety are included. Expert commentary: Steroid eluting implants fulfill a unique niche in the treatment following frontal sinus surgery. They are shown to decrease the need for post-operative interventions and improve outcomes in patients with chronic sinusitis. There is significant potential for growth in the use of steroid eluting implants.

Current trends in topical therapies for chronic rhinosinusitis: update and literature review

INTRODUCTION

Chronic rhinosinusitis (CRS) affects millions of patients worldwide. The disease is multifactorial with influences including anatomic factors, immunological disturbances, and altered sinonasal microbiome. Although oral medications are effective in controlling some symptoms, they are associated with side effects and long-term use is not ideal. Thus, topical therapies have emerged as an alternative delivery method for localized, high-concentration medication with less side effects. Areas covered: This is a review of the various topical therapies available or under investigation for the management of CRS. Common medications such as saline, steroids, and antimicrobials will be discussed. Furthermore, additives including manuka honey, xylitol, surfactant, N-chlorotaurine, Dead Sea salt, and sodium hyaluronate will be addressed. Innovations in topical therapies, such as drug-eluting biomaterials and photodynamic therapy, will also be reviewed. Expert opinion: Although topical therapies provide a high dose of active substance at the site of disease, their efficacy in CRS is not clear. Topical saline and intranasal steroids appear to consistently demonstrate therapeutic benefits. However, other topical medications require further investigation to determine long-term clinical efficacy and safety. A better understanding of their effects on the sinonasal mucociliary system is needed before they become the standard of care in CRS.