Effect of sodium hyaluronate added to topical corticosteroids in chronic rhinosinusitis with nasal polyposis

Efficacy of hyaluronic acid in the treatment of nasal inflammatory diseases: a systematic review and meta-analysis

Background: Hyaluronic acid (HA), the main component of the extracellular matrix, has the ability to promote tissue repair and regulate inflammation. It is used in otolaryngology as an adjuvant treatment to alleviate postoperative nasal symptoms. However, there is currently insufficient evidence demonstrating the therapeutic efficacy of HA for patients with nasal inflammatory diseases (NIDs). Therefore, this study aimed to evaluate the efficacy and safety of topical HA in the treatment of NID patients without receiving surgery. Methods: In this meta-analysis, comprehensive searches were conducted in PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science. Keywords searched included "hyaluronic acid," "sinusitis," "allergic rhinitis," "rhinitis," and "randomized controlled trials (RCTs)." The Cochrane Collaboration's "Risk of Bias Assessment" tool was used to assess the quality of the included trials, and the meta-analysis was performed using the RevMan 5.3 and STATA 15 statistical software. Results: A total of 11 articles and 825 participants were enrolled. For the primary outcomes, the pooled results revealed that HA significantly improves nasal obstruction (SMD, -0.53; 95% CI, -0.92 to -0.14; p = 0.008; and I2 = 79%) and rhinorrhea (SMD, -0.71; 95% CI, -1.27 to -0.15; p = 0.01; and I2 = 90%) in patients with NIDs. As for the secondary outcomes, the pooled results demonstrated that when compared with the control group, HA could significantly improve nasal endoscopic scores (p < 0.05), rhinitis scores (p < 0.05), rhinomanometry (p < 0.05), nasal neutrophils (p < 0.05), and mucociliary clearance (p < 0.05). However, no significant differences were observed between the two groups regarding nasal itching, sneezing, hyposmia, quality-of-life scores, and nasal eosinophils. For the risk of bias, 54.5% and 45.5% of trials had a low risk of bias in the randomization process and deviation of the intended intervention, respectively. Conclusion: In the present study, the results reveal that HA might ameliorate symptoms of patients with NIDs. However, more clinical trials with larger participant cohorts are required to confirm this result. Systematic review registration number: clinicaltrials.gov, identifier CRD42023414539.

QoL Following Dacryocystorhinostomy: Linguistic Adaptation of Italian Version of GBI

The Glasgow Benefit Inventory (GBI) is a generic patient recorded outcome measure assessing the quality of life of patients undergoing ear nose and troth surgery. Although largely used in the clinical practice, it has never been adapted and validated in the Italian language. The aim of the study was to translate the original GBI from English to Italian and to examine its reliability for use in the Italian adult population of patients undergoing endonasal endoscopic dacryocystorhinostomy. After translation and back-translation of the original English we evaluated the reliability of GBI for use in 79 Italian adults undergoing dacryocystorhinostomies. Reliability of GBI-IT was examined by the internal consistency of the scale (using the Cronbach's alpha coefficient), and by the test-retest analysis. The GBI-IT showed adequate internal consistency (Cronbach's alpha = 0.85 for the total scale). The total GBI-IT score showed a strong correlation in retests (CCC 0.87). In conclusion, our study showed that the GBI-IT has satisfactory internal consistency and reliability and is equivalent to the original English version. In addition, it can be considered a valuable measure for both clinical and research uses.

In situ gelling nanosuspension as an advanced platform for fluticasone propionate nasal delivery

In this work we present the development of in situ gelling nanosuspension as advanced form for fluticasone propionate nasal delivery. Drug nanocrystals were prepared by wet milling technique. Incorporation of drug nanocrystals into polymeric in situ gelling system with pectin and sodium hyaluronate as constitutive polymers was fine-tuned attaining appropriate formulation surface tension, viscosity and gelling ability. Drug nanonisation improved the release profile and enhanced formulation mucoadhesive properties. QbD approach combining formulation and administration parameters resulted in optimised nasal deposition profile, with 51.8% of the dose deposited in the middle meatus, the critical region in the treatment of rhinosinusitis and nasal polyposis. Results obtained in biocompatibility and physico-chemical stability studies confirmed the leading formulation potential for safe and efficient nasal corticosteroid delivery.

Clinical Practice Guideline: Nasal Irrigation for Chronic Rhinosinusitis in Adults

The Korean Society of Otorhinolaryngology-Head and Neck Surgery and Korean Rhinologic Society appointed a guideline development group (GDG) to establish a clinical practice guideline, and the GDG developed a guideline for nasal irrigation for adult patients with chronic rhinosinusitis (CRS). The guideline focuses on knowledge gaps, practice variations, and clinical concerns associated with nasal irrigation. Nasal irrigation has been recommended as the first-line treatment for CRS in various guidelines, and its clinical effectiveness has been demonstrated through a number of studies with robust evidence. However, no guidelines have presented a consistent nasal irrigation method. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. The committee developed 11 evidence-based recommendations. This guideline focuses on the evidence-based quality improvement opportunities deemed the most important by the GDG. Moreover, the guideline addresses whether nasal lavage helps treat CRS, what type of rinsing solution should be used, and the effectiveness of using additional medications to increase the therapeutic effect.

Rehabilitation of patients with chronic rhinosinusitis after functional endoscopic sinus surgery

Introduction. In the case of many patients with chronic rhinosinusitis (CRS), antibiotic and steroid therapies fail, and surgery is required. The recovery of patients after surgery equally depends on the postoperative behavior of each individual patient. The paper presents the outcomes of recovery after functional endoscopic sinus surgery (FESS) in a group of 74 patients. Methods. The study was conducted in patients undergoing surgical treatment by FESS, performed by the same surgeon. For the development of the statistical database, the clinical records were collected by the same investigator. Results. On the day of surgery and on the first postoperative day, 72.9% of patients reported facial pain, 41.8% nausea, 9.4% nasal bleeding, 8.8% vomiting. At 6 months postoperatively, 71.6% of patients estimated that they had a better quality of life than before surgery, 64.8% mentioned an improvement of olfaction as an effect, and 6.7% developed septal turbinate synechiae. Conclusions. No major complications were identified in the recovery of CRS patients after FESS. Postoperative facial pain was less well tolerated by young patients (18-35 years old). The improvement of smell and the increase of disease-specific quality of life are the most relevant results of recovery after FESS mentioned by the patients included in our study. The otorhinolaryngologist and the family doctor play an important role in the education of patients regarding the importance of treatment with mineral and thermal waters in post-FESS recovery. Keywords: chronic rhinosinusitis, endoscopic sinus surgery, FESS, rehabilitation, ERAS protocols,

Effectiveness of micronized nasal irrigations with hyaluronic acid/isotonic saline solution in non-polipoid chronic rhinosinusitis: A prospective, randomized, double-blind, controlled study

BACKGROUND

Sodium hyaluronate has been proposed as a treatment for improving the symptoms of chronic rhinosinusitis. The present study evaluated the effect of the intranasal administration of hyaluronic acid in a group of patients affected by chronic rhinosinusitis without nasal polyps (CRSsNP).

MATERIALS AND METHODS

Thirty subjects aged 18-65 years affected by CRSsNP were enrolled. The subjects were randomly administered hyaluronic acid or isotonic saline solution by nasal nebulizer twice per day for 30 days. They were evaluated before (T0) and after the treatment (T1) with Sino-Nasal Outcome Test-22, visual analogue scale for rhinorrhea, nasal obstruction, facial pain and hyposmia/hypogeusia, nasal endoscopy, active anterior rhinomanometry, peak nasal inspiratory flow and nasal cytology.

RESULTS

Comparing the study and the control group, at T1 no significant differences were observed in both objective and subjective parameters. Being included in the study group rather than in the control group did not have a significant effect on the variation of the considered parameters between T0 and T1. Considering the effects of the micronized douches independently from the type of solution used (either hyaluronic acid or isotonic saline solution), although no difference emerged between study and control group for any of the objective parameters, there was an improvement of Sino-Nasal Outcome Test-22 scores (p = .0005), visual analogue scale for nasal obstruction (p = .0006) and for hyposmia/hypogeusia (p = .04).

CONCLUSIONS

The treatment with micronized nasal douches can improve the sino-nasal symptoms of CRSsNP, in particular nasal obstruction and olfactory ability. No advantage of the use of hyaluronic acid over isotonic saline solution emerged.

Unusual Localization of an Emergent Bacterium, Raoultella ornithinolytica

Raoultella ornithinolytica is a bacterium belonging to the family Enterobacteriacae. It is a rare but emergent cause of human pathologies especially in immunocompromised patients. We described the first case in the literature of isolated external otitis sustained by Raoultella ornithinolytica in an immunocompetent host. A 54-year-old Caucasian man with a history of previous myringoplasty came to our attention reporting otalgia and otorrhea. We performed right ear swab for culture examination, meanwhile we started empirical therapy with topic administration of neomycin, without any clinical improvement. The cultural examination showed the presence of a Raoultella ornithinolytica infection. After ten days of treatment with oral ciprofloxacin and topic levofloxacin, there was the complete resolution of pain and inflammation. Raoultella ornithinolytica must be taken into consideration as an emergent cause of human infection, also in case of external otitis. Infection can be severe and can occur both in immunocompromised and in immunocompetent hosts. Culture test is mandatory to choose the proper therapy and avoid potential severe complications.

Septoplasty: is it possible to identify potential "predictors" of surgical success?

Septoplasty is one of the most frequent surgical procedures performed by otolaryngologists. Despite successful surgical correction, many patients are not satisfied with their outcomes. So far, in clinical practice there is no consensus of opinion about the reliability of objective measurements of nasal patency and the correlation between objective measurements and subjective nasal patency symptoms. This study aims to assess the reasons for patient dissatisfaction after septoplasty and optimise pre-operative diagnostic management to predict surgical outcomes. We analysed 494 patients undergoing septoplasties with turbinoplasty by subjective Nasal Obstruction Symptom Evaluation questionnaire (NOSE) and objective active anterior rhinomanometric measurements before surgery and after 6 months. In our series, 17% had postoperative septal re-displacement; all patients had an anterior deviations at baseline. We found that the type of septal deviation, anterior vs posterior, was a significant predictor of postoperative functional improvement, whereas demographic characteristics as age, gender and smoke habit were not. Our data suggest that the anterior segment of the nasal septum was the most critical area for nasal airway resistance and more difficult to manage because it is likely to re-displace vs the posterior one and for this reason it represents a negative predictor of postoperative satisfaction.

Innovative sprayable in situ gelling fluticasone suspension: Development and optimization of nasal deposition

The aim of this study was to develop an innovative in situ gelling suspension for effective nasal delivery of fluticasone. Pectin, gellan gum and sodium hyaluronate were used as gelling/thickening agents, and Tween 80 as a suspending agent. The influence of the formulation and/or administration parameters on formulation sprayability and nasal deposition was explored with an appropriate experimental design with the range for parameters in the design obtained from previous research and domain knowledge. All formulations exhibited appropriate sprayability and instant gelation upon mixing with simulated nasal fluid exhibiting weak gel properties convenient for nasal delivery. Targeted turbinate deposition depended on administration and formulation parameters, including their interactions. Decrease in the administration angle from horizontal plane, increase in inspiratory flow and presence of sodium hyaluronate significantly increased deposition in turbinate region. Parameters in interactions included concentration of polymers, surfactant and fluticasone, as well as administration angle. Selected formulations with high turbinate deposition exhibited significant increase in viscosity upon gelation, showing potential to prolong the drug retention at the nasal mucosa. The highest effect on the gel viscosity, strength and fluticasone release profile was observed for gellan gum, thus recognised as crucial parameter for the optimisation of overall therapeutic effect.

Effects of a Thermosensitive In Situ Gel Containing Mometasone Furoate on a Rat Allergic Rhinitis Model

Background Mometasone furoate, one of the second generation intranasal corticosteroids, is currently used in suspension form due to its poor solubility. However, this is not favorable for nasal application because of the rapid elimination of the instilled drug from the nasal cavity by mucociliary clearance and delayed onset of action due to the slow dissolution of drug in suspension. Objective The aim of this study was to determine the antiallergic effects of mucoadhesive thermosensitive in situ gel containing mometasone furoate that we developed previously to prolong the contact between the drug and nasal mucosa and to prevent drainage of the formulation in an ovalbumin-induced rat model of allergic rhinitis. Methods An experimental allergic rhinitis model was developed in female Wistar albino rats by intraperitoneal injection of ovalbumin every 2 days for 14 days followed by its repeated intranasal instillation for 7 consecutive days. Intranasal instillation of ovalbumin was continued every other day for 14 days. Mometasone furoate in situ gel (5 μg/10 µl), mometasone furoate suspension (5 μg/10 µl), and physiological saline (10 µl) were administered into the bilateral nasal cavities from day 22 to day 35. Antiallergic effects were evaluated through histopathological evaluation, analysis of ovalbumin-specific serum immunoglobulin E, and a symptom score. Results Mometasone furoate in situ gel significantly decreased the nasal symptoms and ovalbumin-specific serum immunoglobulin E level as compared with mometasone furoate suspension and physiological saline. Additionally, inflammatory histological symptoms such as mucosal edema, vascular dilatation, eosinophil infiltration, and loss of cilia within the nasal mucosa of allergic rhinitis model rats were remarkably improved with the treatment of mometasone furoate in situ gel. Conclusion These results suggest that mometasone furoate in situ gel has a better therapeutic potential for the treatment of allergic rhinitis compared to mometasone furoate suspension.

Effectiveness of intranasal sodium hyaluronate in mitigating adverse effects of nasal continuous positive airway pressure therapy

BACKGROUND

Nasal continuous positive airway pressure (CPAP) in moderate-to-severe cases of obstructive sleep apnea can cause nasal discomfort and other undesirable problems.

OBJECTIVE

The aim of our study was to test the effects of sodium hyaluronate on nasal problems that patients experienced in their daily lives, sleepiness, nasal resistance to airflow, nasal mucociliary clearance, changes in inflammatory markers, and compliance to CPAP in three groups of patients with obstructive sleep apnea syndrome on CPAP therapy.

METHODS

A total of 102 patients with a confirmed diagnosis of obstructive sleep apnea syndrome (apnea-hypopnea index [AHI] of ≥10/hour) were randomized into three treatment groups: (1) hyaluronate plus CPAP, (2) saline solution plus CPAP, and (3) CPAP-only groups. Outcome measures were the extent of improvement in the Mini Rhinoconjunctivitis Quality of Life Questionnaire (MiniRQLQ) mean scores, sleepiness, nasal resistance to airflow, nasal mucociliary clearance, changes in inflammatory markers, and compliance to CPAP. Significant improvement in each outcome measure was determined by comparing scores at baseline and after 4 weeks for each treatment group.

RESULTS

Significant improvement in the MiniRQLQ overall mean score was observed both in the hyaluronate plus CPAP (p < 0.00001) and saline solution plus CPAP groups (p < 0.01), although the hyaluronate plus CPAP group had better improvement compared with the saline solution plus CPAP group (0.24 versus 0.12, respectively). An increase in nasal inflammatory markers and saccharin transit test score was observed in all three groups, although it was statistically lower in the hyaluronate plus CPAP group (all p < 0.001).

CONCLUSION

Intranasal hyaluronate showed significant benefits in patients who received CPAP therapy, but future studies over a longer period of time after treatment should be performed to corroborate our findings.

Influence of hyaluronan nasal dressing on clinical outcome after endoscopic sinus surgery: A systematic review and meta-analysis

INTRODUCTION

Hyaluronan nasal dressing might be promising in promoting reepithelialization after endoscopic sinus surgery (ESS). However, the results remain controversial. We conducted a systematic review and meta-analysis to explore the effects of hyaluronan nasal dressing on clinical outcome after ESS.

METHODS

Medical literature data bases were systematically searched. Randomized controlled trials (RCT) that assessed the effect of hyaluronan nasal dressing on the outcome after ESS were included. The results were searched and data were extracted and assessed for quality. The primary outcome was reepithelization. Meta-analysis was performed by using the random-effect model.

RESULTS

Four RCTs, which involved 352 patients, were included in the meta-analysis. Overall, compared with control intervention, hyaluronan nasal dressing significantly promoted reepithelization (odds ratio [OR] 3.18 [95% confidence interval {CI}, 1.33-7.59]; p = 0.009) and reduced edema (OR 0.45 [95% CI, 0.23-0.89]; p = 0.02) after ESS. However, hyaluronan nasal dressing failed to reduce synechia (OR 0.45 [95% CI, 0.19-1.03]; p = 0.06), crust (OR 1.00 [95% CI, 0.20-5.09]; p = 1.00), and infection (OR 0.84 [95% CI, 0.46-1.53]; p = 0.56) compared with the control group in patients who underwent ESS.

CONCLUSION

Compared with "Control intervention" indicates standard nasal dressing without hyaluronan, resorbable hyaluronan nasal dressing could significantly improve reepithelization and decrease edema but had no influence on synechia, crust, and infection after ESS.