Function and structure of the nasal mucosa after 6 weeks' use of nose-drops

Novel nasal formulation of xylometazoline with hyaluronic acid: In vitro ciliary beat frequency study

Acute viral rhinosinusitis (viral ARS), or commonly referred to as the "common cold", is caused by respiratory viruses that cause disruption of the airway epithelial barrier and mucociliary dysfunction. Treatment of ARS is mainly symptomatic, with xylometazoline, a direct-acting α-adrenoceptor agonist, commonly used as a nasal decongestant. Unfortunately, this treatment does not resolve the epithelial dysfunction observed in ARS, and its use might negatively impact the nasal mucosa causing issues such as dryness, stinging, burning, rebound congestion, as well as atrophy. In light of this, a novel nasal spray formulation containing both xylometazoline and hyaluronic acid (HA) was developed to provide a more effective and safer treatment for viral ARS. HA is a natural polysaccharide known to hydrate and moisturise the upper respiratory tract, maintain the integrity of the nasal mucosa, and promote mucociliary clearance and wound healing. To investigate the potential of this combination, this study was conducted using the nasal MucilAirTMin vitro model and high-speed phase-contrast microscopy to examine the effect of xylometazoline and HA on ciliary function by measuring ciliary beat frequency and their cytotoxicity by morphological, histological and ultrastructural analysis. This research is the first to assess the effects of a specific dose and molecular weight of HA as an active pharmaceutical ingredient in nasal spray formulations. The combination of a fast-acting decongestant and an additional active agent targeting nasal epithelial dysfunction has the potential to provide an improved, reliable and safe treatment for viral ARS, and may serve as the basis for future clinical studies.

Allergic and Nonallergic Rhinitis. Classification and Pathogenesis: Part II. Nonallergic Rhinitis

Part I of this review classified and defined the causes of chronic rhinitis, describing in detail the etiology and pathophysiology of allergic rhinitis. Part II focuses on the nonallergic (non-IgE) causes of chronic rhinitis, concentrating on their clinical presentations, differential characteristics, and known or speculative pathophysiology. A comprehensive understanding of the allergic and nonallergic conditions associated with symptomatic rhinitis should aid the clinician in the appropriate diagnosis and treatment of patients with chronic rhinitis.

Therapeutic management of allergic diseases

Allergic diseases are characterized by the activation of inflammatory cells and by a massive release of mediators. The aim of this chapter was to describe succinctly the modes of action, indications, and side effects of the major antiallergic and antiasthmatic drugs. When considering the ideal pharmacokinetic characteristics of a drug, a poorly metabolized drug may confer a lower variability in plasma concentrations and metabolism-based drug interactions, although poorly metabolized drugs may be prone to transporter-based disposition and interactions. The ideal pharmacological properties of a drug include high binding affinity, high selectivity, and appropriate association and dissociation rates. Finally, from a patient perspective, the frequency and route of administration are important considerations for ease of use.

Effect of oxymetazoline on healthy human nasal ciliary beat frequency measured with high-speed digital microscopy and mucociliary transport time

OBJECTIVES

We investigated the effects of oxymetazoline hydrochloride on the regulation of healthy human nasal ciliary beat frequency (CBF) and its influence on nasal mucociliary transport time (MTT).

METHODS

Changes in (cultured) human nasal CBF in response to increasing concentrations of oxymetazoline within 20 minutes were quantified by use of high-speed digital microscopy. Moreover, the MTT before and after application of 0.05% oxymetazoline was determined by use of the saccharin test.

RESULTS

Whereas no statistically significant difference was identified when compared to basal CBF at the concentration of 0.025% or 0.05%, both 0.10% and 0.20% oxymetazoline induced a significantly lower CBF at the end of the observation period. The decrement induced by 0.20% oxymetazoline appeared earlier. At concentrations ranging from 0.025% to 0.20%, the inhibitory effect was dependent on the concentration of oxymetazoline. In addition, the use of 0.05% oxymetazoline increased the mean (+/- SD) human nasal MTT from 474 +/- 21 seconds to 572 +/- 41 seconds (n = 29).

CONCLUSIONS

The clinical concentration of oxymetazoline, 0.05%, has no obvious inhibitory effect on human nasal CBF in vitro. The increased MTT caused by 0.05% oxymetazoline in vivo is within the normal range.

Techniques d’étude pharmacologique et clinique de l’obstruction nasale : application à la xylométazoline

Nasal obstruction, a prominent feature of rhinitis, may be quantified in humans by haemodynamic techniques (measuring local blood flux), static methods (measuring the geometry of nasal cavities) and dynamic methods (assessing the patency of nasal airways through the measure of resistance to air flow). These methods demonstrated the nasal decongestant activity of xylometazoline in healthy volunteers and rhinitis patients. Controlled double-blind studies established the clinical efficacy of xylometazoline in infectious and allergic (seasonal and perennial) rhinitis versus placebo and in comparison with various reference substances. The effects on nasal epithelium ciliary activity which are observed in vitro are modest and even less pronounced in vivo owing to dilution in situ and protective physiological processes.

Rhinitis medicamentosa: a review of causes and treatment

Rhinitis medicamentosa (RM) is a drug-induced, nonallergic form of rhinitis that is associated with prolonged use of topical vasoconstrictors, i.e. local decongestants. Symptoms are exacerbated by the preservative benzalkonium chloride (BKC) in the nasal preparations. Nasal stuffiness is caused by rebound swelling of the mucosa when the decongestive effect of the drug has disappeared. To alleviate this symptom, patients gradually start using larger doses of the vasoconstrictor more frequently. In many cases, the patient is unaware of the condition, thus entering a vicious circle of self-treatment. Careful questioning is required during consultation to establish diagnosis. The pathophysiology of the condition is unclear; however, vasodilatation and intravascular edema have both been implicated. Management of RM requires withdrawal of topical decongestants to allow the damaged nasal mucosa to recover, followed by treatment of the underlying nasal disease. Topical corticosteroids such as budesonide and fluticasone propionate should be used to alleviate rebound swelling of the nasal mucosa. Where possible, avoiding exposure to BKC is recommended.

A study of the effect of nasal steroid sprays in perennial allergic rhinitis patients with rhinitis medicamentosa

OBJECTIVE

To determine if rebound congestion can be reduced with concomitant nasal steroid spray usage.

STUDY DESIGN AND SETTING

Randomized, double blind, controlled single center study.

PARTICIPANTS

Twenty subjects with perennial allergic rhinitis with nasal congestion.

INTERVENTION

All subjects received 3 weeks of twice-daily oxymetazoline. After 2 weeks, subjects were randomized to 2 additional weeks of concomitant budesonide aqueous nasal spray (n = 9) or placebo (n = 10). In the sixth week, all sprays were stopped.

RESULTS

Both groups showed subjective and objective evidence of rebound congestion 24 hours after cessation of oxymetazoline (P < 0.05). Subjective rebound congestion resolved in 48 hours in the budesonide aqueous nasal spray group but persisted for over 1 week in the placebo group.

CONCLUSION

Rebound congestion is objectively present in patients with perennial allergic rhinitis after 3 weeks of oxymetazoline spray. Rebound congestion is reduced by concomitant budesonide aqueous nasal spray use.

SIGNIFICANCE

This study supports the common clinical practice of nasal steroid sprays to ameliorate rebound congestion concomitant with and after cessation of topical decongestant sprays.

Nasal mucociliary transport in pregnancy

Using the saccharin method, we performed tests of mucociliary function four times during pregnancy and once one month after delivery in 27 women. As the transport distance for saccharin varied from 37 to 65 mm, we used the transport speed for evaluation. Pregnancy rhinitis affects at least 20% of pregnancies. The mucociliary transport speed was higher in the group of women with pregnancy rhinitis, and was reduced during pregnancy in the group of women without that condition. We found no significant correlation between mucociliary transport speed and objectively registered nasal peak expiratory flow index. The pathophysiology of pregnancy rhinitis is not known, but is possibly multifactorial. The changes occurring in the nasal mucociliary transport system during normal pregnancy and in pregnancy rhinitis need further studies.

Nasal Congestion: A Review of its Etiology, Evaluation, and Treatment

The most common clinical syndromes that cause nasal congestion are allergic rhinitis, vasomotor rhinitis, chronic sinusitis, and upper respiratory viral infections (common colds). Nasal congestion, in turn, can lead to sequelae such as sinusitis, otitis media, and the onset or worsening of mild to severe sleep disturbances, including obstructive sleep apnea. There is a host of conservative treatments, including decongestant pharmacotherapy, antiallergy measures, and nasal dilation devices. Several surgical procedures are also available. This article reviews the current guidelines for the workup and diagnosis of nasal congestion and briefly describes the many and varied approaches to treatment.

Adverse effects of benzalkonium chloride on the nasal mucosa: allergic rhinitis and rhinitis medicamentosa

Prolonged, repeated use of nasal decongestants for symptomatic relief of allergic rhinitis often results in rhinitis medicamentosa (RM), a condition involving "rebound swelling" and additional congestion. Most decongestant sprays contain the preservative benzalkonium chloride (BKC), which causes toxic reactions in the nose, eyes, ears, and lungs, and may exacerbate the symptoms of allergic rhinitis. Recent studies demonstrate the effects of nasal sprays containing BKC or the decongestant oxymetazoline (OXY) in the development of RM. Using rhinostereometry, a technique that measures nasal mucosal swelling and nasal reactivity (with histamine challenge tests), prolonged use of OXY has been shown to induce nasal mucosal swelling and hyperreactivity. Sustained use of BKC alone induces nasal mucosal swelling and, in combination with OXY, BKC appears to have a long-term adverse effect on nasal mucosa. Its presence may also contribute to the RM resulting from overuse of decongestant sprays. Additional research is needed to confirm the deleterious effects of BKC in nasal products. However, these potential effects may be points of clinical differentiation in the treatment of allergic rhinitis and prevention of RM.

Rhinitis medicamentosa: aspects of pathophysiology and treatment

With modern vasoconstrictors, such as oxy- and xylometazoline, the risk of developing rhinitis medicamentosa (RM) has been considered to be small or even nonexistent. However, recent studies have shown that overuse of these drugs may result in rebound congestion, nasal hyperreactivity, tolerance, and histologic changes of the nasal mucosa. Using rhinostereometry, it has also been shown that the long-term use of the preservative benzalkonium chloride (BKC) in oxymetazoline nasal spray accentuates the severity of rhinitis medicamentosa in healthy volunteers. A nasal decongestant spray composed of a combination of vasoactive substances and BKC has a long-term adverse effect on the nasal mucosa. BKC alone induces mucosal swelling after 30 days use of the nasal spray in healthy subjects, unlike placebo. According to the author, rhinitis medicamentosa can be defined as a condition of nasal hyperreactivity, mucosal swelling, and tolerance that is induced, or aggravated, by the overuse of topical vasoconstrictors with or without a preservative. An adequate treatment of these patients consists of a combination of vasoconstrictor withdrawal and a topical corticosteroid to alleviate the withdrawal process. The underlying nasal disorder must then be treated. Patients with rhinitis medicamentosa who overuse topical decongestants and are able to stop using such drugs should be careful about taking these drugs again, even for a few days. They must be informed about the rapid onset of rebound congestion upon repeated use in order to avoid the return of the vicious circle of nose-drop abuse.

One year follow-up of patients with rhinitis medicamentosa after vasoconstrictor withdrawal

The aim of the study was to systematically follow-up 10 patients with rhinitis medicamentosa for at least 1 year after vasoconstrictor withdrawal. During withdrawal of the decongestants the patients used budesonide nasal spray, 400 micrograms/day, for 6 weeks. The thickness of the nasal mucosa, the decongestive effect of oxymetazoline, and the histamine sensitivity were measured with rhinostereometry during the period. The thickness of the nasal mucosa and the symptom scores of nasal stuffiness were reduced considerably 6 and 12 months after vasoconstrictor withdrawal. The histamine sensitivity reflecting nasal hyperreactivity was still increased after 6 months, but not after 1 year. The decongestive effect of oxymetazoline increased after 6 months, indicating reversible tolerance. We conclude that when given adequate treatment and information about nose-drop overuse, all patients were able to stop using the vasoconstrictors and no one relapsed into a daily long-term overuse of vasoconstrictors during the 1-year follow-up period.

Effect on the nasal mucosa of long-term treatment with oxymetazoline, benzalkonium chloride, and placebo nasal sprays

A parallel, randomized, double-blind study was performed in 30 healthy subjects to investigate the effects on the nasal mucosa of a 1-month treatment with nasal sprays. Ten subjects received oxymetazoline nasal spray; 10 subjects used a nasal spray containing the preservative benzalkonium chloride, and the others were treated with a placebo nasal spray. The three variables that were studied --nasal mucosal swelling, symptom scores, and nasal reactivity-- were estimated by histamine challenge before and after 28 days of treatment. Rhinostereometry was used to measure nasal mucosal swelling and nasal reactivity. After 28 days of use, benzalkonium chloride spray alone induced an increase in nasal mucosal swelling. At the end of the month, the score for nasal stuffiness was significantly higher for the group treated with oxymetazoline than for those treated with benzalkonium chloride. Oxymetazoline nasal spray induced a pronounced increase in nasal reactivity, which was significantly greater than that induced in the placebo group. Long-term use of placebo and benzalkonium chloride nasal sprays also caused an increase in nasal reactivity, but not to the same extent as with the nasal sprays containing oxymetazoline. The authors concluded that long-term use of oxymetazoline induces a sensation of nasal stuffiness, which may be due to unconscious exaggeration of the degree of nasal stuffiness, induced nasal hyperreactivity, or a combination of both. These factors are probably the main reasons for the prolonged use of nasal decongestive sprays and the development of rhinitis medicamentosa. Benzalkonium chloride induces mucosal swelling, which explains why the presence of this preservative in a decongestant spray aggravates rhinitis medicamentosa.

Effects of topical nasal decongestants on histology of nasal respiratory mucosa in rabbits

The aim of this study was to evaluate histologic changes after long-term administration of the topical nasal decongestants phenylephrine and oxymetazoline. Ninety healthy rabbits were divided into 3 groups for topical administration for 1 week, 2 weeks, and 4 weeks. Each group was subdivided into 3 subgroups by topical administration of phenylephrine. oxymetazoline, and physiologic saline as controls. Each study group thus consisted of 10 rabbits. Phenylephrine was administered by 2 puffs in the left nostril 5 times daily and oxymetazoline by 2 puffs twice a day using metered sprayers giving 0.10 ml in each puff with a dosage used in clinical practice. For statistical significance the Kolmogorov-Smirnov test was used. Light and electron microscopic examination were performed after obtaining nasal respiratory mucosa from the nasal septum of the rabbits. Administration of phenylephrine and oxymetazoline for more than 2 weeks caused histologic changes including ciliary loss, epithelial ulceration, inflammatory cell infiltration and subepithelial edema, and the changes were more pronounced with increasing administration duration of the decongestants. Ciliary loss was prominent in the 4-week phenylephrine and oxymetazoline groups. There were significantly severer changes in the morphologic variables in the decongestant groups compared with the control group according to administration duration (p < 0.05). Dilatation or vacuolization of mitochondria and endoplasmic reticula and vesicles ill the cytoplasm were observed in the 2- and 4-week phenylephrine groups as well as the 2- and 4-week oxymetazoline groups. Mild widening of the intercellular space was observed in the 4-week phenylephrine group. Purulent maxillary sinusitis developed in 6 of 10 rabbits treated for 4 weeks with phenylephrine. The results of this study suggest that the administration of decongestants may cause ciliary loss with subsequent inflammatory changes in the nasal respiratory mucosa.

Benzalkonium chloride in a decongestant nasal spray aggravates rhinitis medicamentosa in healthy volunteers

A randomized double-blind parallel study with 20 healthy volunteers was performed to research the effect of a preservative in a decongestant nasal spray on the development of rhinitis medicamentosa. Ten subjects received oxymetazoline nasal spray with benzalkonium chloride and the others used oxymetazoline nasal spray without the preservative three times daily for 30 days. Before starting the course of treatment and after its conclusion, recordings of the mucosal surface positions were made with rhinostereometry followed by histamine challenge tests. Symptoms of nasal stuffiness were estimated on visual analogue scales (0-100) in the morning and the evening just before using the nasal spray. After 30 days, rebound swelling and nasal stuffiness were found in both groups. In the group receiving oxymetazoline nasal spray with benzalkonium chloride the mean rebound swelling was 1.1 mm and the estimated mean evening symptom score for nasal stuffiness was 43. In the group without benzalkonium chloride the corresponding variables were significantly less marked, with a mean rebound swelling of 0.5 mm (P < 0.05) and a mean evening symptom score of 25 (P < 0.05). The increase in histamine sensitivity in both groups was interpreted as a sign of nasal hyperreactivity. A new type of nasal spray bottle was used that has been shown to prevent bacterial contamination. In conclusion, the long-term use of benzalkonium chloride in oxymetazoline nasal spray accentuates the severity of rhinitis medicamentosa in healthy volunteers.

Inhibition of human neutrophil actin polymerization, phagocytosis and oxidative burst by components of decongestive nosedrops

Human neutrophil functions have been examined after exposure of leukocytes to components of decongestive nosedrops in vitro. Both the vasoactive components oxymethazoline chloride and xylomethazoline chloride, as well as the preservative benzalkonium chloride, showed a concentration- and time-dependent deleterious effect on neutrophil actin polymerization, phagocytosis and oxidative burst. The most toxic of the drug components was benzalkonium chloride, which in the commercial nosedrops tested was present in concentrations about 20 times higher than that compatible with intact neutrophil functions. These findings suggest possible inhibition of mucosal neutrophil activity following exposure to nosedrops in vivo, and support earlier reports that have questioned the use of preservatives in decongestive nosedrops.

Computer-assisted video measurement of inhibition of ciliary beat frequency of human nasal epithelium in vitro by xylometazoline

The effect of xylometazoline, an alpha-adrenergic agonist, on ciliary beat frequency (CBF) was tested on samples of human nasal epithelium in vitro. Ciliated tissue was obtained from the inferior nasal turbinates of five normal individuals. CBF was measured from video recordings of ciliary activity using a computer-assisted photometric technique. The mean CBF of cells from the five subjects, followed for 40 min without xylometazoline, was 12.0 +/- 1.1 Hz. All concentrations of xylometazoline significantly decreased ciliary beat frequency. After a 10-min exposure, the mean CBF dropped to 3.8 +/- 0.4 with 0.1% xylometazoline, 4.9 +/- 1.0 with 0.05%, and 8.1 +/- 0.9 with 0.025%. Washing with control culture medium at least partially reversed the inhibition within 10 min. Phentolamine (10(-3) M), an alpha-adrenergic antagonist, did not alter CBF significantly when used alone, but partially blocked the strong cilioinhibitory effect of xylometazoline. This action of xylometazoline is similar to that of several commercially prepared decongestants that contain potentially ciliotoxic preservatives in addition to alpha-adrenergic agonists and supports the view that alpha-adrenergic agonists act directly on ciliated cells to inhibit ciliary activity.

Nasal decongestant effect of oxymetazoline in the common cold: an objective dose-response study in 106 patients

Oxymetazoline has been used as decongesting nosedrops for more than 25 years but so far no objective dose-response study of the drug has been published. In this double-blind clinical trial the decongestant effect on the nasal mucosa by the doses and concentrations traditionally used of oxymetazoline were studied. In 106 men with acute infectious rhinitis, a significant dose-response relationship was found when the decongestant effect was measured objectively by anterior rhinomanometry and subjectively by symptom scores. The concentration and volumes of the drug recommended from clinical experience seem to be adequate.

The inhibition of granulocyte phagocytosis by various components of nasal drops

The effect of two decongestive substances and two preservatives used in nasal drops on phagocytosis by human granulocytes was studied. The vasoactive substances oxymetazoline chloride and zylometazoline chloride incubated with human granulocytes during 20 min. gave a reduction of phagocytosis to almost zero when using concentrations found in commercially used nasal drops (500 mg/l respectively 1000 mg/l). However, a dilution of 1:100 was consistent with an almost normal phagocytic function. The preservatives benzalkonium chloride and thiomersal gave a dose related reduction of phagocytosis down to zero. A dilution of 1:100 of the benzalkonium chloride solution used commercially (200 mg/l) and a dilution of 1:10 of the thiomersal solution used commercially (24 mg/l) were needed to get an almost normal phagocytic function. These results together with previous studies indicate that the addition of preservatives in nasal drops should be questioned, excluded or replaced with other less harmful substances.

Influence of topical phenylpropanolamine on tachyphylaxis and mucociliary clearance in the human nose

Topical nasal phenylpropanolamine in a 2.5 per cent solution (PPA) was used in an evaluation of the possible development of tachyphylaxis and of possible effects on the mucociliary system after one week of treatment in healthy humans. The tendency of PPA to produce tachyphylaxis was evaluated by rhinomanometrie measurements of nasal airway resistance after repeated dose-response provocations. The mucociliary transport time was tested with the saccharine-dye test. No reduced dose-response effect or change in mucociliary transport time was found with PPA, thus indicating that one week of treatment does not contribute to such adverse effects.