Non-diluted seawater enhances nasal ciliary beat frequency and wound repair speed compared to diluted seawater and normal saline

Seawater nasal wash to reduce symptom duration and viral load in COVID-19 and upper respiratory tract infections: a randomized controlled multicenter trial

PURPOSE

The objective was to assess the efficacy of seawater nasal wash on symptom duration, intranasal viral load, household transmission in COVID-19 and URTIs.

METHODS

This prospective, randomized, controlled, multicentric, parallel study included 355 mild/moderate COVID-19 and URTI adults with rhinologic symptoms ≤ 48h. Active group performed 4-daily nasal washes with undiluted isotonic seawater versus control group (without nasal wash). Symptoms were self-assessed daily using the WURSS-21 questionnaire for 3 weeks. Viral load was measured by RT-PCR on nasopharyngeal swabs collected on Day 0, Day 5, Day 14 and Day 21. Digital droplet PCR was additionally performed for SARS-CoV-2.

RESULTS

Overall COVID-19 subjects recovered earlier the ability to accomplish daily activities in the active group (- 1.6 day, p = 0.0487) with earlier improvement of taste (- 2 days, p = 0.0404). COVID-19 subjects with severe nasal symptoms at D0 showed the earliest resolution of anosmia (- 5.2 days, p = 0.0281), post-nasal drip (- 4.1 days, p = 0.0102), face pain/heaviness (- 4.5 days, p = 0.0078), headache (- 3.1 days, p = 0.0195), sore throat (- 3.3 days, p = 0.0319), dyspnea (- 3.1 days, p = 0.0195), chest congestion (- 2.8 days, p = 0.0386) and loss of appetite (- 4.5 days, p = 0.0186) with nasal wash. In URTIs subjects, an earlier resolution of rhinorrhea (- 3.5 days, p = 0.0370), post-nasal drip (- 3.7 days, p = 0.0378), and overall sickness (- 4.3 days, p = 0.0248) was reported with nasal wash. Evolution towards more severe COVID-19 was lower in active vs control, with earlier viral load reduction in youngest subjects (≥ 1.5log10 copies/10000 cells at Day 5: 88.9% vs 62.5%, p = 0.0456). In the active group, a lower percentage of SARS-CoV-2 positive household contacts (0-10.7%) was reported vs controls (3.2-16.1%) among subjects with Delta variant (p = 0.0413).

CONCLUSION

This trial showed the efficacy and safety of seawater nasal wash in COVID-19 and URTIs.

TRIAL REGISTRATION

Trial registry ClinicalTrials.gov: NCT04916639. Registration date: 04.06.2021.

O. K. Efficacy of Normal Saline Nasal Spray Added to Standard Treatment Regimen of Chronic Rhinosinusitis: A Randomised Controlled Trial

Chronic Rhinosinusitis is characterized by inflammation of lining of nose and paranasal sinuses leading to nasal blockage/discharge, facial pressure/pain and loss of smell sensation, generally treated with medical therapy initially. Nasal saline irrigation is one of the treatment modalities commonly used to improve symptoms. The aim was to evaluate efficacy of adding normal saline nasal spray to standard treatment regimen of chronic rhinosinusitis. A randomized, controlled, single blinded study with 40 chronic rhinosinusitis patients. Study group was prescribed Normal Saline nasal spray (1 puff in each nostril, thrice daily) along with topical corticosteroids (Mometasone furoate nasal spray, 1 puff in each nostril, twice daily; 1 puff = 50 µg), and oral antibiotics (Amoxicillin + Clavulanic acid, 30 mg/kg, twice daily), and the control group was only prescribed topical corticosteroids and oral antibiotics. Patients were evaluated using Lund-Kennedy endoscopic scores and Sino-Nasal Outcome Test before and after treatment. There was a significant improvement in LKES, with pre-treatment and post-treatment scores for control group being 5.35 ± 2.43 vs 3.70 ± 1.95 respectively (p = 0.0116), whereas for test group, pre-treatment and post-treatment scores were 8.15 ± 2.62 vs 6.05 ± 2.04 respectively (p = 0.0037). Improvement in SNOT-22 scores were observed as well, with pre-treatment and post-treatment scores for control group being 38.90 ± 12.01 vs 25.70 ± 9.21 respectively (p = 0.0002), whereas for test group, pre-treatment and post-treatment scores were 49.85 ± 11.38 vs 31.55 ± 9.91 respectively (p < 0.0001). The study suggests that there is additional benefit in usage of normal saline in form of symptomatic relief as well as clinical improvement.

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.

[Respiratory physiotherapy in pediatric practice]

Congestion of the upper (URT) and lower respiratory tracts (LRT) is a common symptom in several acute and chronic respiratory diseases that occur in childhood. To eliminate these secretions, airway clearance techniques (ACT) directed to the URT and LRT are frequently prescribed. The rationale for the application of these techniques is the same as in adults, but they need to be adapted to be transposed to children. The physiotherapist will be able to choose among a wide range of techniques, of which the most adequate will depend not only on the age of the child and the indication, but also on the basis of his preferences or habits, as well as those of the child. Upper airway clearance, including nasal irrigation, is now recommended for acute and chronic rhinosinusitis in children. It is also one of the symptomatic treatments recommended for infants with acute bronchiolitis. For LRT clearance, several indications, such as cystic fibrosis, primary ciliary dyskinesia and neuromuscular disease, are now widely advocated. Conversely, other indications, such as for infants with acute viral bronchiolitis, are highly controversial. Thoughtful application of these techniques is lacking in robust and precise tools to objectively assess the presence of bronchial congestion, and to treat it accordingly. Similarly, no precise and reliable evaluation of the effectiveness of these ACTs is available to date. This review is designed to explore the ACTs used by physiotherapists, to provide an overview of their current indications, and to consider complementary approaches.

The Role of Seawater and Saline Solutions in Treatment of Upper Respiratory Conditions

The history of saline nasal irrigation (SNI) is indeed a long one, beginning from the ancient Ayurvedic practices and gaining a foothold in the west at the beginning of the 20th century. Today, there is a growing number of papers covering the effects of SNI, from in vitro studies to randomized clinical trials and literature overviews. Based on the recommendations of most of the European and American professional associations, seawater, alone or in combination with other preparations, has its place in the treatment of numerous conditions of the upper respiratory tract (URT), primarily chronic (rhino)sinusitis, allergic rhinitis, acute URT infections and postoperative recovery. Additionally, taking into account its multiple mechanisms of action and mounting evidence from recent studies, locally applied seawater preparations may have an important role in the prevention of viral and bacterial infections of the URT. In this review we discuss results published in the past years focusing on seawater preparations and their use in clinical and everyday conditions, since such products provide the benefits of additional ions vs. saline, have an excellent safety profile and are recommended by most professional associations in the field of otorhinolaryngology.

Development of an apparatus and procedure for evaluating the efficiency of nasal irrigation

BACKGROUND

Although different methods of nasal irrigation have been utilized, irrigation efficiency in nasal cavities has not been well assessed. The objective of this study was to develop an apparatus and procedure for evaluating the irrigation efficiency and to explore the optimal head position during irrigation.

METHODS

Casts of the left sinonasal cavity from a healthy volunteer were made from high-resolution-computed tomography data using 3D printing with composite materials. An adjustable apparatus that allowed cast fixation at the different head positions was built. The yogurt was used to simulate mucus. The cast with 5 ml yogurt filled around the superior, middle, and inferior turbinate was fixed in six head positions including head tilt 10°, 45°, and 60° forward with or without leaning 30° to the right. The cast was irrigated with 120 ml, 175 ml, and 240 ml dyed water and was video recorded. The irrigation efficiency was calculated based on the weight difference of the cast before and after the irrigation.

RESULTS

Most residual yogurt was located around the superior meatus after the irrigation under different volumes and head positions. The irrigation efficiency of the rinse bottle or the pulsatile device was volume dependent, with the highest irrigation efficiency under 240 ml water. When the left sinonasal cavity was irrigated, the head position of tilt 45° forward with leaning 30° to the right was the optimal head position for these two devices when compared to other positions. The pulsatile device with 240 ml water performed better than the rinse bottle with 240 ml water regarding the irrigation efficiency under the optimal head position (0.8700 ± 0.0138 vs 0.7536 ± 0.0099, p = 0.003).

CONCLUSIONS

The developed apparatus provided a potential method for evaluating the irrigation efficiency. The head position of tilt 45° forward with leaning 30° was suitable for patients to perform the nasal irrigation.

In Vitro Ciliotoxicity and Cytotoxicity Testing of Repeated Chronic Exposure to Topical Nasal Formulations for Safety Studies

Certain active drugs and excipients of nasal formulations may impair ciliary function and mucociliary clearance. The ciliary beat frequency (CBF) is a key parameter for determining mucociliary clearance rate, and in vitro assessments of CBF have proven to be accurate and reproducible. Since topical nasal formulations are applied with repeated doses, it is essential to elucidate their chronic, as opposed to acute, effect on mucociliary clearance and nasal mucosa. The aim of this study was to assess for the first time the ciliotoxicity and cytotoxicity of nasal sprays intended for chronic treatment (with repeated doses) using a previously designed set-up for CBF measurements. For 2 weeks, the 3D nasal MucilAir™ in vitro models were treated daily with undiluted or clinically relevant doses of mometasone nasal spray, placebo nasal spray, culture medium, or they were untreated. We demonstrated a dose-dependent and time-dependent (cumulative) effect of the nasal sprays on ciliary activity and cytotoxicity using CBF measurements and ultrastructural analysis, respectively. Our results indicate that repeated administration of clinically relevant doses of mometasone nasal spray is safe for in vivo use, which is in good agreement with a previous clinical study. Overall, our study suggests that such in vitro assays have great potential for topical nasal drug screening.

Serum, Whole Blood, Hair, and Mucosal Essential Trace Element and Mineral Levels in Children with Verified Chronic Rhinosinusitis Undergoing Functional Endoscopic Sinus Surgery

The objective of the present study was to assess hair, serum, whole blood, and excised tissue essential element content in children with chronic rhinosinusitis (CRS). Eighty-eight children with chronic rhinosinusitis and 66 healthy controls were enrolled in the present study. Evaluation of endoscopic Lund-Kennedy and computed tomography Lund-Mackay scores, as well as tissue sampling, was performed only in children with chronic rhinosinusitis. Assessment of Sino-Nasal Outcome Test-20 (SNOT-20) scores was performed in both cases and controls. Hair, whole blood, blood serum, and excised mucosal tissue (only in patients) analysis was performed using inductively coupled argon plasma mass-spectrometry. The obtained data demonstrate that whole blood Ca, Mg, Se, and Zn, as well as hair Ca, Cu, Mg, and Zn levels in the examined patients were significantly lower as compared with the control values. Only serum Zn concentration in children with CRS exceeded the respective control values, whereas serum Cu levels only tended to decrease in CRS. In turn, hair Fe content in children with CRS exceeded that in healthy controls. Regression analysis demonstrate that hair Ca levels, as well as whole blood Ca, Se, and Zn concentrations, were considered as negative predictors, whereas increased hair iron level was significantly directly associated with CRS. Significant associations between hair, serum, whole blood, and tissue element levels and Lund-Kennedy and Lund-Mackay scores were also revealed. Generally, the obtained data demonstrate that chronic rhinosinusitis is associated with impaired essential metal levels in pediatric patients with chronic rhinosinusitis. The observed alterations may contribute to CRS pathogenesis through modulation of mucociliary clearance, immunity, inflammatory response, and redox environment.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Current Perspective on Nasal Delivery Systems for Chronic Rhinosinusitis

Chronic rhinosinusitis is an upper respiratory disease during which topical drug treatment via the nasal cavity is the most actively utilized therapeutic strategy. In addition to steroids, antibiotics, and antifungal agents, which are widely used in clinical practice, research on novel topical agents to improve the bacterial biofilm or mucociliary clearance remains ongoing. Moreover, owing to the complex structure of the nasal cavity, the effects of nasal drug delivery vary depending on factors related to delivery fluid dynamics, including device, volume, and compounds. In this article, we review methods and compounds that have been applied to chronic rhinosinusitis management and introduce recent advances and future perspectives in nasal drug delivery for upper respiratory diseases.

Paediatric nasal irrigation: The "fencing" method

Nasal irrigation is a grade A recommendation treatment, which is essential in many pathological conditions. Very heterogeneous practices are observed in paediatrics as a result of poor instruction in this technique. We propose to describe the nasal irrigation technique developed by a team of respiratory physiotherapists in Lille for the management of cystic fibrosis and bronchiolitis. This technique is intended for children over the age of 6 months, as it requires an oral breathing reflex and cough reflex that are not systematically acquired before this age. Nasal irrigation is performed on a 30° upward inclined plane on a calm and cooperative child, away from meals. The child is maintained gently, without pressure, in the fencing position with the head turned away from the practitioner. Using a continuous flow spray, the practitioner grasps the top of the upper nostril and irrigates the nostril for an average of 3 s (6mL per nostril). These steps are then repeated until satisfactory patency is achieved in both nostrils. This technique constitutes a practical tool to help healthcare professionals and parents perform nasal irrigation in young children over the age of 6 months.

Pathological Features of Free Graft and Pedicled Flap in the Nasal Cavity: An Animal Study

OBJECTIVES/HYPOTHESIS

Recent developments in reconstructive techniques for mucosal defects using mucoperiosteal materials have enabled rapid recovery of physiological function after endoscopic sinus surgery. Clinical trials have described the advantages, disadvantages, and different outcomes of free graft and pedicled flap, which, respectively, sacrifice or preserve blood flow. However, histological changes, that affect the postoperative outcomes after reconstruction, remain unclear. We created an animal model for the reconstruction of mucosal defects using free grafts and pedicled flaps, and evaluated them histologically.

STUDY DESIGN

Animal study.

METHODS

We created mucosal defects in the left nasal septum of 20 rabbits and performed reconstruction with free grafts and pedicled flaps. The distribution of ciliary and goblet cells at the reconstruction site was evaluated after 7 and 28 days using hematoxylin and eosin-stained sections to calculate the Ciliary Cell Index and Goblet Cell Index. The severity of inflammation was assessed using the Cartilage Inflammatory Cell Score.

RESULTS

Crusting and changes in the mucosal morphology at the reconstruction site occurred only in the free graft group. In addition, the pedicled flap group had significantly greater preservation of ciliary and goblet cells and less inflammatory cell infiltration into the septal cartilage (P < .05) than the free graft group.

CONCLUSIONS

After reconstruction procedures for mucosal defects, histopathological differences were observed between the free graft and pedicled flap. Reconstruction with pedicled flaps had advantages including preservation of healthy mucosal epithelium and suppression of inflammation on the reconstruction site. This indicated that reconstruction with pedicled flaps might have advantages over that with free grafts.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:E428-E433, 2021.

Hypertonic saline and seawater solutions damage sinonasal epithelial cell air-liquid interface cultures

BACKGROUND

Nasal irrigation (NI) is commonly used to treat several sinonasal diseases, including chronic rhinosinusitis with nasal polyps (CRSwNP); however, the effects of NI on the sinonasal epithelium are not fully known. The aim of this study was to investigate the effects of commonly used NI solutions on epithelial mucociliary and barrier functionality in primary cultured human nasal epithelial cells (HNECs).

METHODS

HNECs from control subjects and patients with CRSwNP were established as air-liquid interface (ALI) cultures. Differentiated cultures were treated with different NI solutions, including isotonic 0.9% and hypertonic 3.0% saline, isotonic and hypertonic seawater, and Ringer lactate solution. The changes in ciliary beat frequency (CBF), numbers of ciliated and goblet cells, and cytotoxicity were measured. Epithelial barrier functionality was assessed by measuring the transepithelial electric resistance (TER), paracellular flux, and expression of tight junction protein zonula occludens-1 (ZO-1) and occludin.

RESULTS

Isotonic saline, isotonic seawater, and Ringer lactate solutions did not affect epithelial mucociliary and barrier function in either control or CRSwNP-derived ALI cultures; however, hypertonic saline induced a significant disruption of these cell functions in both cultures. Hypertonic seawater caused a transient decrease of CBF and TER in CRSwNP-derived ALI cultures, in contrast to inducing an obvious mucociliary and barrier dysfunction and cytotoxicity in control ALI cultures.

CONCLUSION

Although isotonic NI solutions appear to not affect epithelial mucociliary and barrier function in control and CRSwNP-derived ALI cultures, hypertonic saline and seawater solutions damaged sinonasal epithelial cells in ALI cultures. The safety and efficacy of these solutions requires further investigation.

Effectiveness of Hypertonic Saline Nasal Irrigation for Alleviating Allergic Rhinitis in Children: A Systematic Review and Meta-Analysis

We aimed to explore the efficacy of hypertonic saline nasal irritation (HSNI) for improving nasal symptoms and quality of life, and for decreasing oral antihistamine consumption in children with allergic rhinitis (AR). We conducted a systematic search of PubMed, Medline, Cumulative Index to Nursing and Allied Health Literature, EMBASE, Chinese Electronic Periodicals Service, and Cochrane Library of Controlled Trials databases for prospective randomized, controlled trials assessing HSNI effects in children with AR and published before December 2017. Two authors independently assessed each trial's quality and extracted data for a meta-analysis. We included four trails comprising 351 patients. HSNI improved patients' nasal symptom scores (mean difference 1.82 points after treatment; 95% confidence interval (CI), 0.35⁻3.30; I² = 64%; p = 0.02) and a significantly lower rescue antihistamine use rate (risk ratio (RR), 0.68; 95% CI, 0.48⁻0.95; I² = 28%; p = 0.02). Analyses comparing HSNI with isotonic saline nasal irrigation (ISNI) showed better nasal symptom scores (mean difference, 1.22 points; 95% CI, 1.01⁻1.44; I² = 0%; p < 0.001) in patients in the HSNI group, although the antihistamine use (RR, 0.84; 95% CI, 0.64⁻1.10; I² = 0%; p = 0.2) and adverse effect rates were similar between groups. Compared with ISNI, HSNI may be a reasonable adjunctive treatment for children with AR.

Influence of Intranasal Drugs on Human Nasal Mucociliary Clearance and Ciliary Beat Frequency

The nasal mucociliary clearance system, which comprises epithelial cilia and mucus from goblet cells, is an important intrinsic defense mechanism of the upper respiratory tract. Intranasal drugs and additives can have a detrimental effect on ciliary activity and mucociliary clearance, and thus impact the integrity of nasal defense mechanisms. This article discusses the current literature on the effects of different classes of intranasal drugs including intranasal corticosteroids, antihistamines, decongestants, antimicrobials and antivirals, as well as various drug excipients and nasal irrigation solutions on human nasal mucociliary clearance and ciliary beat frequency. Available data indicate that some intranasal formulations tend to hamper nasal ciliary function and mucociliary clearance. Therefore, it is of great importance to assess the effects of intranasal drugs and additives on mucociliary function before they are recommended as therapy for different nasal conditions.

Prospective, randomized, controlled, open-label study to compare efficacy of a mineral-rich solution vs normal saline after complete ethmoidectomy

Purposes

The purpose of this study was to compare the efficacy of a mineral-rich solution vs normal saline solution (0.9% NaCl) following endoscopic complete bilateral ethmoidectomy.

Methods

This was a prospective, multicenter, randomized, controlled, open-label trial in subjects suffering from steroid-resistant sinonasal polyposis. Adults performed 4 nasal irrigations of mineral or saline solutions daily for 28 days. Evaluations included subject-reported RHINO quality of life (QoL) and NOSE scores, tolerability, and satisfaction, the Lund–Kennedy endoscopic score and assessments of crusting, secretions and mucociliary clearance (rhinoscintigraphy).

Results

A total of 189 subjects were randomized. Clinically relevant improvements (> 20 points) in RhinoQOL and NOSE scores were measured in both groups without any significant inter-group difference. Among the subjects with impaired RhinoQOL at pre-inclusion, the change in Impact-RhinoQOL score was significantly superior in mineral-rich vs saline solution at day 21 (p = 0.028) and day 28 (p = 0.027). The Lund–Kennedy score continuously improved in both groups earlier with the mineral-rich solution. Crusts were significantly fewer in number and less severe/obstructive in patients receiving mineral-rich vs saline solution at day 7 (p = 0.026) and day 14 (p = 0.016). Furthermore, secretions disappeared significantly more quickly and were less thick/purulent with mineral-rich solution at day 14 (p = 0.002) and day 21 (p = 0.043). Less epistaxis was reported in the mineral vs saline solution (p = 0.008 at day 21).

Conclusions

Our findings indicate that the composition of a nasal irrigation solution influences endoscopic scores and QoL after sinus surgery for patients over 60, those with an initially poor QoL and higher symptom score, and smokers.

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.

Non-diluted seawater enhances nasal ciliary beat frequency and wound repair speed compared to diluted seawater and normal saline

Background

The regulation of mucociliary clearance is a key part of the defense mechanisms developed by the airway epithelium. If a high aggregate quality of evidence shows the clinical effectiveness of nasal irrigation, there is a lack of studies showing the intrinsic role of the different irrigation solutions allowing such results. This study investigated the impact of solutions with different pH and ionic compositions, eg, normal saline, non‐diluted seawater and diluted seawater, on nasal mucosa functional parameters.

Methods

For this randomized, controlled, blinded, in vitro study, we used airway epithelial cells obtained from 13 nasal polyps explants to measure ciliary beat frequency (CBF) and epithelial wound repair speed (WRS) in response to 3 isotonic nasal irrigation solutions: (1) normal saline 0.9%; (2) non‐diluted seawater (Physiomer®); and (3) 30% diluted seawater (Stérimar). The results were compared to control (cell culture medium).

Results

Non‐diluted seawater enhanced the CBF and the WRS when compared to diluted seawater and to normal saline. When compared to the control, it significantly enhanced CBF and slightly, though nonsignificantly, improved the WRS. Interestingly, normal saline markedly reduced the number of epithelial cells and ciliated cells when compared to the control condition.

Conclusion

Our results suggest that the physicochemical features of the nasal wash solution is important because it determines the optimal conditions to enhance CBF and epithelial WRS thus preserving the respiratory mucosa in pathological conditions. Non‐diluted seawater obtains the best results on CBF and WRS vs normal saline showing a deleterious effect on epithelial cell function.