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

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.

Yardstick for the medical management of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is an inflammatory condition of the paranasal sinuses defined by classic symptoms, imaging findings, or endoscopic findings. There are a growing number of emerging pharmacologic therapies being evaluated to treat patients with CRS, some of which have gained indication status in the United States. There have not been updated treatment guidelines published in the United States however since 2014. This document is meant to serve as an updated expert consensus document for the pharmacologic management of patients with CRS. We review available data focusing on prospective clinical trials on oral and intranasal corticosteroids, nasal irrigation, biologics, antibiotics, and allergy immunotherapy for CRS both with and without nasal polyposis, including specific therapies for aspirin-exacerbated respiratory disease-associated CRS and allergic fungal CRS. There are multiple options to treat CRS, and clinicians should be knowledgeable on the efficacy and risks of these available therapies. Allergists-immunologists now have various therapies available to treat patients with CRS.

Budesonide transnasal pulsating nebulization after surgery in chronic rhinosinusitis with nasal polyps

Intranasal corticosteroid drugs are widely used in chronic rhinosinusitis with nasal polyps (CRSwNP). In contrast to classical delivery with nasal pump sprays, pulsating aerosols can deliver significant doses into superior and posterior sinonasal spaces. A case-control study was designed to assess the efficacy of corticosteroid transnasal nebulization on short-term mucosal recovery and quality of life (QoL) following endoscopic sinus surgery in CRSwNP. Thirty patients were prospectively enrolled to receive either 1-month budesonide nasal pump spray or 1-month budesonide 100-Hz acoustic pulsating nebulization at the first postoperative visit (day 8). Patients were evaluated with Lund-Kennedy endoscopic score at day 8 (D8) and 1 month later (M1). CRS-related QoL questionnaires (SNOT22 and RhinoQOL) were fulfilled at M1. The Lund-Kennedy endoscopic scores compared between D8 and M1 were suggestively improved in the group treated with budesonide nebulization (mean difference between groups, - 18.28 units; 95%CI, - 31.29 to - 5.28 units, p = 0.014). QoL measurements were comparable at M1 between the groups of patients. No unexpected adverse event was described with both budesonide delivery protocols. In the early postoperative period, patients with CRswNP may benefit from pulsating nebulization. Large studies should be conducted to confirm the results. Safety profile related to systemic steroid absorption and bioavailability in chronic respiratory diseases also need to be addressed for further use.

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.

Efficacy of buffered hypertonic seawater in different phenotypes of chronic rhinosinusitis with nasal polyps after endoscopic sinus surgery: a randomized double-blind study

PURPOSE

Nasal douching is commonly used as a postoperative management strategy for chronic rhinosinusitis with nasal polyps (CRSwNP). Few studies to date have compared the effectiveness of nasal douching in CRSwNP phenotypes after endoscopic sinus surgery (ESS). We evaluated the efficacy of seawater types in eosinophilic CRSwNP (ECRSwNP) and noneosinophilic CRSwNP (nonECRSwNP) after ESS.

METHODS

Patients with bilateral CRSwNP who had undergone ESS were blindly randomized to receive buffered hypertonic seawater (BHS) (n = 48) or physiological seawater (PS) (n = 45). CRSwNP patients were stratified by phenotypes (ECRSwNP and nonECRSwNP) retrospectively according to whether tissue eosinophils exceeded 10%. Follow-up evaluations were conducted at 2, 8, 16, and 24 weeks after surgery. Evaluations included the 22-item Sino-Nasal Outcome Test (SNOT-22), visual analog scale (VAS), Lund-Kennedy endoscopic score (LKES), saccharine clearance time (SCT), and adverse events.

RESULTS

All of the patients experienced significant improvements in SNOT-22 scores, VAS scores, and LKES over time. BHS resulted in better improvement of LEKS and SCT relative to PS at 8 weeks postoperatively. Mucosal edema formation was significantly reduced with less crusting among HBS recipients at 8 weeks. After stratification, only patients in the nonECRSwNP + BHS subgroup showed a significant improvement in LEKS and SCT at 8 weeks postoperatively. Side effect profiles were not significantly different among the groups.

CONCLUSIONS

BHS has a better inhibitory effect on mucosal edema and crusting during the early postoperative care period of CRSwNP. Among all of the patients, nonECRSwNP patients showed a significant improvement in LEKS and SCT at 8 weeks.

Comparison of effects of baby shampoo vs. saline irrigation on endoscopic sinus surgery outcomes and quality of life

OBJECTIVE

Nasal irrigation is an important step of functional endoscopic sinus surgery (FESS) postoperative care. This study was performed to compare the effects of diluted baby shampoo (BS) and normal saline solution (NSS) irrigation on patients' quality of life (QoL) and surgical outcomes after FESS.

METHODS

This study included 77 patients who underwent FESS to treat chronic rhinosinusitis with nasal polyps. Lund-Mackay score, Lund-Kennedy endoscopic score (LKES), synechia score and QoL (using the Sinonasal Outcome Test (SNOT-22)) were evaluated.

RESULTS

LKES was significantly better in the BS group (p=0.001), especially in terms of nasal discharge and crust formation (p=0.024 and p=0.030, respectively) at 1 month postoperatively. However, no significant difference was found at 3, 6 or 12 months postoperatively (p=0.833, p=0.263, and p=0.346, respectively). The reduction of SNOT-22 score (between preoperative assessment and 1 month postoperatively) was significantly better in the BS than in the NSS group (p=0.025). However, no statistically significant differences were found between groups at 3, 6, or 12 months postoperatively (p=0.312, p=0.280, and p=0.285, respectively). In the evaluation of SNOT-22 subdomains, changes in psychological, rhinological and extranasal rhinological subdomains were significantly better in the BS group at 1 month postoperatively (p=0.019, p=0.010 and p=0.002, respectively).

CONCLUSION

Compared to irrigation with NSS, BS usage following FESS led to reductions of crusting, nasal discharge and synechia formation; moreover, it was associated with improved SNOT-22 scores, especially in psychological, rhinological and extranasal rhinological subdomains.

Computational fluid dynamics simulation to compare large volume irrigation and continuous spraying during nasal irrigation

BACKGROUND

Nasal irrigation is now widely recognized as a treatment for chronic rhinosinusitis and during the postoperative period. However, there are no guidelines for performing irrigation. This study used computational fluid dynamics (CFD) simulation objective physical parameters to optimize and increase the efficiency of nasal irrigation and to compare large-volume, manual, and gravity pressure irrigation vs small-volume continuous spraying.

METHODS

A 3-dimensional (3D) sinonasal model was constructed from a healthy adult high-resolution computed tomography (CT) scan. The 3D nasal model was constructed using a tetrahedral and hex-dominant mesh grid with TGRID™ 16 (ANSYS Inc., Villeurbanne, France) software. A structured hex mesh was created inside the domain using the Hexcore meshing method. The final mesh had a total of 9.6 × 10⁶ cells with an average size of 0.29 mm³ , or an average volume of 2.42 × 10^-2 mm³ . Navier-Stokes equations were resolved with the standard k - ε  model.

RESULTS

Large-volume irrigation (15 mL/s) covered all zones (136 to 310 cm² ) rapidly with strong shear stress and prolonged contact time (310 mPa 3.26 seconds for gravity mode and 280 mPa 3.35 seconds for manual pressure mode). Continuous spraying (3 mL/second) covered all areas (76 to 310 cm² ) but with far less volume, more slowly, with low shear stress (50 mPa), and with shorter contact time (1.84 seconds). The surface wetted by time in contact was 135.4, 113.9, and 46.6 cm² for gravity, manual pressure mode, and continuous spraying, respectively.

CONCLUSION

CFD simulation visualizes the circulation of water during nasal irrigation and makes it possible to determine objective parameters to decide which mode of irrigation may be used.