Hyaluronan in the Treatment of Chronic Rhinosinusitis with Nasal Polyposis

Comprehensive evaluation of xylometazoline hydrochloride formulations: Ex-vivo and in-vitro studies

Xylometazoline is a well-established nasal decongestant that has been used alone and in combination with dexpanthenol as an over the counter (OTC) medicine. Considering the possibility of further improvement of xylometazoline nasal formulations, hyaluronic acid (HA) was evaluated as an additional ingredient. The aim of this study was to investigate the permeation, mucosal retention, and mucoadhesion properties of a new xylometazoline-HA [Xylo-HA] formulation ex vivo and to explore the potential benefits of incorporating HA in the formulation in vitro. Sheep nasal mucosa was used in the ex vivo study, where Xylo-HA was compared with xylometazoline alone [Xylo-Mono], and in combination with dexpanthenol [Xylo-Dex] to understand the impact of formulation changes. The permeation of xylometazoline was generally low (Xylo-Mono 11.14 ± 4.75 %, Xylo-HA 14.57 ± 5.72 % and Xylo-Dex 11.00 ± 3.05 % of the applied dose). The steady state fluxes of xylometazoline were determined as 12.64 ± 3.52 μg/cm2h, 14.94 ± 3.38 μg/cm2h and 12.19 ± 2.05 μg/cm2h for Xylo-Mono, Xylo-HA and Xylo-Dex, respectively. No significant differences were observed between the formulations in the permeation nor mucosal retention studies (p > 0.05 for all), while Xylo-HA exhibited superior mucoadhesive proprieties (p < 0.05 for all). The effects on wound healing and barrier integrity of the three xylometazoline formulations were tested in vitro on HaCaT cells. To better elucidate the role of HA, an additional HA formulation without xylometazoline was prepared (HA-Mono). A scratch test was performed to evaluate wound healing, revealing that the test formulations did not achieve complete wound closure within 72 h and demonstrated a similar effect at the end of the testing period. To assess the effect on barrier integrity, cells were treated for 5 days with daily measurements of transepithelial electrical resistance (TEER). At the end of the experiment, Xylo-Dex showed a moderate 14 % increase in TEER, while Xylo-Mono did not significantly affect this parameter. TEER rose by 951 % in the Xylo-HA, and by 10497 % in the HA group, suggesting that incorporating HA led to enhanced barrier function. Further clinical studies are recommended to better understand the clinical implications and efficacy of the Xylo-HA formulation, with particular focus on the role of HA.

Lymphatic Vessels in Chronic Rhinosinusitis

Purpose

The purpose of this study was to analyze the nasal lymphatic system in order to uncover novel factors that might be involved in pathogenesis of chronic rhinosinusitis (CRS) with (CRSwNP) and without nasal polyps (CRSsNP).

Patients and Methods

Lymphatic vessels (LVs) and macrophages were localized and counted in the inferior and middle turbinate, the uncinate process and the ethmoid of CRSwNP and CRSsNP patients, the NP and the inferior turbinate of controls (n≥6 per group). Lysates of the same tissue types (n=7 per group) were analyzed for lymphatic vessel endothelial receptor 1 (LYVE-1), for matrix metalloproteinase 14 (MMP-14) and for Hyaluronic acid (HA) using ELISA. HA was localized in sections of CRSwNP NP, CRSsNP ethmoid and control inferior turbinate (n=6 per group). The results of HA levels were correlated to the number of macrophages in tissues. The nasal secretions of CRSwNP (n=28), CRSsNP (n=30), and control (n=30) patients were analyzed for LYVE-1 and HA using ELISA.

Results

The number of LVs was significantly lower in tissues of both CRS groups compared to the control. In the tissue lysates, LYVE-1 expression differed significantly between the CRSwNP tissues with a particularly high level in the NP. MMP-14 was significantly overexpressed in CRSwNP uncinate process. There were no significant differences in tissue HA expression. In the mucus LYVE-1 was significantly underexpressed in CRSsNP compared to CRSwNP and control, while HA was significantly underexpressed in both CRS groups. In the NP, HA and macrophages were accumulated particularly below the epithelium. Tissue levels of HA revealed a significant positive correlation with the number of macrophages.

Conclusion

CRS might be associated with an insufficient clearing of the nasal mucosa through the lymphatics. The accumulation of HA and macrophages might promote inflammation, fluid retention, and polyp formation. These results may provide novel CRS-associated factors.

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.

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.

Matrix-Mediated Delivery of Silver Nanoparticles for Prevention of Staphylococcus aureus and Pseudomonas aeruginosa Biofilm Formation in Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is a chronic health condition affecting the sinonasal cavity. CRS-associated mucosal inflammation leads to sinonasal epithelial cell death and epithelial cell barrier disruption, which may result in recurrent bacterial infections and biofilm formation. For patients who fail medical management and elect endoscopic sinus surgery for disease control, bacterial biofilm formation is particularly detrimental, as it reduces the efficacy of surgical intervention. Effective treatments that prevent biofilm formation in post-operative patients in CRS are currently limited. To address this unmet need, we report the controlled release of silver nanoparticles (AgNps) with silk-elastinlike protein-based polymers (SELPs) to prevent bacterial biofilm formation in CRS. This polymeric network is liquid at room temperature and forms a hydrogel at body temperature, and is hence, capable of conforming to the sinonasal cavity upon administration. SELP hydrogels demonstrated sustained AgNp and silver ion release for the studied period of three days, potent in vitro antibacterial activity against Pseudomonas aeruginosa (**** p < 0.0001) and Staphylococcus aureus (**** p < 0.0001), two of the most commonly virulent bacterial strains observed in patients with post-operative CRS, and high cytocompatibility with human nasal epithelial cells. Antibacterial controlled release platform shows promise for treating patients suffering from prolonged sinonasal cavity infections due to biofilms.

Hyaluronic Acid in Rhinology: Its Uses, Advantages and Drawbacks-A Review

Hyaluronic acid has been increasingly involved in recent research due to its many chemical and physical properties. This is a review of the literature for studies involving the use of hyaluronic acid in rhinology. Hyaluronic acid washes and irrigation have been increasingly used in chronic sinusitis medical therapy and post-operatively with mixed results. It has also been shown to play a role in the treatment of nasal polyposis, allergic rhinitis, acute rhinosinusitis and empty nose syndrome. Its effect on biofilm in many disease entities has also been studied. HA is being recently used as ancillary treatment for several rhinologic conditions such as post-operative endoscopy care and chronic sinonasal infections. The properties of HA have intrigued researchers over the past years particularly in biofilm management, healing and inflammation.

Airway Fibroblast Secretory Products Enhance Cell Migration

Background:

The nasal fibroblast secretome, which includes various cytokines, chemokines, and growth factors, promotes cell migration. Currently, the proteomics of airway fibroblast (AF) conditioned medium (AFCM) are being actively studied.

Objective:

This study was aimed at profiling and identifying the AF secreted proteins that can enhance wound healing of the airway epithelium and predict the potential pathway involved.

Methods:

Airway epithelial cells (AECs) and AFs were isolated from redundant human nasal turbinate and cultured. AFCM was collected by culturing the AFs either with serum-free airway epithelium basal medium (AECM) or with serum-free F12:DMEM (FDCM). For evaluating cell migration, the AECs were supplemented with airway epithelium medium and defined keratinocyte medium (1:1; AEDK; control), or with AEDK supplemented with 20% AECM or 20% FDCM. The mass spectrometry sample was prepared by protein precipitation, followed by gel electrophoresis and in-gel digestion.

Results :

AECM promoted better cell migration compared to the FDCM and the control medium. Bioinformatics analysis identified a total of 121, and 92 proteins from AECM and FDCM, respectively: 109 and 82 were identified as secreted proteins, respectively. STRING® analysis predicted that 23 proteins from the AECM and 16 proteins from the FDCM are involved in wound healing.

Conclusion:

Conditioned medium promotes wound healing by enhancing cell migration, and we successfully identified various secretory proteins in a conditioned medium that play important roles in wound healing.

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.

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.

Effect of Prostaglandin D2 on mRNA Expression of Three Isoforms of Hyaluronic Acid Synthase in Nasal Polyp Fibroblasts

BACKGROUND

Hyaluronan is one of the major extracellular matrixes in chronic rhinosinusitis (CRS) associated with tissue remodeling. Prostaglandin D₂ (PGD₂) is also associated with the pathogenesis of CRS. However, little is known about whether PGD₂ regulates hyaluronan production by human airway fibroblasts.

OBJECTIVE

We sought to determine the effect of PGD₂ on the mRNA expression of three isoforms of membrane-bound hyaluronic acid synthase (HAS1, HAS2 and HAS3) in fibroblasts, the major source of hyaluronan production, derived from CRS patients.

METHODS

Nasal polyp-derived fibroblasts (NPDF) and uncinate tissue-derived fibroblasts (UTDF) were established from CRS patients with nasal polyps and those without, respectively. These fibroblasts were stimulated with PGD₂ or PGD₂ receptor (DP/CRTH2)-selective agonists in the presence or absence of receptor-selective antagonists. mRNA levels for HAS1, HAS2 and HAS3 were determined by real-time quantitative PCR.

RESULTS

PGD₂ (1 µM) significantly enhanced HAS1 but not HAS2 or HAS3 mRNA expression by NPDF. Enhanced HAS1 mRNA expression was also obtained by stimulation with a DP receptor-selective agonist, but not with a CRTH2 receptor-selective agonist. In addition, PGD₂-induced HAS1 mRNA expression was significantly inhibited by pre-treatment with DP receptor-selective antagonists. Similar induction of PGD₂-induced HAS1 mRNA expression was seen in UTDF.

CONCLUSION

PGD₂ selectively stimulates HAS1 mRNA expression in local fibroblasts in CRS via DP, but not CRTH2, receptors.

Evaluation of Performance and Tolerability of Nebulized Hyaluronic Acid Nasal Hypertonic Solution in the Treatment of Chronic Rhinosinusitis

BACKGROUND

Nasal solutions are part of the recommended therapy of chronic rhinosinusitis (CRS). Formulations containing hyaluronic acid (HA) may represent a promising topical treatment in CRS patients in light of the anti-inflammatory and protective effect of HA on the sinonasal mucosa.

OBJECTIVE

Primary aim was to evaluate the performance of a new nebulized HA nasal hypertonic solution in the relief of symptoms of CRS. Secondarily, evaluation of symptoms improvement, endoscopic nasal findings, and safety profile were assessed.

METHODS

A monocenter, single arm, not controlled, premarket clinical trial on a new nasal solution containing HA was performed. All the included patients had a history of previously diagnosed or recurrent CRS or they had received a clinical diagnosis of CRS defined, according to the European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Each patient was evaluated on 3 visits. Endoscopic nasal examination and Nasal Obstruction Symptom Evaluation Instrument questionnaire filling were performed during each visit. Patients' adherence to treatment and overall satisfaction, patients' and investigator's global evaluation of performance, and safety parameters were also assessed.

RESULTS

Eighty patients were enrolled. The use of the investigated HA nasal solution revealed to be significantly effective in the relief of symptoms of CRS. According to daily patients' diaries, several signs and symptoms significantly improved after therapy. The comparison between endoscopic assessments before and after treatment confirmed improvement of the condition in at least 75% of patients. Seventy-four percent of the patients were quite or very satisfied with the treatment and 80% reported an improvement. The investigator's global assessment of performance was in agreement with this view, as more than 80% of the patients were considered clinically improved.

CONCLUSIONS

The use of the investigated new nebulized HA nasal hypertonic solution is an effective and safe the treatment of CRS.

The comfort of patients with different nasal packings after endoscopic sinus surgery for chronic rhinosinusitis: A protocol for network meta-analysis

BACKGROUND

Chronic sinusitis (CRS) is a high incidence disease and seriously affects the patients' quality of life, causes tremendous economic burden as well. Endoscopic sinus surgery (ESS) is one of the most common therapies for chronic sinusitis. While whether there is a need for nasal packing and which is the best one is still unclear.

METHOD AND ANALYSIS

A systematic search will be performed using PubMed, EMBASE.com, the Cochrane Central Register of Controlled Trials, Chinese Biomedical Literature Database, China National Knowledge Infrastructure and Wanfang database to include randomized controlled trials (RCTs), comparing the efficacy and comfort in patients with nasal packings after ESS who is diagnosed as CRS. The risk of bias of the included RCTs will be assessed by the Cochrane Handbook version 5.1.0. A Bayesian network meta-analysis will be conducted using R-3.3.2 software.

RESULTS

This study is ongoing and the results will be published in a peer-reviewed journal.

CONCLUSION

The results of this study will be sent to clinicians and healthcare providers in the National Health Service, which is expected to help clinicians make more informed choices on nasal packings.

ETHICS AND DISSEMINATION

Ethical approval is not applicable since this study is a network meta-analysis based on published trials.

PROTOCOL REGISTRATION NUMBER

CRD42019119233.

In vitro characterization of physico-chemical properties, cytotoxicity, bioactivity of urea-crosslinked hyaluronic acid and sodium ascorbyl phosphate nasal powder formulation

An innovative lyophilized dry powder formulation consisting of urea-crosslinked hyaluronic acid (HA-CL) and sodium ascorbyl phosphate (SAP) - LYO HA-CL - SAP- was prepared and characterized in vitro for physico-chemical and biological properties. The aim was to understand if LYO HA-CL - SAP could be used as adjuvant treatment for nasal inflammatory diseases. LYO HA-CL - SAP was suitable for nasal delivery and showed to be not toxic on human nasal septum carcinoma-derived cells (RPMI 2650 cells) at the investigated concentrations. It displayed porous, polygonal particles with unimodal, narrow size distribution, mean geometric diameter of 328.3 ± 27.5 µm, that is appropriate for nasal deposition with no respirable fraction and 88.7% of particles with aerodynamic diameter >14.1 µm. Additionally, the formulation showed wound healing ability on RPMI 2650 cells, and reduced interleukin-8 (IL-8) level in primary nasal epithelial cells pre-induced with lipopolysaccharide (LPS). Transport study across RPMI 2650 cells showed that HA-CL could act not only as carrier for SAP and active ingredient itself, but potentially also as mucoadhesive agent. In conclusion, these results suggest that HA-CL and SAP had anti-inflammatory activity and acted in combination to accelerate wound healing. Therefore, LYO HA-CL - SAP could be a potential adjuvant in nasal anti-inflammatory formulations.

A systemic approach to identify signaling pathways activated during short-term exposure to traffic-related urban air pollution from human blood

The molecular mechanisms that promote pathologic alterations in human physiology mediated by short-term exposure to traffic pollutants remains not well understood. This work was to develop mechanistic networks to determine which specific pathways are activated by real-world exposures of traffic-related air pollution (TRAP) during rest and moderate physical activity (PA). A controlled crossover study to compare whole blood gene expression pre and post short-term exposure to high and low of TRAP was performed together with systems biology analysis. Twenty-eight healthy volunteers aged between 21 and 53 years were recruited. These subjects were exposed during 2 h to different pollution levels (high and low TRAP levels), while either cycling or resting. Global transcriptome profile of each condition was performed from human whole blood samples. Microarrays analysis was performed to obtain differential expressed genes (DEG) to be used as initial input for GeneMANIA software to obtain protein-protein (PPI) networks. Two networks were found reflecting high or low TRAP levels, which shared only 5.6 and 15.5% of its nodes, suggesting specific cell signaling pathways being activated in each environmental condition. However, gene ontology analysis of each PPI network suggests that each level of TRAP regulate common members of NF-κB signaling pathway. Our work provides the first approach describing mechanistic networks to understand TRAP effects on a system level.

Topically administered hyaluronic acid in the upper airway: A narrative review

Hyaluronic acid plays a role in controlling inflammatory airway processes and mucociliary clearance, and it is also involved in tissue healing and remodelling. Some studies have tested the effectiveness of topically administered hyaluronic acid in patients with upper airway diseases with positive preliminary results. This article describes the use of topically administered hyaluronic acid in patients with otolaryngological disorders. Pertinent studies published between January 2000 and October 2016 were selected by means of a MEDLINE search using the following terms: ‘hyaluronic acid’ and ‘otolaryngology’, ‘otitis’, ‘pharyngitis’, ‘tonsillitis’, ‘rhinitis’, ‘rhinosinusitis’ and ‘nose’. Twelve of the 19 initially identified papers were selected, corresponding to 902 patients as a whole. There is some evidence that topically administered hyaluronic acid is effective or moderately effective in different otolaryngological conditions, as it improves the global subjective and clinical status of patients with inflammation of the nasopharyngeal and oto-tubaric complex, those with rhinitis or rhinosinusitis and those who have undergone nasal and sinonasal surgery. However, these findings should be viewed cautiously as they are based on a limited number of studies, some of which were probably under-powered because of their small patient samples.

Update on Intranasal Medications in Rhinosinusitis

This review describes beneficial effects and adverse events of various intranasal medications in treating rhinosinusitis. Application of intranasal steroids has been described in treating all subtypes of adult rhinosinusitis, but reports are limited in pediatrics and mostly in acute pediatric subgroups resulted in benefits While saline irrigation is effective for patients with chronic rhinosinusitis without polyps and in pediatric acute rhinosinusitis, there is no evidence yet for saline drips and sprays. Application of intranasal antifungals and nasal irrigation with surfactant brings more harm than benefits. There is no evidence supporting the use of intranasal antibiotics. We also review influence of devices, methods, and patient head position on nasal and paranasal sinus drug delivery.

Hyaluronate effect on bacterial biofilm in ENT district infections: a review

Bacterial resistance is a growing phenomenon which led the scientific community to search for new therapeutic targets, such as biofilm. A bacterial biofilm is a surface-associated agglomerate of microorganisms embedded in a self-produced extracellular polymeric matrix made of polysaccharides, nucleic acids, and proteins. Scientific literature offers several reports on a biofilm's role in infections regarding various body districts. The presence of a bacterial biofilm is responsible for poor efficacy of antibiotic therapies along with bacterial infections in ear, nose, and throat (ENT) districts such as the oral cavity, ear, nasal cavities, and nasal sinuses. In particular, bacterial biofilms are associated with recalcitrant and symptomatically more severe forms of chronic rhinosinusitis. As of today, there are no therapeutic options for the eradication of bacterial biofilm in ENT districts. Hyaluronic acid is a glycosaminoglycan composed of glucuronic acid and N-acetylglucosamine disaccharide units. Its efficacy in treating rhinosinusitis, whether or not associated with polyposis, is well documented, as well as results from its effects on mucociliary clearance, free radical production and mucosal repair. This review's aim is to evaluate the role of bacterial biofilms and the action exerted on it by hyaluronic acid in ENT pathology, with particular attention to the rhinosinusal district. In conclusion, this paper underlines how the efficacy of hyaluronate as an anti-bacterial biofilm agent is well demonstrated by in vitro studies; it is, however, only preliminarily demonstrated by clinical studies.

Nasal Irrigation: An Imprecisely Defined Medical Procedure

Nasal irrigation (NI) is an old practice of upper respiratory tract care that likely originated in the Ayurvedic medical tradition. It is used alone or in association with other therapies in several conditions—including chronic rhinosinusitis and allergic rhinitis—and to treat and prevent upper respiratory tract infections, especially in children. However, despite it being largely prescribed in everyday clinical practice, NI is not included or is only briefly mentioned by experts in the guidelines for treatment of upper respiratory tract diseases. In this review, present knowledge about NI and its relevance in clinical practice is discussed to assist physicians in understanding the available evidence and the potential use of this medical intervention. Analysis of the literature showed that NI seems to be effective in the treatment of several acute and chronic sinonasal conditions. However, although in recent years several new studies have been performed, most of the studies that have evaluated NI have relevant methodologic problems. Only multicenter studies enrolling a great number of subjects can solve the problem of the real relevance of NI, and these studies are urgently needed. Methods for performing NI have to be standardized to determine which solutions, devices and durations of treatment are adequate to obtain favorable results. This seems particularly important for children that suffer a great number of sinonasal problems and might benefit significantly from an inexpensive and simple preventive and therapeutic measure such as NI.

Prevention of sinonasal inflammation by a synthetic glycosaminoglycan

BACKGROUND

Glycosaminoglycans (GAGs) are polysaccharides that are distributed on respiratory epithelial cells, endothelial cells, and submucosal glands. Uniquely positioned, certain GAGs exhibit anti-inflammatory properties in respiratory diseases and serve important roles in repairing mucosal surfaces and modulating mucociliary clearance. We hypothesized that topical administration of a synthetic GAG (GM-0111) would prevent sinonasal inflammation in a mouse model of rhinosinusitis (RS).

METHODS

To test our hypothesis, C57BL/6 mice were intranasally administered fluorescent GM-0111, and sinonasal tissues were examined for coating and penetration ability. To test therapeutic feasibility, mice (n = 6) were given GM-0111 or hyaluronic acid (HA; 800 μg dose) prior to inducing RS with inflammatory molecule LL-37 (115 μg dose). After 24 hours, sinonasal tissues were harvested for histological and biochemical analysis of inflammatory markers (inflammatory cell infiltration, lamina propria [LP] thickening, and neutrophil enzyme myeloperoxidase [MPO]) and cell death.

RESULTS

GM-0111 was observed within sinonasal tissues 1 hour and 24 hours after intranasal administration, indicating rapid and effective coating and penetration. GM-0111 prevented sinonasal tissues from developing inflammatory changes, with significant reductions in mast cell infiltration (p < 0.05), LP thickening (p < 0.001), and MPO levels (p < 0.01) when compared to tissues treated with LL-37 and those pretreated with HA. GM-0111 reduced cell death within sinonasal tissues in contrast to LL-37-treated tissues.

CONCLUSION

We report a new synthetic GAG (GM-0111) that uniformly coats and penetrates into the sinonasal mucosa to prevent sinonasal inflammation and cell death in a mouse model of RS.

Saline irrigation for chronic rhinosinusitis

BACKGROUND

This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Nasal saline irrigation is commonly used to improve patient symptoms.

OBJECTIVES

To evaluate the effects of saline irrigation in patients with chronic rhinosinusitis.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 9); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 30 October 2015.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with a follow-up period of at least three months comparing saline delivered to the nose by any means (douche, irrigation, drops, spray or nebuliser) with (a) placebo, (b) no treatment or (c) other pharmacological interventions.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the commonest adverse event - epistaxis. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of local irritation and discomfort. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included two RCTs (116 adult participants). One compared large-volume (150 ml) hypertonic (2%) saline irrigation with usual treatment over a six-month period; the other compared 5 ml nebulised saline twice a day with intranasal corticosteroids, treating participants for three months and evaluating them on completion of treatment and three months later. Large-volume, hypertonic nasal saline versus usual care One trial included 76 adult participants (52 intervention, 24 control) with or without polyps.Disease-specific HRQL was reported using the Rhinosinusitis Disability Index (RSDI; 0 to 100, 100 = best quality of life). At the end of three months of treatment, patients in the saline group were better than those in the placebo group (mean difference (MD) 6.3 points, 95% confidence interval (CI) 0.89 to 11.71) and at six months there was a greater effect (MD 13.5 points, 95% CI 9.63 to 17.37). We assessed the evidence to be of low quality for the three months follow-up and very low quality for the six months follow-up. Patient-reported disease severity was evaluated using a "single-item sinus symptom severity assessment" but the range of scores is not stated, making it impossible for us to determine the meaning of the data presented.No adverse effects data were collected in the control group but 23% of participants in the saline group experienced side effects including epistaxis. General HRQL was measured using SF-12 (0 to 100, 100 = best quality of life). No difference was found after three months of treatment (low quality evidence) but at six months there was a small difference favouring the saline group, which may not be of clinical significance and has high uncertainty (MD 10.5 points, 95% CI 0.66 to 20.34) (very low quality evidence). Low-volume, nebulised saline versus intranasal corticosteroids One trial included 40 adult participants with polyps. Our primary outcome of disease-specific HRQL was not reported. At the end of treatment (three months) the patients who had intranasal corticosteroids had less severe symptoms (MD -13.50, 95% CI -14.44 to -12.56); this corresponds to a large effect size. We assessed the evidence to be of very low quality.

AUTHORS' CONCLUSIONS

The two studies were very different in terms of included populations, interventions and comparisons and so it is therefore difficult to draw conclusions for practice. The evidence suggests that there is no benefit of a low-volume (5 ml) nebulised saline spray over intranasal steroids. There is some benefit of daily, large-volume (150 ml) saline irrigation with a hypertonic solution when compared with placebo, but the quality of the evidence is low for three months and very low for six months of treatment.

Hyaluronic Acid: Perspectives in Upper Aero-Digestive Tract. A Systematic Review

Background

To date, topical therapies guarantee a better delivery of high concentrations of pharmacologic agents to the mucosa of the upper aerodigestive tract (UADT). The use of topical drugs, which are able to reduce mucosal inflammation and to improve healing tissues, can represent a relevant therapeutic advance. Topical sodium hyaluronate (SH) has recently been recognized as adjuvant treatment in the chronic inflammatory disease of the UADT.

Aims

The aim of our work was to review the published literature regarding all the potential therapeutic effects of SH in the chronic inflammatory disease of UADT.

Methods

Relevant published studies were searched in Pubmed, Google Scholar, Ovid using keywords (“sodium hyaluronate” and “upper airways”) or Medical Subject Headings.

Results

At the end of our selection process, sixteen publications have been included. Six of them in the post-operative period of nasal-sinus surgery, 2 of them in pediatric patients affected by recurrent upper respiratory tract infections, 4 of them in reducing symptoms and preventing exacerbations of chronic upper airways in adult population, 4 of them in patients with chronic inflammatory disease of UADT, including gastro-esophageal reflux disease (GERD).

Conclusions

Topical administration of SH plays a pivotkey role in the postoperative phase of patients undergoing FESS and nasal surgery, and positive results are generally observed in all the patients suffering from UADT chronic inflammatory disease.