Nasal saline irrigation in pediatric rhinosinusitis: A systematic review

Pediatric endoscopic sinus surgery: Revisited 35 years later

Over the past 35 years, pediatric endoscopic sinus surgery (PESS) has significantly evolved from its inception as a novel intervention to become a cornerstone in the management of pediatric sinus disorders. This evolution is reflective of a broader shift towards a more nuanced understanding and treatment of pediatric chronic rhinosinusitis (PCRS), marked by the introduction of comprehensive guidelines and the refinement of surgical indications. Recent literature and the extensive experience of the senior author, who has been at the forefront of utilizing PESS since its inception, highlight a noticeable shift in the procedure's utilization. This paper reviews the journey of PESS, highlighting the impact of advancements in medical treatment modalities, such as improved diagnostic techniques and the adoption of less invasive procedures. The development and optimization of PESS are discussed in the context of changing practice patterns, including the prevalent use of adenoidectomy and the selective application of PESS for refractory cases. An emphasis is placed on the outcomes associated with different surgical interventions for PCRS, highlighting their efficacy in alleviating symptoms and managing underlying conditions. The paper concludes by emphasizing the importance of ongoing innovation and collaborative research in further refining surgical techniques and expanding treatment options, with the ultimate goal of delivering safe, effective, and patient-centered care to children with sinus-related disorders. This retrospective analysis demonstrates a commitment to enhancing the quality of life for pediatric patients, reflecting the substantial progress achieved in the field of pediatric otolaryngology over the last three decades.

Investigation of the Effectiveness of Nasal Sprays in Allergic Rhinitis

Objectives: We investigated the effectiveness of different types of nasal irrigation sprays in adult allergic rhinitis (AR) patients. Methods: A total of 1700 patients with AR (866 males and 834 females) were assigned to: Group 1: Hypertonic nasal spray group (n = 600) (Sinomarin® hypertonic nasal spray); Group 2: Algae-containing hypertonic nasal spray group (n = 600) (Sinomarin Plus Algae ENT); and Group 3: Isotonic saline nasal spray group (n = 500). All patients underwent an otolaryngological examination, continued their standard AR treatment, and received the assigned nasal spray additionally (1 spray to each nostril, 3 times a day, for 3 weeks). Allergic symptom scores, turbinate examination, total symptom scores, and quality of life (QoL) scores were evaluated during pre- and post-treatment periods. Results: In groups 1 and 2, symptom scores and turbinate color and edema, total symptom scores, and QoL scores increased after treatment (P < .05). In the saline group, there were no significant differences in symptom scores and total symptom scores after treatment; however, improvement was detected in turbinate color and edema values after treatment. QoL scores increased after treatment. When comparing the 3 groups, the total symptom scores of groups 1 and 2 were significantly lower, and the QoL scores of groups 1 and 2 were considerably higher than those of the saline group. There were no significant differences between groups 1 and 2. Conclusion: Algae-containing and hypertonic nasal spray may be added to the standard AR treatment to increase QoL and decrease total symptom scores.

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.

[Pediatric chronic rhinosinusitis]

Pediatric chronic rhinosinusitis (PCRS) differs from adult chronic rhinosinusitis (CRS) in several aspects. The confrontation with the environment takes place in the growing sinus system, and the immune system is also developing. The inflammatory mechanisms differ to some extent from those of adult CRS patients. The adenoid vegetations play an important role, particularly during the first 6 years of life. Other pathogenetic aspects are important (e.g., asthma, gastroesophageal reflux disease, immunodeficiency). Genetically determined systemic diseases such as cystic fibrosis cause specific challenges in diagnostics and treatment already in childhood. Consistent conservative therapy is often successful, but surgical procedures that have been proven to be effective and associated with few complications are also increasingly used.

Naturopathic Management of Acute Pediatric Respiratory Infections: A Modified Delphi Study

Objective: Both the United Nations and the World Health Organization have identified antimicrobial resistance as a significant threat to global health. The Centers for Disease Control and Prevention identified five pediatric respiratory conditions as requiring particular scrutiny in terms of antibiotic stewardship. This study sought to identify strategies used by experienced naturopathic practitioners to treat acute respiratory infections in children. The authors theorize that naturopathic strategies safely fill the gap between watchful waiting and antibiotic prescription, thus reducing the use of antibiotics. Methods: Naturopathic practitioners in Canada, the United States, and Australia with a minimum of 5 years of experience in clinical naturopathic care of children were recruited for a modified Delphi study. A 14-person panel of practitioners was selected to complete a series of four iterative surveys assessing agreement to statements in five domains of knowledge/attitudes, assessment/diagnosis, management, monitoring, and education. Items were deemed to have reached consensus if they reached a predetermined threshold of 70% agreement, or failed to reach a threshold of 40% agreement. Items between these boundaries were modified and retested until either consensus was reached or the four surveys had been completed. Results: Results yielded a large degree of agreement on core naturopathic approaches to the management of acute pediatric respiratory infections, especially lifestyle strategies, including adequate rest and dietary recommendations. The use of vitamins C and D was strongly supported, as were herbs, particularly echinacea and elderberry. Some hydrotherapy and topical applications specific to the individual focus on infection also reached consensus. Results suggested that most respondents, even if they have the authority to prescribe antibiotics, rarely deem it necessary to do so. Conclusion: Findings of this study provide (1) clarity on the role of naturopathic doctors in the management of pediatric health concerns and the stewardship of antibiotics; and (2) initial guidance to less experienced naturopathic practitioners. The findings also identify key priorities for research into the safety and effectiveness of naturopathic interventions to reduce the unnecessary prescribing of antibiotics.

The management of cystic fibrosis chronic rhinosinusitis: An evidenced-based review with recommendations

BACKGROUND

Cystic fibrosis (CF) chronic rhinosinusitis (CRS) has emerged as a distinct diagnostic entity, unique from other endotypes of CRS in its presentation, pathophysiology, diagnosis, treatment, and outcomes. As the sinonasal health of this patient population may have broad effects on pulmonary health and quality of life, a comprehensive understanding of the diagnostic and therapeutic approach to CF CRS is essential. In recognizing recent scientific advances and unique treatment modalities specific to this challenging patient population, in this review we systematically evaluate the scientific literature and provide an evidenced-based review with recommendations (EBRR) for fundamental management principles of CF CRS.

METHODS

A systematic review of the literature was performed. Studies evaluating interventions for the management of CF CRS were included. An iterative review process was implemented in accordance with EBRR guidelines. A treatment recommendation was generated based on an assessment of the benefits, harms, and the overall grade of evidence.

RESULTS

We evaluated the published literature on 5 unique topics. Each of the following therapeutic categories was investigated explicitly for treatment outcomes in patients with CF CRS: (1) nasal saline; (2) intranasal corticosteroids (INCS); (3) topical antibiotics; (4) cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy; and (5) endoscopic sinus surgery (ESS).

CONCLUSION

Based on the currently available evidence, nasal saline, ESS, and CFTR modulators are recommended in the management of CF CRS when appropriate. INCS and topical antibiotics are options. Clinical judgment and experience are essential in caring for patients with this uniquely challenging disorder.

A novel irrigation device with superior nasal irrigation efficiency to the classic rinse bottle

Background

The ability of saline irrigation to detach the mucous and the flow-limiting effect of the nasal valve has not been well explored. The objective of this study was to compare the removal efficiency of a novel irrigation device with an extended nozzle versus a classic rinse bottle.

Methods

Transparent casts of the unoperated sinonasal cavity were made by 3D printing. Yogurt was used to simulate mucous. The cast filled with 5 ml yogurt was fixed in six head positions and irrigated with 120 ml, 175 ml, and 240 ml dyed water through the novel device and the rinse bottle. The irrigation efficiency was the ratio of the weight of yogurt washed away divided by the total weight of yogurt.

Results

The irrigation stream of a long nozzle with a side opening was different from the irrigation stream of the outlet within the nasal vestibule. The novel devices presented with continuous water stream directly upwards to the anterior part of the olfactory cleft. Depending on different head positions, it was easy for the novel devices to achieve an irrigation efficiency of 100% when the cast was irrigated with 120 ml or 175 ml water. There was still a tiny amount of yogurt left in the olfactory cleft when the cast was irrigated with 240 ml water under each head position for the rinse bottle. The irrigation efficiency was volume-dependent, and the average irrigation efficiency of the rinse bottle at 240 ml only reached 69.1%.

Conclusions

The novel irrigation device presented with superior nasal irrigation efficiency to the classic rinse bottle. A continuous water stream directly upwards to the anterior part of the olfactory cleft combined with an extended nozzle overcoming the flow-limiting effect of the nasal valve promotes nasal irrigation efficiency.

Graphical Abstract

Pediatric chronic sinusitis: diagnosis and management

PURPOSE OF REVIEW

Review the diagnosis and management of pediatric chronic sinusitis given recent advances in both surgical and medical management.

RECENT FINDINGS

Balloon catheter dilation (BCD) of the sinuses has been used as an adjunct to adenoidectomy or in lieu of traditional endoscopic sinus surgery. BCD has been shown to be a safe technique in children although its efficacy compared to maxillary sinus irrigation or traditional sinus surgery cannot be determined based on current studies.

SUMMARY

New advances in BCD and biologics may serve as useful adjuncts in surgical and medical therapy respectively with additional research needed to better delineate the optimal indications for each in the treatment continuum.

Effects of the Traditional Mediterranean Diet in Childhood Recurrent Acute Rhinosinusitis

Introduction: There are more and more studies that demonstrate the anti-inflammatory effects of the traditional Mediterranean diet (TMD). The aim of the study was to assess the effects of an intervention with the TMD in patients with recurrent acute and chronic rhinosinusitis. Material and Methods: We performed a pretest–posttest comparison study in 114 patients (56 girls and 58 boys) aged one to five years who had three or more acute rhinosinusitis episodes in the period of 1 year. They were included for a year in the nutritional program “Learning to eat from the Mediterranean”. The anthropometric, clinical, and therapeutic characteristics were studied. Results: All the studied indicators showed a positive and statistically significant evolution. Of the patients, 53.5% did not have any episode of acute rhinosinusitis, and 26.3% had only one, compared to the 3.37 they had on average in the previous year. The use of antibiotics decreased by 87.6%. The degree of satisfaction of the families was very high. The Mediterranean Diet Quality Index (KIDMED) that assesses the quality of the TMD rose from 7.7 to 11 points. Conclusions: The adoption of the TMD could have promising effects in the prevention and treatment of recurrent acute and chronic rhinosinusitis, limiting the pharmacological and surgical intervention in many of these patients.

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.

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.

Wet Cough and Nasal Symptoms in Children: Can We Do Better?

The causes of chronic cough in children are mainly dependent on the setting and age of the child. Protracted bacterial bronchitis is a frequent cause of morbidity in childhood, and antibiotic treatment is beneficial. Prompt recognition and early treatment is important both to prevent inappropriate use of asthma medications and also progression to bronchiectasis, but the diagnosis should not be made uncritically, because chronic wet cough is not necessarily due to lower airway disease. Upper Airway Cough Syndrome (UACS) is considered by some to cause chronic cough in childhood. Underlying UACS are many common conditions, including allergic rhinitis, adenoiditis and rhinosinusitis. Diagnosis relies on a combination of clinical criteria that are relatively sensitive but non-specific. The role of nasal endoscopy in children with chronic cough and signs suggesting UACS is unclear. Nasal saline solution irrigation is commonly used in UACS, but most studies have methodological biases, and efficacy data are scanty. Randomized controlled trials are urgently required. However, if saline washes, rather than oral antibiotics, can effectively treat some children with wet cough associated with upper airway conditions, antibiotic resistance could potentially be reduced. There is a need to further study wet cough and not to assume it to be equivalent to lower airway infection in all children.

Chronic Rhinosinusitis in Children

Purpose of review

Pediatric chronic rhinosinusitis (CRS) is a common condition that is often misdiagnosed and can be challenging to treat. This review aims to 1) Review definitions, presentation, complications, and management of CRS in children. 2) Highlight the paucity of evidence in the management of pediatric CRS.

Recent findings

There are few studies supporting the usual recommended medical therapy for pediatric CRS (antibiotics, nasal saline irrigations, intranasal steroid). Adenoidectomy remains a mainstay of surgical treatment, but recent evidence demonstrates the utility of balloon sinuplasty and functional endoscopic sinus surgery (FESS) for patients who fail adenoidectomy alone.

Summary

Pediatric CRS is distinct from ARS and adult CRS. It is a common problem that is poorly studied, in part because of significant symptomatic overlap with related conditions. Recent evidence supports the use of surgical treatment in children who fail medical management. However, further outcome studies are needed to better evaluate the effectiveness of current medical and surgical management protocols.