Pathological and cytological changes of the nasal mucosa in acute rhinosinusitis: the role of hyaluronic acid as supportive therapy

OBJECTIVE: The aim of this study was to evaluate the reparative role of hyaluronic acid in acute rhinosinusitis (ARS). PATIENTS AND METHODS: 48 patients affected by ARS were submitted to nasal endoscopy, nasal cytology, mucociliary transport evaluation (MCTt) and visual analogue scale questionnaire (VAS) at T0, after 14-18 days (T1) and after 30-35 days (T2). The patients were randomized into two groups, A and B, and received Levofloxacin and Prednisone. Moreover, using a nebulizer ampoule for nasal douche, Group A received high molecular weight Sodium Hyaluronate (3%) plus saline solution (NaCl 0.9%) twice a day for 30 days; Group B received saline solution twice a day for 30 days. RESULTS: At T0 only the VAS score showed differences regarding nasal discharge and post-nasal drip. At T1, in Group A MCTt and the number of bacteria were significantly lower than in Group B. The VAS score showed improvement in Group A. At T2 in Group A, MCTt and number of neutrophils were significantly lower than in Group B. The VAS score showed statistically significant differences between the two groups regarding nasal discharge. CONCLUSIONS: In ARS patients sodium hyaluronate plus saline solution significantly improved symptoms, MCT time and reduced neutrophil count on nasal cytology

Audit on the use of radiological investigations in the management of rhinosinusitis

Objectives: The aim of this audit is to establish the cost to the Maltese health system from the use of radiological imaging in managing rhinosinusitis and to identify areas in which these costs can be minimised by following guidelines on the management of rhinosinusitis. Methods: All plain radiographs and computed tomography scans (CT) of the paranasal sinuses requested in the Mater Dei Hospital over a one year period were analysed. Data was collected regarding: the quantity of investigations ordered, age of the patients, cost and requesting department. Results: Over one year: 205 CT scans and 113 sets of plain radiographs of the paranasal sinuses were requested, costing a total of euro103,440. The majority (73%) were elective requests made by ENT consultants. Five percent of CT scans were requested for patients less than 10 years of age. Conclusion: Rhinosinusitis is diagnosed clinically, only requiring radiological investigation in more complex cases best managed by specialists in ENT. Plain radiographs have limited use in the management of rhinosinusitis. Judicious use of imaging requests whilst following clinical guidelines is required to save money and minimise patient exposure to ionising radiation.peer-reviewe

Intranasal Treatment of Acute Rhinosinusitis - Recommendations, Efficacy and Safety

Introduction and purpose: Acute rhinosinusitis is a common condition worldwide, usually caused by respiratory viruses. Nasal epithelium is their primary point of entry and an active responder to the infection. Therefore, it seems reasonable for the treatment approach to include locally applied drugs. Our purpose is to bring forward up-to-date recommendations of intranasal treatment options for acute rhinosinusitis, and assess their efficacy and safety. Description of the state of knowledge: Rhinosinusitis is an inflammation of the mucosa present in the nose and the paranasal sinuses. It affects many patients yearly, bearing significant adverse effects on quality of life, productivity and healthcare expenditure. Acute rhinosinusitis lasts less than 12 weeks and is divided into viral, post-viral and acute bacterial rhinosinusitis. It is one of the prevailing reasons for unfounded antibiotics prescription, although it is usually self-limiting. Its treatment depends on the clinical stage of the infection, however, each of them encloses medications administered intranasally. Based on EPOS2020 and scientific publications it seems that nasal decongestants may be prescribed in viral rhinosinusitis, nasal corticosteroids in post-viral rhinosinusitis and nasal saline can prove beneficial in all clinical stages of rhinosinusitis. While used appropriately all aforementioned medications prove to be safe. Conclusions: In the light of the findings presented in this paper, it can be concluded that acute rhinosinusitis should be treated not only with oral, but also with intranasal drugs. Nasal decongestants are to be considered in viral rhinosinusitis mainly. Nasal corticosteroids show some positive effect in post-viral rhinosinusitis. Nasal saline can be administered in all clinical stages of acute rhinosinusitis. It is crucial to caution the patients against misuse of the medications, in order to prevent their adverse effects

Antibiotics for acute rhinosinusitis in adults.

Background : Acute rhinosinusitis is an acute infection of the nasal passages and paranasal sinuses that lasts less than four weeks. Diagnosis of acute rhinosinusitis is generally based on clinical signs and symptoms in ambulatory care settings. Technical investigations are not routinely performed, nor are they recommended in most countries. Some trials show a trend in favour of antibiotics, but the balance of benefit versus harm is unclear. We merged two Cochrane Reviews for this update, which comprised different approaches with overlapping populations, resulting in different conclusions. For this review update, we maintained the distinction between populations diagnosed by clinical signs and symptoms, or imaging. Objectives : To assess the effects of antibiotics versus placebo or no treatment in adults with acute rhinosinusitis in ambulatory care settings. Search methods : We searched CENTRAL (2017, Issue 12), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 1950 to January 2018), Embase (January 1974 to January 2018), and two trials registers (January 2018). We also checked references from identified trials, systematic reviews, and relevant guidelines. Selection criteria : Randomised controlled trials of antibiotics versus placebo or no treatment in people with rhinosinusitis-like signs or symptoms or sinusitis confirmed by imaging. Data collection and analysis : Two review authors independently extracted data about cure and side effects and assessed the risk of bias. We contacted trial authors for additional information as required. Main results : We included 15 trials involving 3057 participants. Of the 15 included trials, 10 appeared in our 2012 review, and five (631 participants) are legacy trials from merging two reviews. No new studies were included from searches for this update. Overall, risk of bias was low. Without antibiotics, 46% of participants with rhinosinusitis, whether or not confirmed by radiography, were cured after 1 week and 64% after 14 days. Antibiotics can shorten time to cure, but only 5 to 11 more people per 100 will be cured faster if they receive antibiotics instead of placebo or no treatment: clinical diagnosis (odds ratio (OR) 1.25, 95% confidence interval (CI) 1.02 to 1.54; number needed to treat for an additional beneficial outcome (NNTB) 19, 95% CI 10 to 205; I-2 = 0%; 8 trials; high-quality evidence) and diagnosis confirmed by radiography (OR 1.57, 95% CI 1.03 to 2.39; NNTB 10, 95% CI 5 to 136; I-2 = 0%; 3 trials; moderate-quality evidence). Cure rates with antibiotics were higher when a fluid level or total opacification in any sinus was found on computed tomography (OR 4.89, 95% CI 1.75 to 13.72; NNTB 4, 95% CI 2 to 15; 1 trial; moderate-quality evidence). Purulent secretion resolved faster with antibiotics (OR 1.58, 95% CI 1.13 to 2.22; NNTB 10, 95% CI 6 to 35; I-2 = 0%; 3 trials; high-quality evidence). However, 13 more people experienced side effects with antibiotics compared to placebo or no treatment (OR 2.21, 95% CI 1.74 to 2.82; number needed to treat for an additional harmful outcome (NNTH) 8, 95% CI 6 to 12; I-2 = 16%; 10 trials; high-quality evidence). Five fewer people per 100 will experience clinical failure if they receive antibiotics instead of placebo or no treatment (Peto OR 0.48, 95% CI 0.36 to 0.63; NNTH 19, 95% CI 15 to 27; I-2 = 21%; 12 trials; high-quality evidence). A disease-related complication (brain abscess) occurred in one participant (of 3057) one week after receiving open antibiotic therapy (clinical failure, control group). Authors' conclusions :The potential benefit of antibiotics to treat acute rhinosinusitis diagnosed either clinically (low risk of bias, high-quality evidence) or confirmed by imaging (low to unclear risk of bias, moderate-quality evidence) is marginal and needs to be seen in the context of the risk of adverse effects. Considering antibiotic resistance, and the very low incidence of serious complications, we conclude there is no place for antibiotics for people with uncomplicated acute rhinosinusitis. We could not draw conclusions about children, people with suppressed immune systems, and those with severe sinusitis, because these populations were not included in the available trials

Use of balloon catheter dilation vs. traditional endoscopic sinus surgery in management of light and severe chronic rhinosinusitis of the frontal sinus: a multicenter prospective randomized study

OBJECTIVE: Chronic rhinosinusitis (CRS) of the frontal sinus is a complex pathological condition and many surgical techniques were described to treat this area endoscopically, like traditional endoscopic sinus surgery (ESS) and balloon catheter dilation (BCD). PATIENTS AND METHODS: We designed a multicenter prospective randomized study to assess the validity and safety of BCD vs. ESS in symptomatological chronic rhinosinusitis of the frontal sinus enrolling a population of 102 adult patients (64 men and 38 women; overall 148 frontal sinuses studied) with non-polypoid CRS. For a better evaluation of the disease, in our study we decided to analyze both radiological (Lund-McKay CT scoring modified by Zinreich) and symptomatological results (SNOT-20 questionnaire). We divided the population affected in two groups, one with light/mild frontal CRS and the other with moderate/severe frontal CRS, basing on radiological findings at Lund-MacKay modified by Zinreich score. Every group was divided in two subgroups, in one we used BCD and in the other we used traditional ESS. RESULTS: The current literature does not support the suggestion that indications for BCD and ESS are identical, and additional research is needed to determine the role for BCD in specific patient populations. The results showed a not statistically significative difference between BCD and conventional ESS of the frontal sinus in patients with light/mild CRS and in patients with moderate/severe CRS at Lund-Mackay modified by Zinreich score. The same not statistically significative difference was observed comparing the results of SNOT-20 questionnaire in the group of light/mild frontal chronic rhinosinusitis. However, we noticed a statistically significant better outcome of SNOT-20 score in patients with moderate/severe chronic rhinosinusitis that underwent BCD of frontal sinus compared to ESS. CONCLUSIONS: BCD and ESS are two alternative weapons in the baggage of every endoscopic surgeon, even because they present similar outcomes, safeness and effectiveness both in light/mild and moderate/severe chronic rhinosinusitis of the frontal sinus. An interesting result of our study was the statistically significant better outcome of SNOT-20 score in patients that underwent BCD of frontal sinus for a moderate/severe CRS, compared to those that underwent a traditional ESS

Pharmacoeconomics of Cyclamen europaeum in the management of Acute Rhinosinusitis

Objective. To carry out a pharmacoeconomic analysis of Cyclamen europaeum (CE) in the management of acute rhinosinusitis (ARS) in Spain using data from the PROSINUS study. Study Design. This was a prospective observational study to compare the effectiveness and cost-effectiveness between therapies including CE vs. other therapies in the management of ARS. Methods. The study was carried out as a secondary analysis of the PROSINUS, combining healthcare resource use, productivity loses, and health outcomes from the observational study with costs representative of the Spanish Health System. Results. CE given as monotherapy appears to be more effective (cure rate) than other monotherapies (15.3% higher, p<0.05) and combination (10.3% higher, p<0.05) therapies. The addition of CE to other single-drug or combination therapies showed a statistically significant improvement in terms of cure rates when adding CE to 2-drug combinations (93.9% vs. 76.5%; p<0.05), and no significant effect when added to combinations of three or more drugs (81.1% vs. 79.8; NS). CE based therapies generally showed lower indirect costs, although only the comparison of CE alone vs. other monotherapies, with a net cost savings of 101 per patient, reached statistical significance (331 vs. 432 , p<0.05). In addition, CE-based therapies show lower cost per cured patient in all comparisons except when CE was used in combination with three or more other drugs. Conclusions. The use of Cyclamen europaeum may be associated to better clinical outcomes at no additional cost for the healthcare system, respect to treatments commonly used for ARS in clinical practice

Reflexology for acute rhinosinusitis – Results from a blinded, early-phase comparative trial

Background - Reflexology is commonly used as an adjunct to conventional treatment by patients with respiratory tract infections. The effect of reflexology needs to be tested in a full-scale randomized controlled study. Small early-phase trials can give an indication on whether full-size clinical trials are warranted. The objective of this study is to determine whether the study design is feasible in a full-scale study of reflexology as an add-on to usual care compared to usual care alone in acute rhinosinusitis, and further if there is a statistical indication of an effect of reflexology warranting a full-scale study. Methods - 20 patients with symptoms compatible with acute rhinosinusitis, and an illness duration of 28 days or less were randomized to additional reflexology treatment along with usual medical care, or usual care alone. The patients scored how much each of 16 sinus-related symptoms bothered them in the past few days on a six-point scale (zero = no problem to five = severe problem). To determine if there is a statistical indication of an effect of reflexology warranting a full-scale study, the separation test was used. Results - The methodology was considered feasible and could therefore be applied in a full-scale study of reflexology for acute rhinosinusitis. The mean reduction in symptom score from baseline to day two was 0.95 in the reflexology group and 0.78 in the control group. From baseline to day ten the mean reduction in symptom score was 2.12 in the reflexology group and 1.63 in the control group. A statistical indication of effect in a full-scale study in favor of reflexology was found from baseline to day ten but not from baseline to day two. Conclusions - The research methodology in this study could be used in a full-scale study of reflexology in acute sinusitis. The results from the separation test indicates an effect warranting a full-scale study of reflexology regarding effects in acute sinusitis ten days after treatment