Until now, the treatment of allergic rhinitis has not been satisfactory. Patients with allergic rhinitis are highly dependent on medical pharmacological treatment. Nasal irrigation is expected to help reduce symptoms due to decreased eosinophil counts and recurrence of allergic rhinitis. This study aims to determine the effect of nasal irrigation on eosinophils and the recurrence of allergic rhinitis—experimental research by pre – post-test group design. Twenty samples of allergic rhinitis patients were trained to wash their nose once a day at home—nasal mucosal secretion was collected to count eosinophils before and after intervention. The degree of recurrence was assessed based on the symptoms of nasal congestion, runny nose, sneezing, and itchy nose. The degree is divided into three groups: decrease, remain, and increase. The statistical analysis used in this study for bivariate analysis was Wilcoxon Test. There was a significant decrease in eosinophil count (p = 0.00) and recurrence of nasal congestion (p = 0.00), runny nose (p = 0.00), sneezing (p = 0.001) and itchy nose (p = 0.00) in allergic rhinitis after nasal irrigation intervention. Nasal irrigation treatment can help decrease eosinophil count and recurrence of allergic rhinitis

Maharani, Virgi Mayang

Sulistyanto, Agung

Wardani, Andriana Tjitria Widi

English

Until now, the treatment of allergic rhinitis has not been satisfactory. Patients with allergic rhinitis are highly dependent on medical pharmacological treatment. Nasal irrigation is expected to help reduce symptoms due to decreased eosinophil counts and recurrence of allergic rhinitis. This study aims to determine the effect of nasal irrigation on eosinophils and the recurrence of allergic rhinitisâ€”experimental research by pre â€“ post-test group design. Twenty samples of allergic rhinitis patients were trained to wash their nose once a day at homeâ€”nasal mucosal secretion was collected to count eosinophils before and after intervention. The degree of recurrence was assessed based on the symptoms of nasal congestion, runny nose, sneezing, and itchy nose. The degree is divided into three groups: decrease, remain, and increase. The statistical analysis used in this study for bivariate analysis was Wilcoxon Test. There was a significant decrease in eosinophil count (p = 0.00) and recurrence of nasal congestion (p = 0.00), runny nose (p = 0.00), sneezing (p = 0.001) and itchy nose (p = 0.00) in allergic rhinitis after nasal irrigation intervention. Nasal irrigation treatment can help decrease eosinophil count and recurrence of allergic rhinitis

Sains Medika: Jurnal Kedokteran dan Kesehatan

Effect of nasal irrigation on eosinophil and recurrence in allergic rhinitis

Portal Jurnal Universitas Islam Sultan Agung (UNISSULA)

Author Name, et al. Sains Medika: Jurnal Kedokteran dan Kesehatan, Vol xx, No xx (year): page  (will be filled by the editor)     Effect of Nasal Irrigation on Eosinophil and Reccurence in Allergic Rhinitis  Agung Sulistyanto1*, Andriana Tjitria Widi Wardani1, Virgi Mayang Maharani2   1Department of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, Sultan Agung University, Semarang,  Indonesia 2Medical Profession Study Program, Faculty of Medicine, Sultan Agung University, Semarang,  Indonesia *Correspondence: Agung Sulistyanto; Address: Jl. Kaligawe KM 4; Email address:  agungsulistyanto@unissula.ac.id                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    ARTICLE INFO ABSTRACT  Keywords: Nasal irrigation Allergic rhinitis  Eosinophil Background: Until now, the treatment of allergic rhinitis has not been satisfactory, patients with allergic rhinitis highly dependent on medical pharmacological treatment. Nasal irrigation is expected to help reduce symptoms due to decreased eosinophil counts and reccurence in allergic rhinitis. This study aims to determine the effect of nasal irrigation on eosinophil and recurrence of allergic rhinitis. Method: Experimental research by pre – post-test group design. 20 samples of allergic rhinitis patients were trained on how to wash their nose once a day at home. Nasal mucosal secretion collected to count eosinophils before and after intervention. The degree of recurrence was assessed based on the symptoms of nasal congestion, runny nose, sneezing and itchy nose. The degree divided into three group: decrease, remain and increase. The statistical analysis used in this study for bivariate analysis was Wilcoxon Test. Results: There was a significant decrease in eosinophil count (p = 0.00) and recurrence of nasal congestion (p = 0.00), runny nose (p = 0.00), sneezing (p = 0.001) and itchy nose (p = 0.00) in allergic rhinitis after nasal irrigation intervention.  Conclusion: Nasal irrigation treatment can be useful to decrease eosinophil count and recurrence of allergic rhinitis.      1. Introduction Rhinitis is broadly defined as inflammation of the nasal mucosa. This is a common disorder that affects up to half of the population (Akhouri & House, 2023; Nur Husna et al., 2022). Allergic rhinitis is the most common type of chronic rhinitis, and evidence indicates that the prevalence of this disorder is increasing (Small & Kim, 2011). Symptoms of allergic rhinitis are sneezing, itchy nose, rhinorrhoea or clear secretions and symptoms that often cause patients to seek help are nasal congestion that is intermittent or reversible, can also be spontaneous (Bousquet et al., 2008).  Allergic rhinitis is a health problem with a prevalence reaching 10-30% of the population and is still increasing every year (Pawankar et al., 2013). Eosinophilic inflammation occurred in nasal mucosa of allergic rhinitis patient. As long as the patient still exposed by the allergen, the recurrence of allergic rhinitis will continue. Allergic rhinitis medical therapy consists of oral antihistamines and intranasal corticosteroids. (Choi, 2019; Novakova et al., 2019). Allergen immunotherapy is an effective immune modulation treatment that should be recommended when pharmacological therapy for allergic rhinitis is ineffective or intolerable. However, this therapy has not been accessible to the wider community (Drazdauskaitė et al., 2021; Terada & Kawata, 2022). Corticosteroid   journal homepage: http://jurnal.unissula.ac.id/index.php/sainsmedika/ RESEARCH ARTICLE  2   therapy also has immunosuppressive effects and other unwanted side effects (Fowler & Sowerby, 2021; Rollema et al., 2022). Eosinophils have an important role in allergic reactions releasing various inflammatory mediators in tissues. The benefit of counting the types of eosinophils in the nasal mucosa is to establish a diagnosis and evaluate therapy for allergic rhinitis (Bakhshaee et al., 2010; Sudadi et al., 2019). Nasal irrigation therapy is an easy adjunctive therapy used to treat allergic rhinitis symptoms. Nasal irrigation is an inexpensive nonpharmacological therapy with few side effects (Head et al., 2018). Nasal irrigation therapy has been shown to improve allergic rhinitis symptoms and reduce medication use in allergic rhinitis sufferers. Nasal irrigation can work by cleaning mucus, debris, allergens and pollutants and can reduce inflammatory mediators in the nasal mucosa. Nasal irrigation can also enhance the defence mechanism of the nose, by increasing the rate of mucociliary transport Hermelingmeier et al., 2012; Principi & Esposito, 2017). Providing additional nasal irrigation therapy is expected to be a non-pharmacological therapy that improves the symptoms of allergic rhinitis sufferers. This study aims to determine the relationship between nasal irrigation therapy with eosinophil count and recurrence of allergic rhinitis.  2. Materials and Methods  This research is an experimental research with pre-post design conducted at the Ear Nose and Throat  (ENT) clinic at the Sultan Agung Islamic Hospital in Semarang. This study was approved by the Ethics Committee of the Faculty of Medicine, UNISSULA number 252/VII/2018/Bioethics Committee. Population and Sample          Allergic rhinitis patients diagnosed by an ENT specialist. Method of sampling in this research is purposive sampling. The total sample in this study was 20 patient.  Data Collection and Measurement          The research subjects were taken smears of nasal mucosal secretions before the intervention and assessed the recurrence before the nasal irrigation intervention. The subjects were  taught nasal irrigation and asked to do it daily with normal saline solution, and noted by daily questionnaire, including the recurrence of nasal congestion, runny nose, sneezing and nasal discharge symptoms. After three months, the patient went to the ENT clinic to take a smear of nasal mucosal secretions and the researchers collected data on the recurrence of the patients’ symptoms for 3 months. The degree of recurrence and eosinophils were divided into: decrease, remain and increase compared to before intervention.  Data analysis          Research data analysis was carried out to look for normality and homogeneity of data with a numerical scale. The pre-post comparison was performed using Mann Whitney or Wilcoxon analysis with a significance level of 5%. 3. Results The normality and homogenity test results for both variables showed not normally distributed and not homogeneous, so we continued the bivariate test with the Wilcoxon test. The statistical test results showed that there were significant differences in the symptoms of nasal congestion, runny nose, sneezing and itchy nose (p value < 0,05) (Table 1). Table 1. Statistical Test Results Pre - Post of Symptoms Recurrence  Symptoms p value 3   Nasal congestion Runny nose Sneeze Itchy nose 0,000*a 0,000*a 0,001*a 0,000*a *Significant (p < 0,05) aWilcoxon test The number of subjects with decreased of symptoms reccurence of nasal congestion, runny nose, sneezing and itchy nose were 16, 17, 14 and 17 people, respectively (Table 2).  Table 2. Number of Allergic Rhinitis Subjects based on Symptoms Recurrence and Eosinophils  Variable Degrees Decrease (n) Remain (n) Increase (n) Nasal congestion 16 4 0 Runny nose 17 3 0 Sneeze 14 5 1 Itchy nose 17 2 1 Eosinophils 13 2 0  Collection of nasal swab secretions were only taken in 15 out of 20 patients patients, the eosinophil count was measured pre and post (Table 3).   Table 3. Pre and Post Eosinophils Count Sample Pre  Post  1 0 0 2 1 0 3 1 0 4 1 0 5 1 0 6 1 0 7 1 0 4   8 1 0 9 2 1 10 2 0 11 2 1 12 1 0 13 0 0 14 1 0 15 1 0 Average 1.067 0,133  Wilcoxon test results eosinophil count was p = 0,000 (p <0,05), there were significant difference between the number of eosinophils before and after the intervention (Table 4). It was found that 13 people had decreased eosinophil counts and 2 people remained (Table 2).    Table 4. Mean of Pre and Post Eosinophils Count Pre (max-min) Post (max-min) Sig 1.07 (0-2) 0.13 (0-1) 0.00   4. Disscussion    The results of this study are in line with Head, et al (2018) nasal irrigation with saline could benefit adults and children in reducing the symptoms of allergic rhinitis and there were no harmful side effects (Head et al., 2018). Research conducted on Hajj pilgrims in Mecca (2017) showed that the group who washed their nose during ablution had significantly fewer symptoms of cough, rhinorrhea and nasal congestion than the group who did not receive intervention (Ramli et al., 2018). Nasal irrigation with saline is considered as a non-pharmacological adjunct to the pharmacological treatment of allergic rhinitis, such as antihistamines and intranasal corticosteroids. In Islam, there is a term istinsyaq which means a process of breathing in water into the nose and istintsar, the process of breathing out water from the nose (Yanti et al., 2021). This Islamic approach is similar to the concept of nasal irrigation which has been applied for old practice daily life in various other medical traditions (Principle & Esposito, 2017). Nasal irrigation using sodium hyaluronate post-endoscopic sinus surgery conducted on 56 patients in the group that underwent normal saline nasal irrigation and normal saline plus sodium hyaluronate found better endoscopy appearance and patient satisfaction (Mozzanica et al., 2019). Another nasal irrigation study using a hypertonic solution in children found a lower total symptom/treatment score compared to the group that did not (Mitsias et al., 2020). Nasal irrigation can be used to reduce symptoms in chronic rhinosinusitis, allergic rhinitis, and to clean a dirty nose due to irritants (Hermelingmeier et al., 2012). In addition, nasal irrigation can increase nasal patency and have minimal side effects. Isotonic saline is thought to have a therapeutic effect by mechanically cleaning the nasal mucosa, improving 5   mucociliary transport, reducing the production of inflammatory mediators and improving mucosal edema. Lance et al., mentioned that isotonic saline can reduce edema by inhibiting the production of prostaglandins and LT4 (Rabago & Zgierska, 2009; Ural et al., 2009). Nasal irrigation with sea water reduced the dose of intranasal corticosteroid use and reduced the number of eosinophils in nasal secretions which was observed for 12 weeks (Chen et al., 2014). In this study, nasal irrigation using normal saline solution has beneficial effect to reduce eosinophil count and reccurence in allergic rhinitis patients. The limitation of this study was that there was no control group of subjects who did not receive nasal irrigation intervention. Factors that influence this are the limited research samples that come to the hospital ENT clinic and are willing to return for control within the study period.  5.  Conclusion In conclusion, from this experimental study result demonstrated beneficial effects of nasal irrigation on reducing eosinophils and the degree of recurrence of allergic rhinitis patients.  Acknowledgment The authors would like to thank the Research And Community Service Institutions, Faculty of Medicine, Sultan Agung Islamic Univeristy whose support and made this study possible.    Conflict of interest   All authors have no conflict of interest in this article.   References Akhouri, S. & House, S. A. (2023, 20. May). Allergic Rhinitis. StatPearls Publishing. Bakhshaee, M., Fereidouni, M., Farzadnia, M., & Varasteh, R. (2010). The Nasal Smear for Eosinophils, Its Value, and Its Relation to Nasal Mucosal Eosinophilia in Allergic Rhinitis. Article in Iranian Journal of Otorhinolaryngology, 17, 750.  Bousquet, J., Khaltaev, N., Cruz, A. A., Denburg, J., Fokkens, W. J., Togias, A., Zuberbier, T., Baena-Cagnani, C. E., Canonica, G. 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Effect of Nasal Irrigation on Eosinophil and Reccurence in Allergic Rhinitis

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Sains Medika: Jurnal Kedokteran dan Kesehatan

Portal Jurnal Universitas Islam Sultan Agung (UNISSULA)