xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.22741 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

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Orlandi et al.

treatment duration was 4 weeks. Sinus opacification (Ker schner’s rabbit sinus CT grade), transepithelial Cl − trans port (sinus potential difference assay), airway surface liq uid depth using micro-optical coherence tomography, and submucosal gland density on histopathology were tested before and after treatment. Outcome parameters were ana lyzed by 2 blinded investigators. The results showed a sta tistically significant improvement in all radiologic, histo logic and MCC parameters in high dose treatment group vs placebo. The current literature suggests that phytotherapy is an effective and safe form of ancillary treatment for RS. In particular, herbal drugs made with the technique of phy toneering have proven effective in ARS both in labora tory studies as well as in clinical trials in adults and children. However, additional worldwide multicenter observa tional studies should be performed in order to overcome the bias shown in the available literature and the lack of RC clinical trial in chronic forms. Herbal Medications for CRS Aggregate Grade of Evidence: C (Level 2: 1 study; level 3: 4 studies; level 5: 1 study; Table IX-39). Benefit: Pytotherapy may be safe and effective for RS. Harm: Cannot be currently assessed. Cost: Unknown. Benefits-Harm Assessment: Significant bias in current data making difficult to assess. Value Judgments: Bias in data limits value judg ments. Policy Level: No recommendation. IX.D.12 Management of CRSsNP: Topical Alternative Therapies IX.D.12.a. Topical Alternative Therapies for CRS: Surfactants Because of limited data, CRSsNP and CRSwNP are com bined in this analysis and recommendations. The word surfactant is derived from ""surface" "active" "agent" and refers to a group of amphipathic (both hydrophobic and hydrophilic) compounds that can be sol vent in both water and organic substrates. In the respira tory system, naturally occurring surfactants decrease the surface tension and viscosity of mucus. The orthopedic

literature has established the benefits of chemical surfac tants, commonly found in soaps and shampoos, as ther apeutic detergents to break up and assist in the eradica tion of bacterial biofilms. These agents also have antimi crobial potential as a result of their ability to cause cell membrane disruption and loss of function. Therefore, in the setting of CRS, chemical surfactant may have a ther apeutic benefit both as a mucoactive agent and a bio cide with activity against planktonic and biofilm associated microbes. 1217 The use of baby shampoo, citric acid zwit terionic surfactant and a novel proprietary sinus surfac tant solution (Sinusurf R ; NeilMed Pharmaceuticals, Santa Rosa, CA) have been evaluated invitro , in animal models, and invivo . 589,590,1218 One percent baby shampoo in normal saline was deter mined to be the optimal concentration for inhibition of Pseudomonas biofilm formation, but it had no effect on the eradication of already formed Pseudomonas biofilms. 601 A prospective study using 1% baby shampoo irrigation in the post-ESS setting showed modest symptomatic improve ment, with 2 of 18 patients (11%) discontinuing use due to nasal and skin irritation; there was no control group. 601 A RCT of 1% baby shampoo vs hypertonic saline showed no significant differences in post-treatment symptom scores; however, 20% of patients receiving the surfactant irriga tion solution discontinued use due to side effects. 603 The Sinusurf R surfactant solution was withdrawn from the market in 2011 due to adverse effects, including olfactory disturbance. 1141 A subsequent prospective crossover trial of a reformulated low-concentration Sinusurf R solution showed tolerability issues in a non-CRS population and reversible reductions in olfactory acuity in a subset of participants. 604 Data regarding the effects of surfactant irrigation on the respiratory epithelium/cilia is mixed, with evidence of both a transient increase in cilia beat frequency and an increase in MCC time. 1217,1219 The Sinusurf R surfac tant solution did not elicit cellular toxicity in a mucosal explant model when used at the manufacturer’s recom mended concentration, but showed dose-dependent toxi city with higher concentrations. 1220 In summary, 1 RCT has shown no benefit of baby sham poo over control and patients in the treatment group had higher rate of side effects and study discontinuation. The benefits of surfactants are clearance of thick secretions and interruption of biofilm formation. Harms include nasal irritation as well as negative effects on cilia morphology, ciliary beat frequency, olfaction, and MCC time. Cost of surfactant therapy is low. While there appears to be a bal ance of benefit and harm, because of the limited clinical data, no recommendation is given for the use of surfactants in CRSsNP and CRSwNP.