xRead - Nasal Obstruction (September 2024) Full Articles

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showed no statistically significant difference in SNOT-22 and Lund-Kennedy scores after 30 days of treatment. 1230 However, during acute exacerbation of their CRS, culture negativity was statistically better in patients who irrigated with MH solution. 1230 A 2019 single-blinded, placebo-controlled trial by Ooi et al. investigated MH with augmented MGO rinses in recalcitrant CRS patients. 1232 Twenty-five patients with CRS and positive bacterial culture sinus swab after ESS were randomized to receive 14 days twice daily 16.5% MH + 1.3 mg/mL MGO sinonasal rinses or 10 days of culture-directed oral antibiotic therapy with concurrent topical or oral placebo. The authors found that the MH/MGO sinonasal rinse was safe but not superior to culture-directed antibiotics in terms of endoscopic and patient-reported symptom scores. The in vitro potential benefits of MH and MGO has not yet translated into statistically significant clinical improve ment in the few clinical studies in literature. However, there is a potential for cytokine expression modulation as demonstrated in the study by Manji et al. 1231 Although gen erally well tolerated, reported side effects do include nasal burning, irritation, and possible epithelial injury if higher concentrations of MGO or MH are used. Given the hetero geneity of the study population and variable MH and MGO concentrations as well as paucity of evidence, no recom mendation for the use of Manuka honey in CRSsNP and CRSwNP is possible at this time.

Surfactants for CRS Aggregate Grade of Evidence: not applicable.

IX.D.12.b. Topical Alternative Therapies for CRS: Manuka Honey Because of limited data, CRSsNP and CRSwNP are com bined in this analysis and recommendations. Manuka honey (MH, Leptospermum scoparium ) and its active component methylglyoxal (MGO) have demon strated antimicrobial capabilities against both the plank tonic and biofilm forms of gram-positive and gram negative bacteria including MRSA. 1221–1223 Kilty et al. demonstrated that higher effective concentrations of MGO are needed for biofilms of S. aureus and P. aeruginosa than for their planktonic forms. 1221 Jervis-Bardy et al. demon strated that the biocidal activity against S. aureus biofilms is enhanced when in a honey solution suggesting a role for both the honey component and the MGO. 1222 Most recently, Yang et al. devised a novel platform that gener ates NO using MH and nitrite that produced a potent anti biofilm effect on P. aeruginosa . 1224 In vivo animal studies have confirmed the safety of Manuka honey in the sinonasal cavity. Kilty et al. treated New Zealand rabbits with up to 14 days of daily irri gations of 1.5 mL of 33% mixture of Manuka honey and saline and found no epithelial damage of the nasal respiratory mucosa under light and transmission elec tron microscopy. 1225 Paramasivan et al .’s sheep study also showed no damage to the nasal epithelium or cilia at con centrations of MGO up to 1.8 mg/mL. They did however observe cilia denudation of the epithelium at MGO con centrations of 3.6 mg/mL. 1226 Paramasivan et al. also exam ined the antibiofilm action of MGO on mature S. aureus biofilms established in the frontal sinus of the sheep. They observed no effect of the MGO on the S. aureus biofilm biomass at concentrations less than 0.5 mg/mL and simi lar effects on biomass reduction at 3.6 and 1.8 mg/mL. The authors concluded that Manuka honey/MGO with MGO concentrations around 1.8 mg/mL is probably optimal in terms of safety and efficacy. Clinical studies assessing the efficacy of Manuka honey in treatment resistant post-surgical patients have not demonstrated superior efficacy over saline alone. 1227–1232 Thamboo et al. evaluated 34 AFRS patients, randomized to receive 30 days of atomized MH saline solution to 1 side and saline alone to the contralateral side. No observable difference in symptoms and endoscopic scores was found between the treatment arms. 1227 Similarly, Lee et al .’s randomized control study comparing patients treated with saline irrigations and 10% (vol/vol) MH irrigations, also

Manuka honey for CRS Aggregate Grade of Evidence: B (Level 2: 5 studies; level 4: 1 study; Table IX-40).

IX.D.12.c. Topical Alternative Therapies for CRS: Xylitol Because of limited data, CRSsNP and CRSwNP are com bined in this analysis and recommendations. Xylitol is a 5-carbon sugar that has been shown to enhance the innate immune system. Its mechanism of action occurs via xylitol’s effect on the thin layer of air way surface liquid, enhancing the activity of innate antimi crobial factors present in respiratory secretions. Brown et al. demonstrated that simultaneous administration of xyl itol with P. aeruginosa into the maxillary sinuses of rab bits produced an increase in bacterial killing after 20 min utes when compared to saline. 1233 However, they found that pre-administration of xylitol into the sinus or admin istration of xylitol in an infected sinus did not decrease bacterial counts when compared with saline. In an in-vitro study, xylitol was also found to significantly reduce biofilm