xRead - Nasal Obstruction (September 2024) Full Articles

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Orlandi et al.

Orally administered silver has been described to be absorbed in a range of 0.4% to 18% and seems to be dis tributed to all organ systems with the highest levels being observed in the intestine and stomach. 1239 Prolonged sil ver exposure may lead to deposition of silver particles in the skin leading to the hallmark blue-gray discoloration of the skin (argyria), eye (argyrosis), and internal organs, including the central nervous system. Consumption of large doses of colloidal silver (CAg) can result in significant morbidity including gastrointestinal ulceration, hemoly sis, agranulocytosis, and neural toxicity. Colloidal silver (a colloidal solution of 33.23 ppm ele mental Ag in 99.99% water) has been shown to cause a 99% reduction in biomass of a S. aureus biofilm compared to controls in an in vitro study. 1240 Likewise, in a sheep model, 30-ppm CAg solution administered to infected frontal sinuses for 14 days resulted in significantly greater reduction in S. aureus biofilm mass relative to controls (normal saline irrigations). 599 There have been 2 clinical studies investigating the efficacy of topical CAg in CRS. In a DB randomized crossover trial by Scott et al., 1241 20 patients with recalci trant CRSsNP were randomized to receive either 10 ppm CAg spray for 6 weeks followed by saline intranasal spray for an additional 6 weeks, or saline intranasal spray for 6 weeks followed by 10 ppm CAg spray for 6 weeks. There were no significant differences in the sinonasal symp tom (SNOT-22) and endoscopic scores (LK) between the 2 groups. In terms of adverse events, 1 patient devel oped nasal congestion and another a sinus infection. How ever, no systemic side effects were reported. No cases of argyria were encountered, and no bluish discoloration of the sinonasal mucosa was seen in any of the patients. Subsequently, Ooi et al. compared the outcomes of 22 CRS patients who were randomized into 2 treatment arms, the first group received twice daily saline irriga tions and 10-14 days of culture-directed antibiotics (n = 11) and the second treatment group received only a 10 day course of twice daily CAg irrigation (0.015 mg/mL) (n = 11). 1242 All patients had recalcitrant CRS, had under gone prior sinus surgery, and had signs and symptoms of a sinus infection with positive bacterial culture. The study did not specify whether the patients enrolled had CRSsNP or CRSwNP. Both arms showed similar improve ment in sinonasal symptom (SNOT-22 and VAS) and endoscopic scores (Lund Kennedy), but the result was not statistically significant and there were no signifi cant differences between CAg vs controls. In addition, there was no difference in post-treatment culture neg ativity between the 2 groups. No adverse events were reported, but 4 patients had transient increase in serum silver levels above the normal range within 24 hours of administration. However, follow-up testing after 10 days

showed the serum silver levels had returned to normal parameters. Despite its availability as an over the counter drug, col loidal silver is an unregulated alternative medicine. Col loidal silver products of unknown formulation were tested and found to vary from ineffective to dangerous to pos sibly life threatening. Due to these findings, in 1999, the United States Food and Drug Administration (US FDA) stated that all over the counter drug products containing colloidal silver ingredients or silver salts for internal or external use were misbranded, although they had previ ously been recognized as safe and effective. 1243 In addi tion to these safety concerns, no evidence exists regard ing the efficacy of topical silver treatment in CRSsNP or CRSwNP. Consequently, topical silver is not recommended in CRSsNP and CRSwNP. Colloidal Silver for CRS Aggregate Grade of Evidence: B (Level 2: 2 studies; Table IX-42). Benefit: No benefit for the use of CAg in clinical studies. Harm: Potential increase in serum silver levels. Cost: low (commercially available) to high (com pounding). Benefits-Harm Assessment: No benefit in light of potential harm. Value Judgments: CAg appears to have anti bacterial properties in-vitro , but lacks efficacy in clinical studies. Policy Level: Recommendation against use in CRS. IX.D.12.e. Topical Alternative Therapies for CRSsNP: Furosemide The current literature demonstrates an absence of a well designed investigation that has examined the role of furosemide in the management and treatment of CRSsNP. IX.D.12.f. Topical Alternative Therapies for CRS: Capsaicin Because of limited data, CRSsNP and CRSwNP are com bined in this analysis. Capsaicin is the active ingredient in chili peppers (plant genus Capsicum ) and produces a burning sensation on contact with tissues. This response is secondary to its binding to transient receptor potential vanilloid 1 (TRPV 1), an ion-channel type receptor. It has been used as a topical medication for chronic neuropathic pain 1244 and