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.

TABLE X-17 Evidence for CRSwNP management with nasal saline Study

Year LOE Study Design Study Groups (n) Device

Clinical Endpoint Conclusions

Chong 1048

2016

1

Systematic review RCT, NPC,UB

CRS patients

Nebulizer

Symptom Endoscopy Symptom Endoscopy

Referred to

Cassandro et al.

Cassandro 1049

2015

3

CRSwNP Nebulized saline (20) MFNS (20) NHA(20) MFNS NHA(20)

Nebulizer

Nebulized saline was inferior to intranasal

corticosteroid for improved nasal symptoms and endoscopic appearances.

arm for assessing the effects of other treatments. Thus data from this study did not directly address the effects of saline as a therapeutic in CRSwNP treatment. In addi tion, saline in this study was delivered via a nebulizer with a low volume of 5 mL. Various kinds of delivery meth ods deliver intranasal saline with various volume and pres sure of the saline solution, which impact the fluid distri bution of topical therapies. The volume of nasal saline can be as lowas < 5 mL when using sprays and nebulizers to as large as 250 mL when using squeeze bottles and Neti pots. A positive association between the deeper penetra tion of topical medications and greater beneficial effects was shown for intranasal corticosteroid treatment. 1077 Sys tematic reviews and meta-analyses revealed that the ther apeutic effects of INCS were greater when corticosteroids were effectively delivered with large-volume and high pressure devices. 1533 By extension, the same may be true for saline. For nasal saline treatment, its primary mechanism of action is mechanical clearance of thick mucus and inflammatory mediators. 1534 Thus, effective saline delivery would seem to be beneficial in the treatment of patients with CRSwNP, particularly those with eosinophilic mucin. CRSwNP with eosinonphiic mucin is typically associ ated with Type 2 sinonasal inflammation, high tissue eosinophilia, and asthma. 1535 A meta-analysis by Hermel ingmeier et al. 1536 revealed that saline treatment improved MCC time from 2.7% to 31.6%. Improved mucociliary function 1536 is achieved when saline thins mucus 1537 and improves ciliary beat function. 1538 Bonnomet et al. 1538 mea sured CBF of airway epithelial cells obtained from nasal polyps and suggested that saline treatment enhanced cil iary beat frequency and preserved the respiratory mucosa in pathological conditions. Safety of saline treatment was shown by the study of Cassandro et al. 1049 The incidence of throat irritation (0% vs 5%), nasal burning (0% vs 5%), headache (15% vs 10%),

upper respiratory infection 15% vs 15%, and treatment related epistaxis (5% vs 10%) were similar between the saline group and the intranasal steroid group. To date, although there has been no clinical trial to support the use of nasal saline spray for treating CRSwNP, there is evidence showing the benefits of saline treatment on improved mucociliary function. Due to the safety profile of saline treatment and its low cost of around USD$0.24 per day, 1141 there is a greater balance of benefit over harm. Saline for CRSwNP Aggregate Grade of Evidence: Saline sprays: No study. Saline nebulization: B (Level 1: 1 study; level 3: 1 study; Table X-17). Saline irrigations: No study. Benefit: Mechanical removal of mucus and improved mucociliary function. Harm: Minor adverse effects of throat irritation, nasal burning, and epistaxis (see Table II-1). Cost: Minimal (US$0.24/day). Benefits-Harm Assessment: Balance of benefit and harm. Value Judgments: Patients with CRSwNP usually present with thick nasal and postnasal discharge, which requires topical management. Nebulized saline (5 mL) treatment with effective delivery may be given for mechanical removal of thick mucus. Policy Level: Option. Intervention: Nebulized saline (5 mL) treatment is an option for treating CRSwNP, particularly patients with thick mucus.