Original contributionEffects of sulfurous, salty, bromic, iodic thermal water nasal irrigations in nonallergic chronic rhinosinusitis: a prospective, randomized, double-blind, clinical, and cytological study
Introduction
Rhinosinusitis is a common disease that affects more than 31 million people in the United States every year [1]. Nasal irrigations are often recommended among the adjunctive measures for treating several sinonasal conditions. In 2000, Hamilos [2] discussed the rational treatment of chronic sinusitis and advocated the use of nasal irrigations; Benninger et al [3] also suggested including nasal irrigations in the treatment of most patients with rhinosinusitis. There is some controversy over the efficacy of nasal irrigation solutions of different tonicities and the use of additives in the solution [4]. In 2002, Rabago and coworkers [5] found that hypertonic nasal irrigations improved quality of life and overall symptom severity in patients with rhinosinusitis. Further investigations confirmed that hypertonic nasal irrigations were superior to isotonic solutions [6], [7]. When Staffieri and Abramo [8] measured the mucociliary transport time before and after inhalatory treatment with sulfurous, arsenical, ferruginous thermal water in 37 consecutive patients with chronic rhinosinusitis, they found a significant reduction in the transport time after the treatment. However, most of the available studies on nasal irrigations are based on limited, inadequately controlled series; and the exact mechanism behind the effects of nasal irrigations remains highly controversial. Some believe that nasal irrigations take effect mainly by clearing the mucus; others are convinced that they remove nasal inflammatory mediators [9]. Staffieri et al [10] found a direct correlation between sulfurous, salty, bromic, iodic (SSBI) thermal water irrigations and nasal secretory immunoglobulin A and albumin concentrations, concluding that this might be one of the mechanisms by which such irrigations may be effective in treating nasal inflammation.
Interest in cytological studies on the nasal mucosa is due to the relative simplicity of sample collection and to their utility in the clinical follow-up, especially to monitor the efficacy of medical and surgical treatments [11]. Normal nasal mucosa contains 4 types of cell: ciliated cells (Fig. 1), mucus-secreting cells, basal cells, and striated cells. In 2003, Gelardi and coworkers [11] found a hyperchromatic area in the cytoplasm of ciliated cells (Fig. 2) of healthy individuals, termed the hyperchromatic supranuclear stria (HSS) because of its position above the nucleus; the authors hypothesized that the HSS might express a high protein content because of a good metabolic activity of the cells and that it might consequently be a valid marker of the anatomical and functional integrity of the ciliated cells in the nasal mucosa [11].
Our prospective, double-blind, randomized study investigated the effects of nasal irrigations with SSBI thermal water vs isotonic sodium chloride solution (ISCS) in patients with nonallergic chronic rhinosinusitis, considering the clinical and microbiological evidence, and the cytological picture (the numbers of the HSS-positive and total ciliated cells).
Section snippets
Study design
The present investigation was a prospective, randomized, double-blind study conducted in accordance with the 1996 Helsinki Declaration. The study protocol was approved by the Ethics Committee of Padova University Hospital in Italy (protocol no. 7302).
The inclusion criteria were age ranging from 18 to 65 years and nonallergic chronic rhinosinusitis; the exclusion criteria were autoimmune diseases, cystic fibrosis, and diabetes. At enrolment, patients provided microbiological nasal swabs and
Results
Sixty-six patients (82.5%) completed the 1-month treatment protocol and underwent final clinical, functional, microbiologic, and cytological assessment. Of these, 35 had used SSBI thermal water; and 31, ISCS.
Discussion
Epithelial cells play an important part in host defense and regulating immune response. They mediate innate immune responses by secreting dozens of distinct antimicrobial products; and they regulate adaptive immune responses by involving dendritic cells and also T and B cells, which are regulated by the release of cell-subtype–specific chemokines and the expression of soluble and cell-surface–expressed molecules that govern T and B cell differentiation, proliferation, and survival. In airway
Conclusions
We demonstrated the efficacy of a 1-month treatment with nasal irrigations (using either SSBI thermal water or ISCS) in improving the clinical (endoscopic) and microbiological features of patients with nonallergic chronic rhinosinusitis. From a functional respiratory standpoint, only the SSBI thermal water irrigations significantly reduced the total nasal resistance determined by active anterior rhinomanometry. Nasal irritation (6 patients) and extremely limited epistaxis (5 patients) were
Acknowledgments
The present study was partially supported by a grant from Federterme Scientific Foundation, Italy. Prof A Staffieri is a member of the Scientific Committee of Sirmione Spa, Italy. The authors thank Frances Coburn for checking the English version of this paper.
References (15)
Chronic sinusitis
J Allergy Clin Immunol
(2000)- et al.
The efficacy of hypertonic saline nasal irrigation for chronic sinonasal symptoms
Otolaryngol Head Neck Surg
(2005) - et al.
Epithelium: at the interface of innate and adaptive immune responses
J Allergy Clin Immunol
(2007) - et al.
The effect of sulphurous-arsenical-ferruginous thermal water nasal irrigation in wound healing after functional endoscopic sinus surgery for chronic rhinosinusitis: a prospective randomized study
Am J Otolaryngol
(2008) - et al.
Polypoid mucosa with eosinophilia and glandular hyperplasia in chronic sinusitis: a histopathological and immunohistochemical study
Laryngoscope
(2002) - et al.
The medical management of chronic rhinosinusitis
Otolaryngol Head Neck Surg
(1997) - et al.
Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: a randomized controlled trial
J Fam Pract
(2002)