COMPARISON OF SALINE, HYALURONIC ACID AND XYLITOL NASAL IRRIGATION SOLUTIONS AFTER ENDOSCOPIC SINUS SURGERY: A PROSPECTIVE RANDOMIZED STUDY

Osman ERDOĞAN ¹, MD; Onur İSMİ ², MD; Yusuf VAYISOĞLU ², MD; Kemal GÖRÜR ², MD; Cengiz ÖZCAN ², MD;

¹Şanlıurfa Eğitim ve Araştırma Hastanesi, Kulak Burun Boğaz Hastalıkları, Şanlıurfa, Turkey
²Mersin Üniversitesi Tıp Fakültesi, Kulak Burun Boğaz Hastalıkları, Mersin, Turkey

Summary

Objective: To evaluate the effectiveness of saline, xylitol and hyaluronic acid nasal irrigation solutions after endoscopic sinus surgery (ESS) on edema, discharge, crusting, and mucociliary clearance.

Methods: Thirty-four patients who were undergone ESS for chronic sinusitis with or without nasal polyps were prospectively included. Patients were randomly divided into three groups according to the nasal irrigation solutions they used: saline group, hyaluronic acid group, and xylitol group. Nasal obstruction was measured with visual analog scale (VAS). Edema, discharge and crusting levels were scored by nasal endoscopic examination in the first week and first month. Mucociliary clearance was evaluated by applying the saccharin clearance test in the first month.

Results: While there was no difference in crusting between the three groups in the first month, it was observed that there was less crusting in xylitol group than in saline group in the first week (p=0.025). In the saline, hyaluronic acid and xylitol groups, less crusting was observed in the first month compared to the first week (p=0.006, p=0.008 and p=0.014, respectively).

Conclusion: Saline, hyaluronic acid, and xylitol irrigation solutions reduced crusting in patients underwent ESS. Xylitol solution showed this effect in the early period. After ESS, saline, hyaluronic acid, and xylitol solutions can be effectively used for nasal irrigation. Xylitol solutions can be recommended to patients with a history of crusting or prone to crusting in dry climates.

Summary

Introduction

Chronic rhinosinusitis is one of the most important health problems because it significantly increases health expenditures and has a significant effect on lower respiratory tract diseases and general health[1]. Chronic rhinosinusitis without nasal polyps was reported as the most common chronic disease in the USA in 1997, according to the basic data of the National Institute of Allergy and Infectious Diseases, 16.3% of the entire population was affected by this disease[2]. Nasal irrigation is recommended after endoscopic sinus surgery (ESS) in chronic rhinosinusitis with or without nasal polyps. Postoperative nasal irrigation aims to remove infected debris and crusts, reduce synechia formation, accelerate mucosal healing, increase sinonasal drainage, and mucociliary clearance[3,4]. In the first article on the importance of nasal irrigation, published in 1902 by Wingrave[5], various solutions were used for the removal of dense secretions, deposits, and foreign bodies in the nasal cavity, for antisepsis and for diagnostic purposes.

To date, normal saline (0.9% sodium chloride) solution has been most commonly used for nasal irrigation. Many nasal irrigation solutions with different contents have been compared in the literature. These solutions include tap water, normal saline, hypertonic saline, solution containing xylitol, solution containing hyaluronic acid, hypertonic seawater, lactated Ringer's solution, saline containing sodium bicarbonate, solution containing surfactant, and solution containing budesonide[6-12].

Changes in salt concentrations in the airway surface liquid (ASL) affect antimicrobial factors. Xylitol, a five-carbon sugar-alcohol, is non-ionic and has low transepithelial permeability, thus increasing the antimicrobial activity by reducing ASL salt concentration. [13]. In addition, it causes less crust formation by reducing mucus viscosity with its humectant feature[14].

Hyaluronic acid is a non-sulfated, major glycosaminoglycan. It is one of the most important extracellular matrix components in the nasal and tracheobronchial mucosa. It plays an important role in epithelial mucociliary clearance, repair of the mucosal surface, wound healing process, and viscoelasticity of structures during speech[15].

In this study, the efficacy of solutions such as saline, hyaluronic acid and xylitol used for nasal irrigation after ESS for chronic rhinosinusitis with or without nasal polyps were evaluated. Considering the nasal mucosal protective effects of hyaluronic acid and xylitol solutions, it has been hypothesized that they will be more effective than saline solution on postoperative nasal congestion, edema, discharge, crusting, and mucociliary clearance.

Introduction

Methods

Study design
This prospective and randomized study was approved by the Clinical Research Ethics Committee. Informed consent was obtained from the patients.

Study population
Thirty-four patients who underwent ESS for chronic sinusitis with or without polyps were included in the study. The inclusion criteria of the patients were defined as chronic sinusitis with or without polyps and bilateral localization of the disease. Patients with a history of immunosuppression, cystic fibrosis, primary ciliary dyskinesia, active smoking, antifungal medical therapy, radiation to the head and neck region, pregnancy, and granulomatous disease were excluded from the study.

Treatment
All patients underwent ESS with the Messerklinger approach. In line with the approach, maxillary antrostomy, anterior and posterior ethmoidectomy were performed, but the frontal and sphenoid sinuses were not intervened. Merocel nasal packing was applied for 2 days after the surgery. Patients used nasal decongestant spray for 5 days after nasal packing removal. Patients were randomly divided into three groups according to the nasal irrigation solutions they used: saline group (0.9% sodium chloride), hyaluronic acid group (0.9% sodium chloride + sodium bicarbonate + hyaluronic acid) and xylitol group (0.9% sodium chloride + sodium bicarbonate + xylitol). They performed nasal irrigation with these solutions three times a day for a period of one month postoperatively. They were instructed to douche each nasal cavity with 100 ml of solution with a squeeze bottle. During nasal douching, they were asked to adjust their head position by leaning their face 45 degrees forward.

Examination
Edema, discharge and crusting levels were determined by nasal endoscopic examination without the use of nasal decongestants and local anesthetics in the first week and first month follow-ups of the patients. In endoscopic nasal scoring, edema (0: absent, 1: mild-moderate, 2: moderate-severe), discharge (0: absent, 1: thin and clear, 2: thick and purulent) and crusting (0: absent, 1: mild-moderate, 2: moderate-severe) rated according to severity[16]. Before the nasal endoscopic examination, patients were asked to record perceived nasal obstruction on a scale of 0% to 100% (no obstruction to worst obstruction) via 10 cm visual analogue scale (VAS). In the first month follow-up examination, the mucociliary activity was evaluated by applying the saccharin clearance test. In this test, a saccharin tablet was placed in the anteroinferior of the left inferior turbinate and the time elapsed until the taste of sugar in the patient's mouth was noted.

Statistical analysis
The data of the groups were shown as mean ± standard deviation. The continuous data were tested for normality with the Shapiro Wilk test. Independent nasal irrigation groups were compared with the Kruskal Wallis test. Pairwise comparisons of the nasal irrigation groups were made with Mann-Whitney U-test with Bonferroni correction. Wilcoxon signed rank test was used to compare the nasal endoscopic scores in the first week and the first month. Statistical significance level was accepted as <0.05.

Methods

Results

The mean age of thirty-four patients included in the study was 43.47 ± 15.48 (range 16-70). The female to male ratio is 12:22. Demographic data of the patients were given in Table 1.

Table 1: Demographic data of the patients are presented as n (%)

There was no difference between the groups in VAS scores of the first week and first month, in which nasal obstruction was measured. In endoscopic nasal scoring, there was no difference between the three groups in edema and discharge scores at the first week and the first month. While there was no difference in the crusting between the three groups in the first month, there was a statistically significant difference between them in the first week (p=0.029). In the pairwise comparison, it was observed that there was less crusting in the xylitol group than in the saline group (p=0.025). There was no difference between the three groups in the saccharin clearance test. The nasal endoscopic scores of the three groups were presented in Table 2.

Table 2: Nasal endoscopic scores and saccharine clearance test results of salin, hyaluronic acid, and xylitol groups were compared

When comparing the nasal endoscopic scores of each group between the first week and the first month, no significant difference was found in the nasal obstruction, edema, and discharge. In the saline, hyaluronic acid and xylitol groups, less crusting was observed in the first month compared to the first week (p=0.006, p=0.008 and p=0.014, respectively). First week and first month nasal endoscopic scores were shown in Table 3.

Table 3: Comparison of first week and first month nasal endoscopic scores of salin, hyaluronic acid, and xylitol groups

Results

Discussion

The present study showed that while the xylitol group eliminated crusting more than the saline group in the first week, both solutions reduced crusting by the similar amount in the first month. After ESS, there was a decrease in crusting in all three solution types in the first month compared to the first week. According to the hypothesis of the present study, the expected positive effect on nasal obstruction, edema, discharge, crusting, and mucosal clearance in hyaluronic acid and xylitol solutions compared to saline solution was observed only in xylitol solution on crusting in the early period.

Weissman et al. reported that xylitol solution provided improvement in sinonasal symptoms by reducing the SNOT-20 score compared to saline solution, but did not create a difference in well-being VAS score[11]. Kim et al. reported greater improvement in SNOT-20 and snoring, headache and facial pain VAS scores after ESS and/or septoplasty in the xylitol group compared to the saline group[17]. The present study revealed that xylitol solution was not superior to the other solutions, except for its effect on crusting in the early period.

In chronic rhinosinusitis, wet viscoelastic mucus is usually seen in the nasal cavity before surgery, while thick mucus and crusting are seen after surgery[18,19]. The crusting can cause postoperative scar formation, increased bacterial activity, and recalcitrant diseases[20]. While nasal irrigation solutions such as hypertrophic saline or normal saline significantly reduce postoperative crusting, they are not superior to each other[21]. Hardcastle et al. reported in their in vitro study that xylitol was more effective in dissolving crusting than saline solution. They proposed that xylitol causes water retention within the crust to dissolve it. In addition, they suggest that the symptoms of chronic rhinosinusitis can be alleviated by providing hydration of the nasal mucosa with water retention[22]. In the present study, the superiority of xylitol solution in reducing crusting in the early period can be explained by the water retention and nasal mucosa hydration effect.

Hyaluronic acid plays an important role in mucociliary clearance, wound healing, and repair of mucosal surfaces[23,24]. Gelardi et al. reported that after FESS, less nasal discharge and nasal congestion were observed with hyaluronic acid used for nasal irrigation compared to saline solution[15]. In a study by Casale et al. in which they evaluated turbinate edema, secretion, and crusting after inferior turbinate radiofrequency treatment, they achieved better scores, especially in crusting, in patients who performed nasal irrigation with hyaluronic acid compared to the saline group[25]. In the present study, hyaluronic acid was not superior to saline and xylitol solutions on edema, discharge, nasal congestion and mucociliary clearance. Although all solutions have a positive effect on crusting in the first month compared to the first week, there is no difference between the solutions.

Studies on mucociliary clearance have reported that ringer-lactate, hyaluronic acid, buffered hypertrophic saline solutions increase mucociliary clearance more than saline solutions in the postoperative period[4,9,15,26]. On the contrary, a study by Boek et al. reported that saline solution may have a negative effect on mucociliary activity[27]. In the present study, xylitol and hyaluronic acid solutions were not superior to saline solution in terms of mucociliary clearance.

Discussion

Conclusion

While all three solutions evaluated in the present study reduced crusting, xylitol was the solution that showed this effect in the early period. After ESS, saline, hyaluronic acid, and xylitol solutions can be effectively used for nasal irrigation. In order to reduce crusting in the early postoperative period, xylitol solutions can be recommended to patients with a history of crusting or prone to crusting in dry climates.

Conclusion