Comparison of Hypertonic Saline with Normal Saline in Nasal Irrigation Post Endoscopic Sinus Surgery (2024)

Abstract

Functional endoscopic sinus surgery (FESS) is indicated for the treatment of chronic rhinosinusitis that is refractory to medical treatment. Nasal irrigation is a classic and powerful adjunctive method for the management of chronic rhinosinusitis after FESS [5]. This study aimed to compare the effects of hypertonic saline and isotonic saline nasal irrigation following endoscopic sinus surgery. The study was conducted in the Department of Otorhinolaryngology at Mahatma Gandhi Medical College and Hospital, Jaipur, India, on 156 patients, who had chronic rhinosinusitis with or without nasal polyposis, and were resistant to conservative management. All patients underwent functional endoscopic sinus surgery. Patients were advised to perform nasal douching post-surgery, and were randomly divided into two groups based on the douching solution they used. Group 1 was given hypertonic saline (3%) while Group 2 was given isotonic saline (0.9%). Patients were examined at weeks 1, 3 and 6 post-operatively. Outcomes of irrigation using both solutions were assessed by- 20-item Sino-Nasal Outcome Test (SNOT20) scores [13], Visual analogue scale (VAS) scores [1, 2], mucociliary clearance (MCC) assessment [14] and endoscopic examination. The group receiving hypertonic saline showed significant improvement in 20-item Sino-Nasal Outcome Test scores, Visual analogue scale scores and improvement of sino-nasal mucosa from polypoidal to cobblestone, in the follow up period. However improvement in mucociliary clearance and resolution of postoperative crustings was consistent in both groups. Hypertonic saline nasal irrigation post FESS brings greater benefits on symptom improvement and normalization of the sino-nasal mucosa over isotonic saline.

Introduction

Chronic rhinosinusitis is a common disease that significantly affects quality of life [1]. It leads to inflammation of the nasal cavity and paranasal sinuses, with or without formation of nasal polyps [1]. It is a heterogeneous, often refractory disease, with variable responses to medical therapies. Functional endoscopic sinus surgery (FESS) is indicated for the treatment of chronic rhinosinusitis that is refractory to medical treatment [2, 3]. As inflammatory processes continue to play a significant role in chronic rhinosinusitis patients after FESS, the continued use of medical therapy, especially topical treatment, is indispensable [4]. Nasal irrigation is a classic and powerful adjunctive method for the management of chronic rhinosinusitis after FESS [5]. Nasal irrigation flushes out nasal secretions, clotted blood, allergens and infective debris, minimizes crusting, reduces the probability of synechiae formation and accelerates mucosal healing [6]. Nasal irrigation also appears to improve mucociliary transport function of the nasal mucosa which is the first stage of the host defence mechanism, and plays a critical role in protection against infections [7]. In addition, nasal irrigation clears inflammatory mediators, resulting in better control of adverse nasal symptoms [8].

A variety of solutions can be used for nasal irrigation. Various studies have examined the efficacies of these solutions in the postoperative period. The efficiency of various delivery methods of nasal irrigation solutions has also been studied previously. Multiple studies have confirmed on the benefit of high-volume, low-pressure irrigation over other methods of delivery [9, 10]. Isotonic saline irrigation has been used earlier and had been most preferred. Recently hypertonic saline has become the preferred solution as it has been seen that it reduces mucosal oedema and relieves nasal breathing by affecting osmotic pressure [11, 12]. This study aimed to compare the effects of hypertonic saline and isotonic saline nasal irrigation following endoscopic sinus surgery.

Materials and Methods

A prospective, open label, randomized study was performed on 160 patients between the ages 18 to 60years. All patients had chronic rhinosinusitis with or without nasal polyposis and were resistant to conservative management. Exclusion criteria were applied to exclude patients with non-inflammatory etiologies like who had Systemic granulomatous disease or were known cases of mucociliary clearance disorders or were smokers, had head and neck malignancies or a history of previous radiotherapy/chemotherapy to the head and neck or had history of previous ESS. All patients underwent functional endoscopic sinus surgery in the Department of Otorhinolaryngology at Mahatma Gandhi Medical College and Hospital, Jaipur, India. The study was performed between June 2019 and December 2019. Informed consent was obtained from all patients and the study was approved by the institution’s Ethics board. Bilateral ESS was performed on all patients, involving drainage of the maxillary and anterior and posterior ethmoid sinuses. Frontal and sphenoid sinuses were also addressed wherever clinically needed. Standard mucosal sparing techniques of ESS were applied with the assistance of a microdebrider. Nasal-pack placed after surgery was removed 48h following surgery. Same medications were administered to patients for 3weeks after surgery.

Patients were randomly divided into two groups. Group 1 was given hypertonic saline (3%) while Group 2 was given isotonic saline (0.9%) for nasal irrigation. They were instructed to use irrigation fluids 3 times a day for a period of 6weeks postoperatively. A total of 200mL solution was used for each nasal irrigation, with 100mL for each nasal cavity. Patients were advised to perform douching with a squeeze bottle and in the head down position. They were also given advice on proper bottle cleaning to avoid microbial contamination.

Patients were examined at weeks 1, 3 and 6 post-operatively. Outcomes of irrigation using both solutions were assessed by- 20-item Sino-Nasal Outcome Test (SNOT20) scores [13], Visual analogue scale (VAS) scores [1, 2], mucociliary clearance (MCC) assessment [14] and endoscopic examination.

20-item Sino-Nasal Outcome Test (SNOT20) scores were used to assess quality of life due to chronic rhinosinusitis. Visual analogue scale (VAS) scores were used to assess severity of symptoms, such as nasal blockage or congestion, headache, facial pain, alteration in sense of smell, and nasal discharge. A score of 0 was given by patients with no symptoms while a score of 10 was given by patients with worst symptoms. Mucociliary clearance (MCC) was measured using saccharine clearance test. It was performed by placing one-quarter of a saccharine tablet on the medial aspect of the inferior turbinate, 1cm from the anterior end. Patients were instructed to sit upright, without sniffing, blowing of the nose, or excessive swallowing. Time from placement of the saccharine to the first taste of sweetness was noted. Endoscopic assessment was done using a 0 degree nasal endoscope to assess the presence of crusting, synechiae and the appearance of the nasal mucosa. Crusting was documented as no crusts/few crusts, < 50% crusts and > 50% crusts. Nasal mucosa was documented as either normal, edematous/cobblestoned, polypoidal or gross polypoidal. Assessment of both crusting and endoscopic appearance of the nasal mucosa was done in terms of percentage.

Data were compiled and analysed using the Statistical Package for the Social Sciences (SPSS), Version 20.0 (IBM Corp., Armonk, New York, USA). Descriptive statistics such as percentages were used to summarise data. Statistical significance of between group differences was determined using Student’s t test and Chi –square test. Odds ratios were calculated by cross tabulation with a 95% confidence interval. Data was tabulated using mean (SD). The magnitude of change in outcome measures of SNOT20, VAS and mucociliary clearance (MCC) was determined by using the following calculation: change = follow up measurement (3rd/6th week postoperatively)—baseline measurement (1st/3rd week postoperatively). For all statistical analyses, a P value of < 0.050 was considered significant.

Results

The study was conducted on 156 patients between 18 and 60years of age, after applying the inclusion and exclusion criteria. Of these patients, 52% were diagnosed as CRS without polyps and 48% with nasal polyps. Patients were randomly divided into 2 groups with 78 patients in each group. Mean age of group one was 34.9 (20–60) while in group two was 34.33 (18–55). Group one comprised of 32 females (41%) and 46 males (59%) while group two comprised of 36 females (46%) and 42 males (54%). There was no significant difference in age distribution or gender distribution (p > 0.05). Each group was examined separately.

Discussion

Functional endoscopic sinus surgery (FESS) is beneficial in treating the symptoms of patients suffering from CRS, by improving the drainage of the sinuses as well as delivery of topical medications to the sinuses [1, 2, 10]. Nasal irrigation after (FESS) remains one of the most important postoperative management strategies [1, 15]. Different kinds of solutions have been used for nasal irrigation such as normal saline, lactated Ringer’s solution and various concentrations of hypertonic saline. This study was done to compare the clinical effectiveness of hypertonic saline and isotonic saline irrigation in patients following FESS. It’s seen in this study that hypertonic saline irrigation brings greater beneficial effects than isotonic saline in improvement of symptoms and their severity. This may be due to the greater ability of hypertonic saline in moving out water from edematous mucosa leading to decreased nasal obstruction. Isotonic saline improves mucociliary clearance mostly through mechanical cleaning, while hypertonic saline solutions exert their effect through stimulation of ciliary beat frequency, suppression of inflammation, thinning of mucus and excessive hydration [11, 16]. Hypertonic solutions increase Ca + 2 release from intracellular stores possibly by regulating the availability of adenosine triphosphate by the ciliary axoneme and thus stimulate the ciliary beat frequency [17]. This study shows that the improvement in mucociliary clearance as measured by the saccharine clearance test is slow and modest, with no difference among both the groups. This could reflect the slow nature of recovery of the nasal mucosa after the insult from surgery [18]. Nasal irrigation post-ESS also improves the appearance of the nasal mucosa [19]. This effect is seen in this study, where the amount of crusting and polypoidal appearance of the mucosa improves over time with treatment. There is no difference between the rate of crust resolution among both groups. However, hypertonic saline solution results in quicker resolution of polypoidal mucosa.

Inspite of its advantages, hypertonic saline is reported to cause burning sensation due to the stimulation of nociceptive nerves and subsequent substance P release. It also releases histamine which further leads to nasal hyper reactivity and hypersecretion causing decrease in nasal airway volume [20]. These adverse effects are minor and the benefits hypertonic saline outweighs risk. Kumar J et al. and Dichapong K in their studies found that hypertonic saline was more effective than isotonic saline post ESS.

To achieve greater beneficial effects of hypertonic solution, saline with tonicity of less than 5% should be used [11, 21]. Homer JJ et al. have in their study shown that mucociliary clearance improved with tonicity of hypertonic solutions between 3 and 5%.

High-volume, low-pressure delivery system is the most efficient method of delivery of nasal solution into the sinuses [22]. In this study, squeeze bottles were used to deliver low-pressure and high volume solutions. Optimal penetration of the solution into various sinuses is also dependent on the position of the patient while irrigating. Most effective penetration, especially into the frontal sinus is noted with patient’s head at 90° to the vertical axis [23]. In this study, patients were advised to perform douching in head down position. Salib et al. have have in their study also found high volume low pressure saline irrigations to be more effective than low volume high pressure saline irrigations following ESS in the early post-operative period.

The limitations of this study include the study not being able to be double blinded and lack of long term follow-up of post-operative patients.

Conclusion

Nasal irrigation post FESS helps in achieving resolution of symptoms and normalization of the sino-nasal mucosa. Hypertonic saline irrigation post FESS brings greater benefits on symptom improvement and normalization of the sino-nasal mucosa over isotonic saline. In addition, patients using large volume, low-pressure nasal irrigation and hypertonicity of less than 5% experience greater benefits.

Declarations

Footnotes

References