Elsevier

American Journal of Otolaryngology

Volume 29, Issue 4, July–August 2008, Pages 223-229
American Journal of Otolaryngology

Original contribution
The effects of sulfurous-arsenical-ferruginous thermal water nasal irrigation in wound healing after functional endoscopic sinus surgery for chronic rhinosinusitis: a prospective randomized study

https://doi.org/10.1016/j.amjoto.2007.07.002Get rights and content

Abstract

Purpose

Although several publications reported the benefits of nasal irrigation in the management of chronic rhinosinusitis and in sinonasal postoperative care, the available data are poorly controlled. The aim of this prospective randomized study was to compare the effects of sulfurous-arsenical-ferruginous thermal water nasal irrigation vs isotonic sodium chloride solution nasal irrigation after functional endoscopic sinus surgery (FESS) for chronic sinonasal disease considering the histomorphological characteristics of mucosal repair after sinus surgery.

Materials and Methods

Eighty patients who consecutively underwent FESS were randomly assigned (1:1) to postoperative nasal irrigation with sulfurous-arsenical-ferruginous thermal water or isotonic sodium chloride solution for 6 months. Intraoperative and postoperative (1, 3, and 6 months) mean counts of lymphocytes, neutrophils, eosinophils, plasma cells, histiocytes, and mast cells in ethmoid biopsies were blindly determined by a pathologist.

Results

Fifty-six patients underwent at least 2 postoperative biopsies. A statistically significant reduction of eosinophil count was disclosed 6 months postoperatively only after sulfurous-arsenical-ferruginous solution nasal irrigation (P = .04). After isotonic sodium chloride solution nasal irrigation, the mean eosinophil count in 6-month postoperative biopsies did not decrease. After both irrigation modalities, the mean mast cell counts in 6-month postoperative biopsies were significantly lower than in intraoperative biopsies (P < .05). Neutrophils, lymphocytes, histiocytes, and plasma cell counts were not significantly different between intraoperative vs 6-month postoperative biopsies independently from irrigation modality.

Conclusions

Considering the important role of eosinophils in allergic response, we should suggest sulfurous-arsenical-ferruginous solution nasal irrigation in particular, which significantly reduces local eosinophil count, for allergic patients after FESS for chronic rhinosinusitis.

Introduction

Rhinosinusitis is a common disease that affects more than 31 million people in the United States each year [1]. Although several publications reported the benefits of nasal irrigation in the management of acute and chronic rhinosinusitis, allergic and nonallergic rhinitis, septum perforations, and the postoperative care of surgical patients, the available investigations are often small and poorly controlled, and unsupported conclusions are sometimes drawn [2].

Controversies exist regarding the efficacy of different nasal irrigation tonicity and the use of additives to the irrigating solution [3], [4], [5]. In 2007, Miwa et al [6] concluded that hypertonic saline enhances the electrical permeability of the nasal epithelial mucosa but not the transport of macromolecule in the short term. Ringer's lactate solution nasal irrigation was compared to isotonic saline solution after nasal septum surgery. Significantly lower mucociliary clearance times were described after irrigation with Ringer's lactate solution [7].

Recently, Staffieri and Abramo [8] considered the anterior active computerized rhinomanometry, mucociliary transport time, nasal cytology, and chemicophysical evaluation of nasal mucus before and after inhalatory treatment with sulfurous-arsenical-ferruginous thermal water in 37 consecutive patients with chronic rhinosinusitis. Rhinomanometric evidences confirmed statistically significant improvement in nasal flows and reduction of nasal resistance after a course of sulfurous-arsenical-ferruginous water inhalation. An improvement of mucociliary function due to sulfurous-arsenical-ferruginous water inhalation was confirmed by a significant reduction of mean mucociliary transport time.

Very limited information are available in literature about the significance of nasal irrigation in wound healing after sinonasal surgery. The aim of this prospective randomized study was to compare the effects of sulfurous-arsenical-ferruginous thermal water from Levico Spa (Levico Terme, Trento, Italy) nasal irrigation vs isotonic sodium chloride solution nasal irrigation after functional endoscopic sinus surgery (FESS) for chronic sinonasal disease. The histomorphological characteristics of wound healing and the roles played by inflammatory cells in mucosal repair after sinus surgery were investigated.

Section snippets

Study design

The present investigation was a prospective randomized study conducted in accordance with the 1996 Declaration of Helsinki. The study protocol was approved by the local ethics committee of the University Hospital of Padova, Italy. Since 1960, sulfurous-arsenical-ferruginous thermal water inhalation has been performed in Levico Spa for the treatment of upper airway inflammatory diseases. No cases of toxicity or neoplasm occurrence due to thermal water inhalation have been documented in the

Results

Fifty-six patients underwent at least 2 postoperative anterior ethmoid biopsies after FESS, followed by a course of nasal irrigation: 38 with sulfurous-arsenical-ferruginous thermal water and 18 with isotonic sodium chloride solution nasal irrigation. Thirteen of 56 patients were allergic; 9 of 56 patients smoked cigarettes and 9 had smoked in the past. Fisher exact test ruled out the significant differences in the distribution of allergy or cigarette smoking status between the groups of

Discussion

Considering the present study design and the achieved evidences, the inflammation specifically related to wound repair after FESS was associated with the background chronic inflammatory disease. Sobol et al [10] stated that the number of T lymphocytes, eosinophils, and basophils, and the amount of subepithelial collagen deposition were significantly higher in the mucosa of patients with chronic sinusitis compared with normal control subjects.

Wound healing is a highly organized process involving

Conclusions

Increased tissue eosinophilia in chronic rhinosinusitis with and without nasal polyposis seems to be related to increased severity of disease [14]. Sulfurous-arsenical-ferruginous solution nasal irrigation locally reducing the eosinophil number may limit eosinophil-mediated production of cytokines and inflammatory molecules, which damage nasal mucosa, leading to edema and sinonasal inflammation. Considering that eosinophils play a particularly important role in allergic response through the

Acknowledgments

This work was supported by a grant from the Provincia of Trento, Italy.

The principal investigator responsible for the present investigation (AS) is a Member of the Scientific Committee of Levico and Vetriolo Spa, Italy.

The authors thank Mr Bruno Giacon, chief hospital attendant of the ambulatory of Otolaryngology Section of Padova University, Italy, and his staff for the postoperative controls organization.

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