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Case study

Impact of isotonic and hypertonic saline on mucociliary activity in various nasal pathologies
Sandesh Chodankar1, Carnegie D'sa2 ,Markandey Tiwari3, H.C.Goel4, D. Andhale5 - Goa
Abstract
The nasal mucociliary clearance system transports the mucus layer that covers the nasal epithelium towards the nasopharynx by
ciliary beating. Its function is to protect the respiratory system from damage by inhaled substances. Impairment of nasal
mucociliary clearance can result in diseases of the upper airways. Therefore, it is important to study the effects of drugs on nasal
mucociliary clearance. The present study consists of nasal mucociliary clearance(NMC) in allergic, acute and chronic
rhinosinusitis and the effect of hypertonic and isotonic saline nasal irrigations on them.We studied a total of 90 patients with
either of the 3 nasal pathologies. There were 20 healthy subjects as controls. NMC was determined using saccharine test pre and
post treatment with isotonic and hypertonic saline. We found that Hypertonic saline when added to the standard treatment of the
respective nasal pathologies improved the NMC in all groups. The possible mechanism in hypertonic saline is that in addition to
mechanically washing out the inspissated mucus, it also reduced the mucosal oedema due to its strong osmotic property and by
inhibiting the neutrophil chemotaxis.We concluded that addition of hypertonic saline nasal irrigation to the standard line of
treatment can be a simple, inexpensive and safe modality to treat above mentioned nasal pathologies.
Keywords- Nasal Mucociliary clearance, Hypertonic saline, Allergic Rhinitis, Chronic rhinosinusitis, Acute Rhinosinusitis
Introduction
The respiratory tract is protected from airborne infections and
debris by a mucociliary layer that lines the sinonasal cavity.
This layer is made up of columnar ciliated epithelium with
mucus secreting goblet cells and secretions from submucosal
glands. Atmospheric particles get trapped in the mucus and
are propelled towards nasopharynx just like a conveyer
belt.Nasal mucociliary clearance (NMC) is the time taken by
a particle to traverse the length of the nasal cavity. Its
estimation is a general measure of sinonasal health and can be
measured in various ways in vivo. Puchele et al.(1)compared
the three methods of dye, saccharin and radiolabelled
particles and found saccharin to be simple, noninvasive and
sensitive.NMC is impaired by reduction in number of cilia or
their slow rate of beating or thick, scanty, viscid mucus mostly
seen in inflammed nasal mucosa. Such conditions prevail in
diseases like allergic rhinitis, acute and chronic
rhinosinusitis.This study was aimed at estimating the nasal
mucociliary clearance in common nasal pathologies i.e.
allergic rhinitis, acute and chronic rhinosinusitis and
compared them with healthy subjects. Further the effect of
nasal irrigation using isotonic and hypertonic saline solutions
on nasal mucociliary clearance was compared in these nasal
pathologies.
Materials and methods
The present study 'Impact of isotonic and hypertonic saline on
mucociliary activity in various nasal pathologies' was
conducted as a cross sectional prospective study in

Department of ENT, Goa Medical College, which is a tertiary
care multispeciality hospital. A total of 90 patients in the age
group of 15 to 50 years and either sex were diagnosed with
allergic rhinitis, acute and chronic rhinosinusitis and were
included in the study. There were 35 patients diagnosed with
allergic rhinitis (group A), 20 with acute rhinosinusitis (group
B) and 35 of chronic rhinosinusitisitis (group C). The nasal
mucociliary clearance was also estimated in a group of 20
healthy subjects in same age group as above and of either sex
which served as the control group. Patients with diabetes,
history of smoking, and more than one nasal pathologies were
excluded from the study.Nasal mucociliary clearance was
estimated before the start of the treatment using saccharine
particle (Anderson et al.).(2) A quarter of saccharin tablet was
placed medial to inferior turbinate 1.5 cm behind anterior end
of inferior turbinate. Patient was asked to make swallowing
attempts every 30 seconds, and time was noted between
placement of tablet and feeling of sweet taste. The test was
performed by the same examiner, in the same room at constant
humidity and temperature and at the same time of the day.
Patient was instructed to breathe silently through the nose and
not to sniff. The NMC was assessed again after 10 days of
treatment.
Results
The mean NMC of was estimated in 20 healthy individuals in
the age group between 15 to 50 years and was found to be 7.9
minutes with standard deviation 2.04.The mean NMC was
estimated in 35 patients with allergic rhinitis and was found to

1

Associate Professor,2,3Assistant Professor,4Professor & Head,5Resident, Department of ENT,
Head and Neck Surgery, Goa Medical College, Bambolim-Goa

9

National Journal of Otorhinolaryngology and Head & Neck Surgery, Vol. 2(11) No. 2, August 2014

(7) In the present study there were 35 patients with allergic rhinitis and their mean NMC was found to be 13.05 being significant).05 being significant).e.(10)(11) The prevalence of sinusitis has been reported to exceed that of any other chronic condition(12) and is apparently on the increase. Whereas 12 patients were given oral medications with hypertonic saline nasal irrigation and 13 patients were given oral medications with isotonic saline nasal irrigation and their mean NMC were determined.(3) Its benefits likely to be are: Improvement in nasal mucociliary clearance .6 minutes which was close to the mean NMC of control group which was 7.e. NMC in Acute Rhinosinusitis.The mean NMC was estimated in 35 patients with chronic rhinosinusitis and was found to be 16. Nasal mucociliary clearance in chronic rhinosinusitisChronic rhinosinusitis affects 5-15% of the urban population. It was surprising to note that this group reverted the mean NMC to 6.9 minutes. After being subjected to three different modalities of treatment i. oral medication with hypertonic saline and oral medication with isotonic saline.035 respectively. The mean NMC was estimated in 20 patients with acute rhinosinusitis was found to be 16. It was also seen that the group irrigated with hypertonic saline showed maximum benefit and surprisingly attained a mean NMC of 6. only oral medication.6 minutes with standard deviation 3. the last group showed the maximum benefit. 0. But the groups in which oral medication with hypertonic saline and oral medication with isotonic saline irrigation was given showed significant improvement with p values 0. was significant. Whereas 8 patients were given oral medications with hypertonic saline nasal irrigation and 7 patients were given oral medications with isotonic saline nasal irrigation and their mean NMC were determined. Discussion Nasal irrigation will bring down cost on medical resources and decrease the use of antibiotics thus preventing antibiotic resistance.Mechanical cleaning of inspissated mucus(4).Decrease inflammatory mediators. Nasal mucociliary clearance in acute rhinosinusitis-Infective rhinosinusitis is one of the most common disorder encountered.04. On comparison between the subgroups by student t test it was found that the improvement in group administered only oral medication and given oral medication with isotonic saline irrigation was not significant. oral medication. NMC in Chronic Rhinosinusitis-Out of 35 patients with chronic rhinosinusitis 10 patients were given only oral medication with steroid nasal spray(antibiotic Roxithromycin 150mg BID and Fluticasone furoate nasal spray 1 puff BID) with no irrigation.9 minutes.9 minutes.be 13. August 2014 . It was also seen that this group attained a mean NMC of 8. allergic rhinitis significantly alters patients' social life and affects performance at school and work productivity. with p value 0. steroid spray with isotonic saline nasal irrigation and their NMC were determined. It was also seen that the group irrigated with hypertonic saline showed maximum benefit and attained a mean NMC of 8. Whereas 12 patients were given oral medications. On comparison between the subgroups by 10 student t test it was found that the improvement in all three groups i.5 minutes with standard deviation 2.095and 0.9 minutes.6 minutes which was close to mean NMC of the control group of 7.6 minutes which was better than the mean NMC of the control group of 7.6 minutes which was better than the mean NMC of control group of 7. with p values 0.78 minutes which was significantly deranged as compared to the control group.6±3.91minutes which was close to the mean NMC of control group which was 7. NMC in Allergic Rhinitis-Out of 35 patients with allergic rhinitis 10 patients were given only oral medication (levocetrizine 5mg HS) with no irrigation. steroid spray with hypertonic saline nasal irrigation and 13 patients were given oral medications. 2.04 minutes which was significantly deranged as compared to the control group. oral medication with isotonic saline nasal irrigation and oral medication with hypertonic saline nasal irrigation.9 minutes.000 respectively (p value <0.000 and 0.(9)In the present study there were 20 patients with acute rhinosinusitis and their mean NMC was found to be 16. with p values 0.34 minutes with standard deviation 1. But the group in which oral medication with hypertonic saline was given showed significant improvement with a p value 0. Vol.000 each (p value <0. oral medication.78. 2(11) No.34±1.Out of 20 patients with acute rhinosinusitis 5 patients were given only oral medication(antibiotic amoxicillin-clavulanic acid 625mg TID and analgesic ibuprofen 400mg BID) with no irrigation.001 (p value <0. (8) Sinusitis affects about 15% of the population.099. It also reverted the mean NMC to 8. oral medication with isotonic saline nasal irrigation and oral medication with hypertonic saline nasal irrigation. the group treated with hypertonic saline showed the maximum benefit.(5) (6)Although not a severe disorder. On comparison between the subgroups by student t test it was found that the improvement in group administered only oral medication was not significant. After subjecting to three different modalities of treatment i.05 being significant). Nasal mucociliary clearance in allergic rhinitis-It is a global health problem and is increasing in prevalence.33. In the present study there were 35 National Journal of Otorhinolaryngology and Head & Neck Surgery.e.Decrease in mucosal edema .001.

Arch Environ Health 1974. Comparison of three methods for measuring nasal mucociliary clearancein man.04 minutes. Stammberger H et al. Benson V MM. Lund VJ. 6:285 Gwaltney JM. 23:1209-25. Proc Mayo Clin1931.gsbaoicon.The first brochure has also been sent to you .wix. Anabwani G.9±2. Rosenberg SI.The dates are 20th and 21st December 2014.5±2.33 minutes which was significantly deranged as compared to the control group. oral medication with steroid nasal spray with isotonic saline nasal irrigation and oral medication with steroid nasal spray with hypertonic saline nasal irrigation. Paediatric Allergy & Immunology. and A. Address for correspondence Dr. 2005. References 1. Aug. Epidemiology evidence for asthma and allergic rhinitis comorbidity. It reduces the viscosity of the nasal mucus and washes out the inflammatory mediators responsible for mucosal congestion. Bambolim-Goa. 10. 18: 1-87. Nose ant throat Journal. It gives us immense pleasure to announce that South Gujarat Academy of Otolaryngologist is hosting the 38th Annual conference of Gujarat State Branch of Association of Otolaryngologist of India . EAACI Task force.com Cell : +91 9422062770 CONFERENCE ANNOUNCEMENT 38TH GSBAOICON Dear Colleagues. 25: 815-9 Leynaert B. Journal of allergy and clinical immunology 1998. The group treated with hypertonic saline showed the maximum benefit. inexpensive and safe modality to treat above mentioned nasal pathologies and may prove to be useful in limiting the use of higher antibiotics and preventing antibiotic resistance.The venue is picturesque Treat Resort .9 minutes. Impact of upper allergic respiratory diseases on quality of life. Ohnishi T. 6. T. Pham. 102: S386-91. Sinusitis. 46 : 2-32. Ear. etiology and management. Neukrich F. 106: S201-5. 1997. Bertrand.e. F. Vol. 2000. A comparison nasal and tracheobronchial clearance. Hilding A. oral medication with steroid nasal spray. Weiland S. Clinical symposia1994 . Rhinology. 2(11) No. Erikson B. Josephson JS. Clinical Infectious Diseases.10:1-269 4. Silvassa . Puchelle.Sibbald B. Aberg N. Anderson HR et al. Bachert C. After being subjected to three different modalities of treatment i. Sandesh Chodankar Department of ENT. 1996.Addition of hypertonic saline nasal irrigation to the standard line of treatment can be a simple. 9. Lund VJ. StrachnanD.29:290-3. Fokkens W. August 2014 . E. Juniper EF. Increase of asthama. 2. Proctor DF. Anderson I. Supplement. 76:12. Baquero F. European position paper on rhinosinusitis and nasal polyps. 1997. Hesselmar B. all three groups showed significant improvement. Camner P. Journal of allergy and Clinical Immunology. Q. Head and Neck surgery Goa Medical college. Clement P.patients with chronic rhinosinusitis and their mean NMC was found to be 16.The details have been made available on web site www. Ait-Khalid N. 3. 91: 297–303 (1981).8:161-76 11 5. It also reverted the mean NMC to 8. oedema and pH changes. 11. Gwaltney J. allergic rhinitis. Ciliary activity and course of secretion current on the nose. Hypertonic saline has an additional advantage in treating the mucosal oedema due to its strong osmotic property and by inhibiting the neutrophil chemotaxis. Acta Otolaryngol. 1995. Clinical and Experimental Allergy. Hope to see you at 38th GSBAOICON ! Dr Rupa Parikh Organising Chairperson. Vital Health Statistics 1994. 7. Conclusion Mean value of nasal mucociliary clearance in the present study titled 'Impact of isotonic and hypertonic saline on mucociliary activity in various nasal pathologies' was found to be 7. Demoly P.We have lined up a list of prominent luminaries from India and USA . eczema in Swedish schoolchildren between 1979 and 1991.91 minutes which was close to mean NMC of the control group of 7. Jensen PL. Bousquet J. Nasal mucociliary clearance is significantly affected in all three nasal pathologies i. Infectious Rhinosinusitis in adults: classification. 8.India – 403002 E-mail : drsandeshc@gmail. In all the groups saline irrigations help in washing out inspissated and infected nasal secretions which are responsible for decreasing the ciliary beat frequency.e. Acute community acquired sinusitis. Current estimates from the 1993 National Health Interview Survey. Hellings P. allergic rhinitis. 2. Holmstrom M et al.com/2014 So please mark the date and register at the earliest. Philipson K. Mann W. 12. 38th GSBAOICON National Journal of Otorhinolaryngology and Head & Neck Surgery. acute rhinosinusitis and chronic rhinosinusitis as compared to healthy subjects and is significantly improved on addition of hypertonic saline nasal irrigation to the standard line of treatment of the respective diseases. Aberg B.