Concept and Philosophy of

Nasal Hygiene in Management

of
Upper Airway Inflammation
R e t n o S Wa r d a n i
Rhinology Division – ORL HNS Department
Faculty of Medicine Universitas Indonesia
Dr. Cipto Mangunkusumo Hospital Jakarta
 Do not prescribe Antibiotic for Acute Viral Infection
World Antimicrobial Awareness Week 18-24 November 2021
Winner of Nasal Hygiene for Public Education 2016
 P U B L I C E D U C AT I O N
HNS (Hand, Nose, Sleep) Hygiene – Higiene THT (Tangan, Hidung, Tidur)
for Viral Infection of Upper Airway

Hand Hygiene
• Wash / decontaminate your hands in 5
moments / situation
Respiratory Hygiene
• Clean hands after sneezing, coughing or
blowing your nose
• Keep hands away from eye, nose and
mouth
Cough Etiquette
• Sneeze / cough/blow your nose into a
tissue
• If no tissue: use upper arm (not hand)
• Turn away from others when sneezing
or coughing
 Virus Perspectives
(Mechanism of Infection)
 Human Host Defense
(Mechanism of Resilience)
Airway Epithelial Dynamic &
The Respiratory Tract
Microbiome

• Huffnagle GB, Dickson RP, Lukacs NW. The respiratory tract microbiome

• and lung inflammation: a two-way street. Mucosal immunology. 2017 Mar;10(2):299-306.

Laulajainen-Hongisto A, Toppila-Salmi SK, Luukkainen A, Kern R. Airway Epithelial Dynamics in
Allergy and Related Chronic Inflammatory Airway Diseases.
Frontiers in cell and developmental biology. 2020;8.
Invernizzi R, Lloyd CM, Molyneaux PL. Respiratory microbiome and epithelial interactions shape
immunity in the lungs. Immunology. 2020 Jun;160(2):171-82.
Physical, Chemical, Neurogenic
Barrier

Nasal Respiratoric & Olfactoric Mucosa

Shah L, Yadav S, Amiji M. Nanotechnology for CNS delivery of bio-therapeutic
agents. Drug delivery and translational research. 2013 Aug 1;3(4):336-51.
• Intrinsic
• Always present in the uninfected cell
• A p o p t o s i s , a u t o p h a g y, R N A s i l e n c i n g , a n t i v i r a l
proteins
• Innate immune system: induced by infection
• A d a p t i v e i m m Human
u n e s y s t Host
e m : t aDefense
ilored to pathogen

(Mechanism of Resilience).
 The Airway
Epithelium
Soldier In The Fight Against Respiratory
Viruses
Vareille M, Kieninger E, Edwards MR, Regamey N. Clinical
Intrinsic Human Host Defense
microbiology reviews. 2011 Jan 1;24(1):210-29.

(Mechanism of Resilience).
´ H
OSTSU SResilience
C
EPTIB ILITYfactors=
An´ability
Host R
esponseadaptation
for (Inflammation) and
=R ESILIE
NCE
bounce
´anback
abilityto from
bounceadversity
backfromadversityof
of insult and damage
´H
ost LIFES TY LE ,P E
R SO NALH IG
IE
NES
´B alancedD iet
Nasal Epithelium is the Primary Portal
´C ardio-respiratoryE of
nduraEntry for
nceActivity, Respiratory Viruses and
´N asal &S Immediate
leepH ygiene Target for Viral Replication in The Airway
• Upregulation PRR: 4 hours post-infection (hpi)
• Exponentially elevated IFN: 8 – 72 hpi
• Rapid production chemokines & inflammasomes: 24 – 72 hpi
• Cell damage and death → steady decline in viability, integrity and
 The Strategy to Maintain Mutual Partnership
(Symbiosis) with Human Microbiome
• Avoid Antibiotic in Viral Infection
→ Antibiotic can not differentiate good and bad bacteria
• Take probiotic → Living beneficial bacteria can interact with
other microbiome by producing antimicrobials, competitive
colonization, inhibition pathogen growth
• Nasal irrigation → A microbiome friendly alternative compare
to aggressive therapy options for Respiratory Tract infection /
inflammation
• Avoid sleep deprivation → sleep quality linked to gut
Kumpitsch diversity
microbiome C, Koskinen K, Schöpf V, Moissl-Eichinger C. The microbiome of the
upper respiratory tract in health and disease. BMC biology. 2019 Dec 1;17(1):87.
 Nasal Hygiene for Public Education 2018
Cover “Putus Nyambung”
Cuci hidung.. Cuci hidung.. Cuci hidung
Ini untuk kesehatan kita
Kualitas hidup berbahagia Yuk cuci hidung, biar gak tersumbat
Hal sederhana sangat Kalau tersumbat, nafas pun tak enak,
berguna tidur tak nyenyak….
Cuci hidung gaya hidup
semua
Cuci hidung.. Cuci hidung .. Cuci
hidung..
Cuci hidung dengan NaCl
Ingus kental meler jadi encer Kalau hidung bersih, nafas jadi enteng
Radang tenggorok bisa Kuman, debu polusi bisa dihindari
dicegah kalau dicuci hidung…
 P U B L I C E D U C AT I O N
HNS (Hand, Nose, Sleep) Hygiene – Higiene THT (Tangan, Hidung, Tidur)
for Viral Infection of Upper Airway

Hand Hygiene
• Wash / decontaminate your hands in 5
moments / situation
Respiratory Hygiene
• Clean hands after sneezing, coughing or
blowing your nose
• Keep hands away from eye, nose and
mouth
Cough Etiquette
• Sneeze / cough/blow your nose into a
tissue
• If no tissue: use upper arm (not hand)
• Turn away from others when sneezing
or coughing
SLEEP AND SUSCEPTIBILITY TO THE COMMON COLD
Cohen S, Doyle WJ, Alper CM, Janicki-Deverts D, Turner RB. Sleep Habits and susceptibility to the common cold.
Arch Intern Med 2009; 169(1):62-67.
Prather AA, Janicki-Deverts D, Hall MH, Cohen S. Behaviorally Assessed Sleep and Susceptibility to the Common Cold.
Sleep 2015; 38(9)”1353-1359.

• Shorter night time sleep increased susceptibility to common

cold.
• People with poorer sleep efficiency
• tossing and turning during the night or
• lying awake not sleeping
→ more than five times more likely to catch
a cold than those who sleep soundly.
93% OF PHYSICIANS THINK THAT A GOOD NIGHT SLEEP
HELPS COLD SUFFERERS RECOVER FASTER. 1

7/14/2021 ERS congress Paris 2018: P&G German Doctor Survey 2017
CONFIDENTIAL 17
7
 1
8
7/14/2021 CONFIDENTIAL 18
Individual Symptoms Occur Frequently During The Cold

• Nasal congestion:
≥85% of cold episodes,
• Sore throat & Sneezing:
82% & 67% of cold episodes,
respectively
• Cough peaked at Day 2 (69%) &
remained high until day 4 (66%)

Witek TJ, Ramsey DL, Carr AN, Riker DK. The natural history of community-acquired 9

common colds symptoms assessed over 4-years. Rhinology 2015;53(1):81-8.

 Witek TJ, Ramsey DL, Carr AN, Riker DK. The natural history of community-acquired common colds
symptoms assessed over 4-years. Rhinology 2015;53(1):81-8.

• Characterization of the onset, duration, severity & intersection of symptoms in colds.

• A more complete understanding of the symptom frequency & burden in colds
1. Individual symptoms occur frequently during the cold
2. Most patients suffer from multiple symptoms during each day
3. Patients bothered by different symptoms over the first 7 days of cold

• The single most bothersome

symptoms on:
• Day 1: Sore Throat
• Days 2 to 5: Nasal Congestion
• Days 6 to 7: Cough 2
0
 Anosmia in Covid-19

• APOPTOSIS
• strategy used by the olfactory epithelium to defend against
viral infection
• to limit the degree of viral dissemination into the CNS
(Mori, 2002)
• OSNs are a renewable neuronal population, despite this ability to rebuild
➢Apoptosis due to infection and inflammation within the olfactory
epithelium can be detrimental to olfactory function
➢giving rise to a temporary or permanent loss of smell.
(Landis, 2010. Tian 2016)
ACE2-Positive Cells in the Nasal Respiratory Epithelium,
Olfactory Epithelium, and the Olfactory Bulb Possible Mechanism of Chemosensory Disturbances in Covid-19
Cooper KW, Brann DH, Farruggia MC, Bhutani S, Pellegrino R, Tsukahara T, Weinreb C, Joseph PV, Larson ED, Parma V, Albers
MW. COVID-19 and the chemical senses: supporting players take center stage. Neuron. 2020 Jul 1. OSN = olfactory sensory neuron
Cooper KW, Brann DH, Farruggia MC, Bhutani S, Pellegrino R, Tsukahara T, Weinreb C, Joseph PV, Larson ED, Parma
V, Albers MW. COVID-19 and the chemical senses: supporting players take center stage. Neuron. 2020 Jul 1.
 Possible Mechanism of Chemosensory Disturbances in Covid-19
Cooper KW, Brann DH, Farruggia MC, Bhutani S, Pellegrino R, Tsukahara T, Weinreb C, Joseph PV, Larson ED, Parma V, Albers
MW. COVID-19 and the chemical senses: supporting players take center stage. Neuron. 2020 Jul 1. OSN = olfactory sensory neuron
 The Effective Management of Sinonasal
(Acute) Infection & Inflammation in Covid-19 Pandemic Era

Maintain A Good General Well Being

 Self Assesment Diagnosis
(Acute) Infection & Inflammation in Covid-19 Pandemic Era
Maintain A Good General Well Being
5 = well, no problems
4 = quite well with occasional sneeze, not disruptive to
normal routine
3 = can feel a cold coming on, some minor symptoms
2 = feeling low and beginning to exhibit symptoms
1 = full symptoms of acute infection & inflammation
(headache / sneezing / runny nose / dry throat / sore throat / cough /
tiredness)
 The Effective Management of Sinonasal
(Acute) Infection & Inflammation in Covid-19 Pandemic Era
Maintain A Good General Well Being
5 = bangun tidur merasa segar dan bersemangat
4 = belum ada gejala, bangun tidur tidak segar, kurang bersemangat
3 = gejala ringan, bangun tidur tidak segar, tidak bersemangat
2 = terdapat 1 atau 2 gejala , bangun tidur tidak segar, tidak
bersemangat
1 = terdapat >3 gejala, bangun tidur sakit kepala, merasa lemah
(sakit kepala / bersin / pilek / tenggorok kering - gatal /
sakit tenggorok / batuk / lelah, sering berbaring
 Skoring Gejala Skala Visual Analogue 1 – 10
0 = tidak ada
1 = ada, sangat ringan … 10 = ada, sangat berat

1. Demam 5. Hidung tersumbat / suara sengau

2. Sakit kepala 6. Pilek
3. Sakit tenggorok 7. Hilang fungsi penciuman
4. Batuk 8. Hilang fungsi pencecap
Uji Penghidu Alkohol (UPA) 1. Kapas alkohol yang mengandung ethyl
alkohol 70% dibuka dari bungkusnya
sehingga 0,5 cm dari kapas alkohol terpapar
2. Kapas alkohol diletakkan di bawah nostril
disertai dengan gerakan inspirasi sebanyak 2
kali untuk mengenalkan bau alkohol
terhadap subjek dan ditanyakan kepada
subjek apakah terdeteksi bau alkohol
3. Subjek diminta menutup mulut dan mata
dan bernafas normal
4. Alkohol swab diletakkan 30 cm dibawah dari
hidung dengan bantuan pengukur, swab
alkohol digerakkan mendekati nares
sebanyak 1 cm tiap kali subjek melakukan
ekspirasi sampai terdeteksi bau
5. Prosedur diulang sebanyak 4x dan
ditentukan rerata dari jarak swab alkohol ke
nares untuk menentukan ambang
 Uji Penghidu Intravena (UPI)
1. Pemeriksaan UPI (Uji Penghidu Intravena) dilakukan
dengan menginjeksikan fursultiamin dosis 12,5 mg (5
ml) pada vena antekubiti dengan kecepatan konstan
selama 20 detik
2. Kedua mata subjek ditutup dan subjek diminta
memberi tanda apabila sudah tercium bau
menyerupai bawang putih
3. Subjek diminta memberi tanda kepada pemeriksa
apabila bau sudah hilang
4. Waktu pertama kali tercium bau didefinisikan
sebagai nilai onset dan lama waktu bau tercium
didefiniskan sebagai nilai durasi
 Nasal Treatment Protocol for Anosmia Covid-19
Intranasal Steroid NaCl 0,9% Topical Decongestant Aromatic Balm

production mucocilliary transport, Perbaikan patensi nasal, cool and fresh

surfactan, lisozym production, sensation (ilusi kognitif melalui reseptor
Collectin, lactoferin, epithelial TRPM-8 pada ujung saraf I, V, X)
complement integrity
protein Sleep quality improvement w/ 25% REM sleep

interferon (IFN)-γ

Innate Immune Response

SARS-CoV2
Elimination
Smell Function Improvement
INTRANASAL STEROID TARGETTING
Surfactant Layer
MUCO-CILLIARY TRANSPORT /
EPITHELIAL FUNCTION & INTEGRITY
Inhalation of menthol = typical
mint smell
• does not alter upper airway resistance
in humans
• stimulation of TRPM8 on nasal
trigeminal endings
• brings cooling and freshness
sensations, eliciting a cognitive
illusion of airway flow from the
cooling sensation
Transient Receptor Potential channels-
Melastatin 8 (TRPM8)
• Located at the peripheral nerve endings
(trigeminal, vagus, olfactory)
• Mainly thermoreceptor with activation
threshold around 24°C
• Giving the feeling of innocuous cold and
freshness
Buddy T et al. Modulation of
cough response by sensory
inputs from the nose - role of
trigeminal TRPA1 versus
TRPM8 channels. Cough

• reduces dyspnoea, cough &

2012.

respiratory drive perception

Bindu B, Singh GP,
• decreases trigeminal sensitivity to Chowdhury T, Schaller B.
Rhinitis and sleep disorders:
irritants The trigeminocardiac reflex
link?. Medical hypotheses.
2017 Jun 1;103:96-9.
“For the shaytan spends the
night inside one’s nostril”
The Microbiota and Host Immune System
Interaction in the Nose

Di Stadio A, Costantini C, Renga G, Pariano M, Ricci G, Romani L.

The Microbiota/Host Immune System Interaction in the Nose to
Protect from COVID-19. Life. 2020 Dec;10(12):345.
 Treatment Concept
To Kill vs To Increase Defense
 Take Home Message
•Covid-19 pandemic
•push us to investigate and find the best
evidence in diagnostic and treatment
•bravery, honesty and resilience
 King D, Mitchell B,
Williams CP, Spurling GK.
Saline nasal irrigation for
acute upper respiratory
tract infections. Cochrane
Database of Systematic
Reviews. 2015(4).
Author’s Conclusion 2015
• Nasal saline irrigation possibly has benefits for
relieving the symptoms of acute URTI’s.
• However the included trials were generally too
small and had a high risk of bias, reducing
confidence in the evidence supporting this.
• Future trials should involve larger number of
participants and report standardized and clinically
meaningful outcome measures.

Author’s Conclusion 2010

• Included trials were too small and had too high
Kassel JC, King D, a risk of bias to be confident about the possible
Spurling GK. Saline
nasal irrigation for
benefits of nasal saline irrigation in acute
acute upper URTI’s.
respiratory tract • Future trials should involve much larger
infections. Cochrane
Database of numbers of participants and be rigorously
Systematic Reviews. designed and control
 Renin, ACE2, Mas receptors and AT1 & 2 receptors Ø can serve as targets
FOR FUTURE ANXIOLYTIC AND ANTIDEPRESSANT MEDICATIONS
• Olfaction’s unique
connection to the
limbic system explains
why scents tend to have
strong emotion
associations
• Limbic system:
olfactory cortex,
amygdala, hippocampus,
piriform cortex,
entorhinal cortex:
aspect of emotion,
memory, executive
decision

Component of RAS, Chrissobolis S, Luu A, Waldschmidt R, Yoakum M, D'Souza MS.

AT1 & 2, Mas Receptor Targeting the renin angiotensin system for the treatment of anxiety and depression.
Expressed in Brain Pharmacology Biochemistry and Behavior. 2020 Oct 26:173063.
Surfactant Layer
 References
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against respiratory viruses . Clinical microbiology reviews. 2011 Jan 1;24(1):210-29.
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delivery and translational research. 2013 Aug 1;3(4):336-51.
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respiratory tract in health and disease. BMC biology. 2019 Dec 1;17(1):87.