Eur Arch Otorhinolaryngol DOI 10.1007/s00405-014-3094-3
Rhinology
Effects of surfactant on biofilm formation on silicone nasal splints Turhan San · Omer Cagatay Ertugay · Tolgahan Catli · Mustafa Acar · Cigdem Kalaycik Ertugay · Ilknur Dag · Cemal Cingi
Received: 28 January 2014 / Accepted: 8 May 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Biofilms are sessile communities of bacteria embedded in self-produced extracellular polysaccharide matrix and are considered to be responsible for bacterial infections in humans. Topical surfactant use on silicone nasal splints may have a preventive effect on biofilm formation. The objective of this study is to investigate the effect of surfactant-containing nasal solutions on biofilm formation over the surface of silicone nasal splints. Forty patients were randomized after septoplasty to receive surfactant-containing saline solution (group 1) or saline without surfactant (group 2). At the postoperative 48th, 72th and 96th hours, pieces of splint samples were taken and prepared for scanning electron microscopic evaluation. Biofilm formation was observed in 3, 6 and 14 of 20 samples in group 1 (surfactant used) and 3, 14 and 20 of 20 samples in group 2 (control) at 48th, 72th and 96th hours, respectively. Biofilm formation incidences of groups at 48th hour were similar (p > 0.05), whereas it was significantly lower at group 1 regarding 72th and 96th hours
(p 0.05). Removal after 72 h: 13/20 (65 %) of patients in control group demonstrated biofilm formation, whereas it was 6/20 (30 %) in surfactant group. Chi square test was applied to
Fig. 2 Electron microscobic view of 48-h sample of a control patient, showing no biofilm formation
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Fig. 3 Electron microscobic view of 72-h sample of the same patient, demonstrating biofilm existence
Fig. 4 Electron microscobic view of 96-h sample of the same patient, demonstrating biofilm existence
in foreign nature and have a potential of causing serious pack-related infectious complications such as toxic shock syndrome [11]. In this study we observed that especially after 48 h postoperatively, biofilm formation occur over the surfaces of intranasal silicone splints. This finding is in concordance with the finding that risk of bacteremia after nasal septal procedure increases after 48 h [12]. As a reflection of technological advancement, various types of nasal packs have been designed by different companies and each of the products has their own texture and structural properties. There is a wide varience in materials for splinting and packing as well as its duration. While Merocel (Medtronic Xomed, USA-kind of foam pack made of polyvinyl acetal is packaged in a compressed, dehydrated state to allow ease of insertion) has a porous structure, silicone splints (Invotec, Jacksonville, Florida-kind of pack made of synthetic silicone) have smoother surfaces. In a prospective
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Eur Arch Otorhinolaryngol
study, Yilmaz et al. have mentioned the clinical importance of these structural differences [13]. They compared three structurally different packing materials (biodegradable synthetic polyurethane foam, silicone nasal splint and Merocel) regarding the level of pain and discomfort during packing and removal. They observed that patients with silicone splints felt more comfortable than patients with Merocel during packing and removal. This clinical finding seems to be related with the smoother surface of silicone splint. In addition to the clinical consequences of the surface properties of silicone splints, our findings revealed that smooth texture of silicone material is suitable for biofilm formation. Biofilm formation is effected by various environmental factors. Schmidlin et al. mentioned that increased surface roughness and wettability influence the biofilm formation under experimental conditions [14]. Different proportions of biofilm formation between groups at 72th and 96th hours seem to be associated with the different surface characteristics of the groups. We consider that the surface actors of the silicone splints in group 1 (surfactant group) could have been altered by the application of surfactantcontaining solutions. Surface tension lowering effect of surfactant is considered to be the reason of reduced rates of biofilm formation at 72th and 96th hours in group 1. Proportion of biofilm formation at 48th showed no difference between groups. This finding is in concordance with the finding that risk of bacteremia after nasal septal procedure increases after 48 h [12]. Consequently, we may suggest that 48th hour is optimal time for pack removal to prevent patient from infection-related complications of nasal packing. In rhinology practice, clinical experience suggests that infected splints especially those removed in less than a week are not a major issue and therefore there is no strong evidence for surfactant need. Our study could be criticized on this issue. We tried to clarify the inhibitory effect of surfactant on biofilm formation and observed its safety in terms of patient compliance and wanted to pioneer any further studies on this subject to discuss whether it is meaningful to use it topically or not.
Conclusion In conclusion our study showed that biofilm formation over the surfaces of the intranasal silicone splints significantly increases in time especially after 48 h. Inhibitory effects of surfactant-containing nasal solutions on biofilm formation over the surfaces of intranasal silicone splints become evident after 48 h. Maybe in the future, surfactant-containing nasal solutions are going to take place in the rhinological practice to reduce the risk of bacterial colonization of silicone splints those used after septoplasty.
Eur Arch Otorhinolaryngol Acknowledgments This work was supported by a grant from Eskis¸ehir Osmangazi University (Project No. 201341D04) Conflict of interest The authors have no conflict of interest to report.
References 1. Donlan RM, Costerton JW (2002) Biofilms: survival mechanisms of clinically relevant microorganisms. Clin Microbiol Rev 15(2):167–193 2. Stewart PS, Costerton JW (2000) Antibiotic resistance of bacteria in biofilms. Lancet 358:135–138 3. Soto SM (2013) Role of efflux pumps in the antibiotic resistance of bacteria embedded in a biofilm. Virulence. 4(3):22–29 4. Sanderson AR, Leid JG, Hunsaker D (2006) Bacterial biofilms on the sinus mucosa of human subjects with chronic rhinosinusitis. Laryngoscope 116(7):1121–1126 5. Chole RA, Faddis BT (2002) Evidence for microbial biofilms in cholesteatomas. Arch Otolaryngol Head Neck Surg 128(10):1129–1133 6. Joshi RR, Nepal A, Chhetri ST, Bhandary S, Panta TB, Regmi D (2012) An evaluation of merocel and neosporin impregnated ribbon gauze packs in patients following nasal surgery: a prospective randomised trial. Health Renaissance 10:30–34
7. Caniello M, Passerotti GH, Goto EY, Voegels RL, Butugan O (2005) Antibiotics in septoplasty: is it necessary? Braz J Otorhinolaryngol 71(6):734–738 8. Winkler C, Hohlfeld JM (2013) Surfactant and allergic airway inflammation. Swiss Med Wkly 29(143):w131 9. Chole RA, Faddis BT (2002) Evidence for microbial biofilms in cholesteatomas. Arch Otolaryngol Head Neck Surg 128(10):112–133 10. Campbell JB, Watson MG, Shenoi PM (1987) The role of intranasal splints in the prevention of post-operative nasal adhesions. Laryngol Otol 1(11):1140–1143 11. Hajiioannou JK, Bizaki A, Fragiadakis G, Bourolias C, Spanakis I, Chlouverakis G et al (2007) Optimal time for nasal packing removal after septoplasty. A comparative study. Rhinology 45(1):68–71 12. Caniello M, Passerotti GH, Goto EY, Voegels RL, Butugan O (2005) Antibiotics in septoplasty: is it necessary? Braz J Otorhinolaryngol 71(6):734–738 13. Yilmaz MS, Guven M, Elicora SS, Kaymaz R (2013) An evaluation of biodegradable synthetic polyurethane foam in patients following septoplasty: a prospective randomized trial. Otolaryngol Head Neck Surg 148(1):140–144 14. Schmidlin PR, Müller P, Attin T, Wieland M, Hofer D, Guggenheim B (2013) Polyspecies biofilm formation on implant surfaces with different surface characteristics. J Appl Oral Sci 21(1):48–55
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Rhinology
Effects of surfactant on biofilm formation on silicone nasal splints Turhan San · Omer Cagatay Ertugay · Tolgahan Catli · Mustafa Acar · Cigdem Kalaycik Ertugay · Ilknur Dag · Cemal Cingi
Received: 28 January 2014 / Accepted: 8 May 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Biofilms are sessile communities of bacteria embedded in self-produced extracellular polysaccharide matrix and are considered to be responsible for bacterial infections in humans. Topical surfactant use on silicone nasal splints may have a preventive effect on biofilm formation. The objective of this study is to investigate the effect of surfactant-containing nasal solutions on biofilm formation over the surface of silicone nasal splints. Forty patients were randomized after septoplasty to receive surfactant-containing saline solution (group 1) or saline without surfactant (group 2). At the postoperative 48th, 72th and 96th hours, pieces of splint samples were taken and prepared for scanning electron microscopic evaluation. Biofilm formation was observed in 3, 6 and 14 of 20 samples in group 1 (surfactant used) and 3, 14 and 20 of 20 samples in group 2 (control) at 48th, 72th and 96th hours, respectively. Biofilm formation incidences of groups at 48th hour were similar (p > 0.05), whereas it was significantly lower at group 1 regarding 72th and 96th hours
(p 0.05). Removal after 72 h: 13/20 (65 %) of patients in control group demonstrated biofilm formation, whereas it was 6/20 (30 %) in surfactant group. Chi square test was applied to
Fig. 2 Electron microscobic view of 48-h sample of a control patient, showing no biofilm formation
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Fig. 3 Electron microscobic view of 72-h sample of the same patient, demonstrating biofilm existence
Fig. 4 Electron microscobic view of 96-h sample of the same patient, demonstrating biofilm existence
in foreign nature and have a potential of causing serious pack-related infectious complications such as toxic shock syndrome [11]. In this study we observed that especially after 48 h postoperatively, biofilm formation occur over the surfaces of intranasal silicone splints. This finding is in concordance with the finding that risk of bacteremia after nasal septal procedure increases after 48 h [12]. As a reflection of technological advancement, various types of nasal packs have been designed by different companies and each of the products has their own texture and structural properties. There is a wide varience in materials for splinting and packing as well as its duration. While Merocel (Medtronic Xomed, USA-kind of foam pack made of polyvinyl acetal is packaged in a compressed, dehydrated state to allow ease of insertion) has a porous structure, silicone splints (Invotec, Jacksonville, Florida-kind of pack made of synthetic silicone) have smoother surfaces. In a prospective
13
Eur Arch Otorhinolaryngol
study, Yilmaz et al. have mentioned the clinical importance of these structural differences [13]. They compared three structurally different packing materials (biodegradable synthetic polyurethane foam, silicone nasal splint and Merocel) regarding the level of pain and discomfort during packing and removal. They observed that patients with silicone splints felt more comfortable than patients with Merocel during packing and removal. This clinical finding seems to be related with the smoother surface of silicone splint. In addition to the clinical consequences of the surface properties of silicone splints, our findings revealed that smooth texture of silicone material is suitable for biofilm formation. Biofilm formation is effected by various environmental factors. Schmidlin et al. mentioned that increased surface roughness and wettability influence the biofilm formation under experimental conditions [14]. Different proportions of biofilm formation between groups at 72th and 96th hours seem to be associated with the different surface characteristics of the groups. We consider that the surface actors of the silicone splints in group 1 (surfactant group) could have been altered by the application of surfactantcontaining solutions. Surface tension lowering effect of surfactant is considered to be the reason of reduced rates of biofilm formation at 72th and 96th hours in group 1. Proportion of biofilm formation at 48th showed no difference between groups. This finding is in concordance with the finding that risk of bacteremia after nasal septal procedure increases after 48 h [12]. Consequently, we may suggest that 48th hour is optimal time for pack removal to prevent patient from infection-related complications of nasal packing. In rhinology practice, clinical experience suggests that infected splints especially those removed in less than a week are not a major issue and therefore there is no strong evidence for surfactant need. Our study could be criticized on this issue. We tried to clarify the inhibitory effect of surfactant on biofilm formation and observed its safety in terms of patient compliance and wanted to pioneer any further studies on this subject to discuss whether it is meaningful to use it topically or not.
Conclusion In conclusion our study showed that biofilm formation over the surfaces of the intranasal silicone splints significantly increases in time especially after 48 h. Inhibitory effects of surfactant-containing nasal solutions on biofilm formation over the surfaces of intranasal silicone splints become evident after 48 h. Maybe in the future, surfactant-containing nasal solutions are going to take place in the rhinological practice to reduce the risk of bacterial colonization of silicone splints those used after septoplasty.
Eur Arch Otorhinolaryngol Acknowledgments This work was supported by a grant from Eskis¸ehir Osmangazi University (Project No. 201341D04) Conflict of interest The authors have no conflict of interest to report.
References 1. Donlan RM, Costerton JW (2002) Biofilms: survival mechanisms of clinically relevant microorganisms. Clin Microbiol Rev 15(2):167–193 2. Stewart PS, Costerton JW (2000) Antibiotic resistance of bacteria in biofilms. Lancet 358:135–138 3. Soto SM (2013) Role of efflux pumps in the antibiotic resistance of bacteria embedded in a biofilm. Virulence. 4(3):22–29 4. Sanderson AR, Leid JG, Hunsaker D (2006) Bacterial biofilms on the sinus mucosa of human subjects with chronic rhinosinusitis. Laryngoscope 116(7):1121–1126 5. Chole RA, Faddis BT (2002) Evidence for microbial biofilms in cholesteatomas. Arch Otolaryngol Head Neck Surg 128(10):1129–1133 6. Joshi RR, Nepal A, Chhetri ST, Bhandary S, Panta TB, Regmi D (2012) An evaluation of merocel and neosporin impregnated ribbon gauze packs in patients following nasal surgery: a prospective randomised trial. Health Renaissance 10:30–34
7. Caniello M, Passerotti GH, Goto EY, Voegels RL, Butugan O (2005) Antibiotics in septoplasty: is it necessary? Braz J Otorhinolaryngol 71(6):734–738 8. Winkler C, Hohlfeld JM (2013) Surfactant and allergic airway inflammation. Swiss Med Wkly 29(143):w131 9. Chole RA, Faddis BT (2002) Evidence for microbial biofilms in cholesteatomas. Arch Otolaryngol Head Neck Surg 128(10):112–133 10. Campbell JB, Watson MG, Shenoi PM (1987) The role of intranasal splints in the prevention of post-operative nasal adhesions. Laryngol Otol 1(11):1140–1143 11. Hajiioannou JK, Bizaki A, Fragiadakis G, Bourolias C, Spanakis I, Chlouverakis G et al (2007) Optimal time for nasal packing removal after septoplasty. A comparative study. Rhinology 45(1):68–71 12. Caniello M, Passerotti GH, Goto EY, Voegels RL, Butugan O (2005) Antibiotics in septoplasty: is it necessary? Braz J Otorhinolaryngol 71(6):734–738 13. Yilmaz MS, Guven M, Elicora SS, Kaymaz R (2013) An evaluation of biodegradable synthetic polyurethane foam in patients following septoplasty: a prospective randomized trial. Otolaryngol Head Neck Surg 148(1):140–144 14. Schmidlin PR, Müller P, Attin T, Wieland M, Hofer D, Guggenheim B (2013) Polyspecies biofilm formation on implant surfaces with different surface characteristics. J Appl Oral Sci 21(1):48–55
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