Electrolyzed acid water nasal irrigation after functional endoscopic sinus surgery Rong-San Jiang, M.D.,1,2,3 Kai-Li Liang, M.D.,1,2,3 Shang-Heng Wu, M.D.,1 Mao-Chang Su, M.D.,2,4,5 Wen-Kang Chen, Ph.D.,6 and Fung-Jou Lu, Ph.D.7
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ABSTRACT
Background: Electrolyzed acid water (EAW) has been recognized to have strong bactericidal activity, and the feasibility and safety of EAW irrigation in body cavities has been reported in the literature. This study was conducted to evaluate the effect of EAW nasal irrigation on the postoperative care of functional endoscopic sinus surgery (FESS). Methods: Patients with chronic rhinosinusitis who received FESS for treatment were recruited and randomly assigned to three groups at 1 month postoperatively. Patients in group 1 received EAW for nasal irrigation daily for 2 months, those in group 2 received neutral normal saline (NS) daily for 2 months, and those in group 3 did not receive nasal irrigation after surgery. Before and 3 months after FESS, sinonasal symptoms were assessed by questionnaire and patients received endoscopic examination, acoustic rhinometry, smell test, saccharine transit test, and bacterial culture from middle meatus. Results: There were 185 patients enrolled between May 2009 and March 2012. Among the patients who completed the study, 36 received EWA irrigation, 35 received NS irrigation, and 39 (group 3) received no irrigation. Patients with nasal irrigation had a better outcome based on questionnaire score and saccharine transit time. However, there was no difference in outcome between patients who received irrigation with EAW and NS. Conclusion: Our study showed that EWA irrigation did not confer a greater benefit than that of NS irrigation in post-FESS care. (Am J Rhinol Allergy 28, 176 –181, 2014; doi: 10.2500/ajra.2014.28.4015)
N
asal irrigation has become a common adjunctive method for management of allergic rhinitis and chronic rhinosinusitis (CRS).1,2 Its benefit may be because of mechanical clearance of mucus, but other potentially beneficial physiological effects have also been proposed, including improvement in mucus clearance; enhanced ciliary beat activity; removal of antigens, biofilm, or inflammatory mediators; and a protection of sinonasal mucosa.3 Recently, irrigation solutions have been added with antifungal or antibiotic agents to increase the potential to kill microorganisms in the nasal secretion.4,5 Although nasal irrigation has been widely used to manage rhinosinusitis, there is currently no consensus about the optimal salinity, pH, or delivery system.6,7 Electrolyzed acid water (EAW) is generated by the electrolysis of a weak sodium chloride solution.6 During electrolysis, the weak sodium chloride solution dissociates into EAW, which has pH values of 2–3, an oxidation-reduction potential of ⬎1100 mV, and an active chlorine content of 10–90 ppm, and electrolyzed basic water that has a pH of 10–13 and an oxidation-reduction potential of ⫺800 to ⫺900 mV.7 EAW has been recognized to have strong bactericidal activity and has been used as a sanitizer in the food industries of many countries.8,9 The feasibility and safety of EAW irrigation in body cavities has been reported in the literature.8,10,11 However, whether EAW is suitable for nasal irrigation and its efficacy in CRS management has not been investigated. In this study, we investigated the efficacy and adverse effects of EAW nasal irrigation in postoperative care of CRS patients after functional endoscopic sinus surgery (FESS).
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MATERIALS AND METHODS
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From: 1Department of Otolaryngology, Taichung Veterans General Hospital, Taichung, Taiwan, 2School of Medicine, Chung Shan Medical University, Taichung, Taiwan, 3Faculty of Medicine, National Yang-Ming Medical University, Taipei, Taiwan, 4Department of Otolaryngology, Chung Shan Medical University Hospital, and School of 5Speech Language Pathology and Audiology, Chung Shan Medical University, Taichung, Taiwan, 6National Tainan Institute of Nursing, Tainan, Taiwan, and 7 Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan Presented at the 20th International Federation of Oto-Rhino-Laryngological Societies World Congress, Seoul, Korea, June 1–5, 2013 The authors have no conflicts to declare pertaining to this article Address correspondence to Fung-Jou Lu, Ph.D., Institute of Medicine, Chung Shan Medical University, 110, Section 1, Chien-Kuo North Road, Taichung 402, Taiwan E-mail address: [email protected] Copyright © 2014, OceanSide Publications, Inc., U.S.A.
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Subjects
The flowchart and design of this study are shown in Fig. 1. One hundred eighty-five CRS patients who responded poorly to medical treatment and subsequently underwent FESS were enrolled in this study between May 2009 and March 2012. The diagnosis of CRS was based on guidelines of the Sinus and Allergy Health Partnership Task Force in 2002, which included a history of rhinosinusitis for ⬎12 weeks, the findings of nasal endoscopy, and a radiological examination.12 Any patient who had a history of immunodeficiency or a previous sinus surgery was not enrolled. Patients who took antibiotics within a week before bacterial culture were also excluded. This study was approved by the Ethics Committee of Taichung Veterans General Hospital (IRB TCVGH No. C08008). Written consent was obtained from each patient.
Preoperative Assessment Before the FESS procedure, all patients completed a Taiwanese version of the 20-item Sino-Nasal Outcome Test (SNOT-20) questionnaire.13 Patients also received acoustic rhinometry, smell test, saccharine transit test, hearing test, nasal bacterial culture, and an endoscopic examination. Acoustic rhinometry was performed to measure the second minimal cross-sectional area (MCA2) of the nasal cavity. The MCA2 of right and left nasal cavity was averaged to give a mean MCA2 (cm2). The smell function was evaluated by Smell Threshold Test (Sensonics, Inc., Hadden Heights, NJ)14 and a traditional Chinese version of the University of Pennsylvania Smell Identification Test (UPSIT-TC; Sensonics, Inc.).15 Saccharine transit test was performed by putting saccharine granules under the head of the inferior turbinate in the nostril with more severe disease and then measuring the time interval between placement of saccharine granules and sensation of sweetness in the patient’s throat. The hearing test included tympanometry and pure tone audiometry. Bacterial cultures were performed by taking swab specimens from the bilateral middle meatus, using a cotton-tipped stick. The endoscopic appearances were quantified on a 0- to 2-point scale according to the staging system devised by Lund and Mackay.16 Endoscopic appearances included the presence of polyps (0, no polyp; 1, polyps confined to the middle meatus; 2, polyps beyond the mid-
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Figure 1. Flowchart and design of the study.
dle meatus), discharge (0, no discharge; 1, clear, thin discharge; 2, thick, purulent discharge), and edema.
Postoperative Care After surgery, patients were followed up at the outpatient clinic; nasal local treatment was performed to remove crusts and discharge from the nasal cavities. No antibiotic, intranasal or oral antihistamine, and/or intranasal or oral steroid was prescribed. One month after surgery,
patients were randomized into three groups. In group 1, patients irrigated their noses with 250 mL of EAW every day for 2 months. In group 2, patients irrigated their noses with 250 mL of neutral normal saline (NS) every day for 2 months. In group 3, patients did not irrigate their noses. During these 2 months, no medication was given to any patient. Debridement was not performed either. Randomization assignments were generated by an independent statistician. The physicians were blinded for the randomization.
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Table 1 Comparison of preoperative and postoperative clinical characteristics in group 1
SNOT-20 score MCA2 Smell threshold UPSIT-TC score Saccharine transit time Tympanogram Type B Type C Endoscopic score Bacterial culture rate#
Patient No.
Pre-FESS
Post-FESS
p Value
36 35 36 36 28
40.56 ⫾ 15.92* 0.48 ⫾ 0.26 2.90 ⫾ 2.43 20.19 ⫾ 9.36 20.50 ⫾ 9.54 29 3 Ears 6 Ears 6.06 ⫾ 2.01 47.2%
30.83 ⫾ 17.59 0.51 ⫾ 0.25 3.19 ⫾ 2.55 21.17 ⫾ 7.97 19.29 ⫾ 9.04
0.002 0.358 0.536 0.535 0.644
36 36
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6 Ears 5.47 ⫾ 1.99 48.6%
0.081 1.000
*Mean ⫾ SD. #Bacterial culture taken from bilateral middle meatus. SNOT-20 ⫽ 20-item Sino-Nasal Outcome Test; MCA2 ⫽ second minimal cross-sectional area; UPSIT-TC ⫽ traditional Chinese version of University of Pennsylvania Smell Identification Test.
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Table 2 Comparison of preoperative and postoperative clinical characteristics in group 2
SNOT-20 score MCA2 Smell threshold UPSIT-TC score Saccharine transit time Tympanogram Type B Type C Endoscopic score Bacterial culture rate#
Patient No.
Pre-FESS
35 35 35 35 23 27
34.60 ⫾ 19.22* 0.48 ⫾ 0.18 ⫺3.47 ⫾ 2.75 20.69 ⫾ 8.44 19.17 ⫾ 9.14
34 35
T
1 Ear 7 Ears 5.71 ⫾ 2.33 34.3%
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Post-FESS
25.54 ⫾ 20.69 0.52 ⫾ 0.18 ⫺3.83 ⫾ 2.33 22.43 ⫾ 7.84 15.96 ⫾ 8.93
6 Ears 5.15 ⫾ 1.92 68.6%
p Value 0.001 0.162 0.409 0.134 0.272
0.226 ⬍0.001
*Mean ⫾ SD. # bacterial culture taken from bilateral middle meatus. SNOT-20 ⫽ 20-item Sino-Nasal Outcome Test; MCA ⫽ second minimal cross-sectional area; UPSIT-TC ⫽ traditional Chinese version of University of Pennsylvania Smell Identification Test. Table 3 Comparison of preoperative and postoperative clinical characteristics in group 3
SNOT-20 score MCA2 Smell threshold UPSIT-TC score Saccharine transit time Tympanogram Type B Type C Endoscopic score Bacterial culture rate#
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Patient No
Pre-FESS
Post-FESS
p Value
39 37 39 39 28 31
37.59 ⫾ 20.62* 0.42 ⫾ 0.20 ⫺3.48 ⫾ 2.81 21.10 ⫾ 8.79 16.07 ⫾ 9.98
30.82 ⫾ 19.12 0.58 ⫾ 0.25 ⫺4.50 ⫾ 2.78 22.38 ⫾ 8.28 16.39 ⫾ 9.55
0.024 ⬍0.001 0.024 0.335 0.881
2 Ears 4 Ears 5.82 ⫾ 2.42 59.0%
3 Ears 4 Ears 4.54 ⫾ 1.97 48.7%
39 39
0.001 0.261
*Mean ⫾ SD. #Bacterial culture taken from bilateral middle meatus. SNOT-20 ⫽ 20-item Sino-Nasal Outcome Test; MCA2 ⫽ second minimal cross-sectional area; UPSIT-TC ⫽ traditional Chinese version of University of Pennsylvania Smell Identification Test.
Irrigation Device and Preparation of Irrigation Fluid A Sanvic SH903 pulsatile irrigator (Yun-Wang Industrial Co., Tainan, Taiwan) was used to irrigate nasal cavities in this study. The Sanvic SH903 irrigator is a high-volume delivery device. EWA was generated using a Long-Life YS-A717 water ionizer (Yi Shan Electro Industrial Co., Taichung, Taiwan). Two thousand milliliters of tap water was placed into two containers, and 1 g of sodium
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chloride was equally added into two containers. The solution was electrolyzed to produce EWA. The pH value of EWA was measured using a pH meter and was between 2.3 and 2.5. Next, another 9 g of sodium chloride was added into 1000 mL of EWA to achieve an osmolarity of 309 osmol/L. Neutral NS was prepared from neutral water. Neutral water was generated using a Health Control water ionizer (Yi Shan Electro Industrial Co.). The pH value of neutral water was measured using a pH meter and was between
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Table 4 Bacteriology before and 3 mo after FESS Group
1 (72*) Pre-FESS
Species Aerobic and facultative bacteria Gram-positive Coagulase-negative staphylococci Staphylococcus aureus Streptococcus pneumoniae Streptococcus viridans Corynebacterium spp. Moraxella catarrhalis Gram-positive bacillus Gram-positive coccus Gram-negative Haemophilus influenza Klebsiella pneumonia Klebsiella oxytoca Klebsiella ozaenae Pseudomonas aeruginosa Pseudomonas stutzeri Pseudomonas putida Pseudomonas oryzihabitans Enterobacter aerogenes Enterobacter cloacae Citrobacter koseri Citrobacter freundii Escherichia coli Proteus vulgaris Proteus mirabilis Acinetobacter johnsonii Bacillus cereus Bacillus sp. Nonfermentative Gram-negative bacillus Aeromonas hydrophila Shewanella algae Total aerobic and facultative bacteria Anaerobic bacteria Gram-positive Propionibacterium acnes Propionibacterium sp. Peptostreptococcus magnus Gram-negative Fusobacterium nucleatum Nonfermentative Gram-negative bacillus Total anaerobic bacteria Total bacterial isolates
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2 (70)
After FESS
Pre-FESS
3 (78)
After FESS
Pre-FESS
After FESS
11 11 1
8 15 2
No. of Isolates
12 6
4 8 2
8 5
1 5
2 1
3 2
2
2
1 2
7
5
O N 2 44
1
2
2 2 1
O C 2 4
2 2
2 6
1 1
1 2 2 4 3 4 2 1
3 1
2 2 1
1
1
32
22
1 1 1
2
1 1 5 37
1 1
14 1
T
1
1 1
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1 3 2
1 3 1 2 1 1 1
2 1 2 42
4 16
2 24
52
2 53
44
2
0 52
2 55
0 44
*Number of specimens. FESS ⫽ functional endoscopic sinus surgery.
6.8 and 6.9. Next, 9 g of sodium chloride was added into 1000 mL of neutral water to make the osmolarity of 279 osmol/L.
Postirrigation Assessment Three months after surgery, patients completed another SNOT20 questionnaire. Patients also received acoustic rhinometry, smell test, saccharine transit test, hearing test, nasal bacterial culture, and an endoscopic examination. The comfort of nasal irrigation was measured by using a 10-point visual analog scale with 0 representing least comfort and 10 representing most comfort.
Assessment of Potential Adverse Events of Nasal Irrigation The adverse events of nasal irrigation were assessed subjectively and objectively. Patients were asked to report any adverse event relating to nasal irrigation. Whether nasal irrigation affected smell function, mucociliary function, or E-tube function was evaluated by smell test, saccharine transit test, and hearing test.
Sample Size and Statistical Analysis Sample size was calculated with the study design of one-way ANOVA by use of the PASS software Version 12.0.3 (NCSS, LLC,
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Kaysville, UT). The minimum required sample size was driven by the improvement of SNOT-20 score after 2 months of treatment. A minimum of 36 subjects was required in each study arm to have 90% power (␣ ⫽ 0.05) and an improvement of three scores in SNOT-20. A score change of ⱖ3 is believed to be clinically meaningful according to the results of validation of Taiwanese version of SNOT-20.13 All data were presented as mean ⫾ SD. The sex of patients, bacterial culture rate, rate of prolongation in the saccharine transit time and the rate of prolongation in the saccharine transit time, and impairment rate of E-tube function 3 months after FESS were compared among three groups by Pearson chi-square test. The age of patients, SNOT-20 score, mean MCA2, smell threshold, UPSIT-TC score, saccharine transit time, and endoscopic score were compared by AVONA test. The comfort of nasal irrigation was compared between EAW and NS groups by AVONA test. The pre- and post-FESS SNOT-20 scores, mean MCA2, smell threshold, UPSIT-TC score, saccharine transit time, and endoscopic score were compared by paired samples t-test. The pre- and post-FESS bacterial culture rates were compared by Pearson chi-square test. All computations were performed using SPSS Version 17.0 (SPSS, Inc., Chicago, IL). Two-tailed values of p ⬍ 0.05 were considered statistically significant.
Postoperative Clinical Characteristics among the Three Groups There were no significant differences in postoperative SNOT-20 scores, mean MCA2, smell threshold, UPSIT-TC scores, saccharine transit time, and endoscopic scores among the three groups. The bacterial culture rate was significantly higher in group 2 (p ⫽ 0.037). There were seven patients who refused to receive EAW for nasal irrigation because they experienced irritation in their nose during the nasal irrigation instruction. When asked about the comfort level while using nasal irrigation in patients who finished the 2-month irrigation period, those receiving NS irrigation felt greater comfort than those receiving EAW (p ⬍ 0.001).
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RESULTS
Assessment of Potential Adverse Events of Nasal Irrigation
Patients As shown in Fig. 1, 110 patients were included in the final analysis with 36 in group 1, 35 in group 2, and 39 in group 3. There were 25 men and 11 women in group 1. Their ages ranged from 22 to 71 years old with a mean of 44.9 years. There were 23 male and 12 female subjects in group 2. Their ages ranged from 10 to 71 years old with a mean of 42.8 years. There were 27 male and 12 female subjects in group 3. Their age ranged from 15 to 84 years old with a mean of 45.3 years. There were no significant differences in sex and age among the three groups (p ⫽ 0.93 and 0.77, respectively).
There was no significant difference in preoperative SNOT-20 score, mean MCA2, smell threshold, UPSIT-TC score, saccharine transit time, and endoscopic score among the three groups. The bacterial culture rate was significantly lower in group 2 (p ⫽ 0.011).
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Preoperative and Postoperative Clinical Characteristics
The clinical characteristics before FESS and 3 months after FESS in the three groups are shown in Tables 1–3. In patients receiving EAW irrigation, the SNOT score was significantly lower after irrigation. The mean MCA2 and UPSIT-TC score increased after surgery, but the smell threshold, saccharine transit time, and endoscopic score decreased. The bacterial culture rate was almost the same after surgery. In patients receiving NS irrigation, the SNOT score was significantly lower after irrigation. The mean MCA2 and UPSIT-TC score increased after surgery, but the smell threshold, saccharine transit time, and endoscopic score decreased, although not significantly. The bacterial culture rate decreased after surgery. In patients receiving NS irrigation, the SNOT score was significantly lower after irrigation. The mean MCA2 and UPSIT-TC score increased after surgery, but the smell threshold, saccharine transit time, and endoscopic score decreased, although not significantly. However, the bacterial culture rate significantly increased after surgery. In patients without nasal irrigation, the SNOT score was significantly lower after irrigation. The mean MCA2 significantly increased after surgery and UPSIT-TC score also increased, but not significantly. The smell threshold and endoscopic scores significantly decreased. However, the saccharine transit time increased (not significantly) and the bacterial culture rate decreased after surgery.
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Preoperative Clinical Characteristics
Several adverse events have been reported. One patient complained of loss of smell after completing EAW irrigation but found his sense of smell came back later. No patients complained of loss of smell after completing NS irrigation. Five patients withdrew from the EAW irrigation protocol because of adverse events. Among them, two patients felt their smell was impaired after nasal irrigation for a few days, but their smell returned to normal during follow-up. Two other patients suffered from nasal stuffiness after nasal irrigation for a few days. When nasal irrigation was stopped, the feeling of nasal stuffiness disappeared. The fifth patient reported feeling swollen in his legs after nasal irrigation, but the symptom resolved after stopping irrigation. No adverse event occurred in patients receiving NS irrigation. When the results of smell tests and saccharine transit time were compared before and 3 months after FESS among the three groups, EAW nasal irrigation did not impair smell function or prolong saccharine transit time. Saccharine transit time was prolonged in 13 of 28 (46.4%) patients after EAW irrigation, in 10 of 23 (43.5%) patients after NS irrigation, and in 16 (57.1%) of 28 patients without irrigation 3 months after FESS. The rate of prolongation in the saccharine transit time was not significantly different among the three groups (p ⫽ 0.579). Twenty-nine patients who received EAW irrigation underwent a hearing test. Five ears with type A before FESS became type C after irrigation. Twenty-seven patients who received NS irrigation received the hearing test. One ear with type A before FESS changed to type C after irrigation. Thirty-one patients without nasal irrigation underwent the hearing test. One ear with type A before FESS became type C, and two ears with type A before FESS changed to type B 3 months after FESS. The impairment rate of E-tube function 3 months after FESS (type A changing to type B or C) was not significantly different among the three groups (p ⫽ 0.268).
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DISCUSSION The antibacterial activity of EAW has been investigated in several studies. The active factors responsible for the bactericidal effect of EAW are chlorine-related substances, such as chlorine, hypochlorous acid, and hypochlorous ion.17 Its antibiotic activity can reach as high as 50 times that of hypochlorous acid and kills germs in a short time.18 EAW is considered to be safe for human consumption.17 In addition to its strong antibacterial activity, EAW has other advantages as an irrigating solution. It is minimally invasive to tissue because of its low cytotoxicity, is ecological because its breakdown produces only saline and traces of chlorine gas, and is economical because only tap water and a little salt are needed to produce EAW.8 It has also been shown that EAW can be stored for 21 days without significant changes in pH and oxidation-reduction potential values.17 Therefore, it may have potential as a nasal irrigant for management of CRS. In this study, it was shown that FESS effectively improved patients’ symptoms whether or not postoperative nasal irrigation was performed, but SNOT-20 scores decreased more in patients with nasal
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irrigation than without irrigation. The mean scores decreased from 40.56 to 30.83 (p ⫽ 0.002) in patients with EAW irrigation, from 34.6 to 25.54 (p ⫽ 0.001) in patients with NS irrigation, and from 37.59 to 30.82 (p ⫽ 0.024) in patients without irrigation. Furthermore, nasal irrigation seemed to improve mucociliary function. The mean saccharine transit time decreased in patients with EAW and NS irrigation but increased in patients without irrigation, although all changes were not significant. The saccharine transit time decreased in 50% (14/28) of patients receiving EAW irrigation and in 52.2% (12/23) of patients receiving NS irrigation, but decreased only in 28.6% (8/28) of patients without irrigation. However, no difference was found between patients receiving EAW irrigation and those receiving NS irrigation. It has been shown that EAW has good antibiotic activity for Bacillus subtilis, Enterococcus hirae, Staphylococcus aureus, Staphylococcus epidermidis, and Escherichia coli, and a weaker activity against Streptococcus pyogenes and Pseudomonas aeruginosa.18 When the bactericidal activity of EAW was tested on anaerobes isolated from dental root canals, it had a good effect against anaerobes, but the effect against Streptococcus intermedia, Veillonella parvula, Propionibacterium acnes, and Prevotella melanimogenica was weaker.17 In our previous study, the results showed that EAW could effectively inhibit the growth of bacteria isolated from the nasal secretion, and its antibacterial activity was as effective as 70% alcohol, but our results also showed the antibacterial activity of EWA was weaker against anaerobes than against aerobes.19 In this study, postoperative bacteriology showed EAW irrigation did not inhibit the bacterial growth and more anaerobes grew in patients receiving EAW irrigation (Table 4). Interestingly, significantly higher bacterial growth was found in patients receiving NS irrigation. Whether this resulted from the NS fluid being nonsterile requires further investigation. Because EAW, especially at pH values of 2–3, has been shown to be irritating17 it may have potentially deleterious effects when used as a nasal irrigant. Therefore, we investigated its effects on smell function, mucociliary clearance function, and E-tube function. Our results showed that EAW irrigation might impair smell function but this deleterious effect was temporary. However, EAW irrigation was more irritating and uncomfortable than NS irrigation.
CONCLUSION
3.
4.
5.
6.
7.
8.
9. 10.
11.
12.
13.
14.
15.
16. 17.
18.
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Hermelingmeier KE, Weber RK, Hellmich M, et al. Nasal irrigation as an adjunctive treatment in allergic rhinitis: A systematic review and meta-analysis. Am J Rhinol Allergy 26:e119–e125, 2012.
Burton MJ, Eisenberg LD, and Rosenfeld RM. Extracts from The Cochrane Library: Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Otolaryngol Head Neck Surg 137:532–534, 2007. Harvey R, Hannan SA, Badia L, and Scadding G. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database Syst Rev 3:CD006394, 2007. Liang KL, Su MC, Shiao JY, et al. Amphotericin B irrigation for the treatment of chronic rhinosinusitis without nasal polyps: A randomized, placebo-controlled, double-blind study. Am J Rhinol 22:52–58, 2008. Lim M, Citardi MJ, and Leong JL. Topical antimicrobials in the management of chronic rhinosinusitis: A systematic review. Am J Rhinol 22:381–389, 2008. Liang KL, Su MC, Tseng HC, and Jiang RS. The impact of pulsatile nasal irrigation on the prognosis of functional endoscopic sinus surgery. J Otolaryngology Head Neck Surg 37:148–153, 2008. Morong S, and Lee JM. Microwave disinfection: Assessing the risks of irrigation bottle and fluid contamination. Am J Rhinol Allergy 26: 398–400, 2012. Kubota A, Nose K, Yonekura T, et al. Effect of electrolyzed strong acid water on peritoneal irrigation of experimental perforated peritonitis. Surg Today 39:514–517, 2009. Hricova D, Stephan R, and Zweifel C. Electrolyzed water and its application in the food industry. J Food Prot 71:1934–1947, 2008. Hayashi H, Kumon K, Yahagi N, et al. Successful treatment of mediastinitis after cardiovascular surgery using electrolyzed strong acid aqueous solution. Artif Organs 21:39–42, 1997. Kubota A, Hoki M, Yonekura T, et al. Effectiveness of acid oxidative potential water in peritoneal lavage for perforated appendicitis. Asian J Surg 22:282–283, 1999. Benninger MS, Ferguson BJ, Hadley JA, et al. Adult chronic rhinosinusitis: Definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg 129(suppl):S1–S32, 2003. Liang KL, Twu CW, Shiao JY, et al. Validation of the Taiwanese version of the 20-item Sino-nasal Outcome Test. J Taiwan Otolaryngol Head Neck Surg 46:6–13, 2011. Doty RL (Ed.). Interpretation of detection threshold values. In The Smell Threshold Test Administration Manual. Haddon Heights, NJ: Sensonics, Inc., 14–16, 2000. Jiang RS, Su MC, Liang KL, et al. A pilot study of a traditional Chinese version of the University of Pennsylvania Smell Identification Test for application in Taiwan. Am J Rhinol Allergy 24:45–50, 2010. Lund VJ, and Mackay IS. Staging in rhinosinusitis. Rhinology 31:183– 184, 1993. Horiba N, Hiratsuka K, Onoe T, et al. Bactericidal effect of electrolyzed neutral water on bacteria isolated from infected root canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 87:83– 87, 1999. Liang WL, and Lu FJ. Antibiotic activity of Hi-Clo-Soft acidic ionized water. Forman Sci 55:52–58, 2004. Jiang RS, Wu SH, Liang KL, et al. Antibacterial effect of electrolysed acid water on the nasal discharge from patients with chronic rhinosinusitis. Eur J Clin Microbiol Infect Dis 29:551–554, 2010. e
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Our results showed that post-FESS nasal irrigation resulted in better outcomes with regard to SNOT-20 scores and saccharine transit times, but EWA irrigation did not confer a greater benefit than NS irrigation in post-FESS care. Although EAW irrigation was more irritating and uncomfortable than NS irrigation, it did not have deleterious effects on smell function, mucociliary clearance function, and E-tube function.
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2.
19.
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ABSTRACT
Background: Electrolyzed acid water (EAW) has been recognized to have strong bactericidal activity, and the feasibility and safety of EAW irrigation in body cavities has been reported in the literature. This study was conducted to evaluate the effect of EAW nasal irrigation on the postoperative care of functional endoscopic sinus surgery (FESS). Methods: Patients with chronic rhinosinusitis who received FESS for treatment were recruited and randomly assigned to three groups at 1 month postoperatively. Patients in group 1 received EAW for nasal irrigation daily for 2 months, those in group 2 received neutral normal saline (NS) daily for 2 months, and those in group 3 did not receive nasal irrigation after surgery. Before and 3 months after FESS, sinonasal symptoms were assessed by questionnaire and patients received endoscopic examination, acoustic rhinometry, smell test, saccharine transit test, and bacterial culture from middle meatus. Results: There were 185 patients enrolled between May 2009 and March 2012. Among the patients who completed the study, 36 received EWA irrigation, 35 received NS irrigation, and 39 (group 3) received no irrigation. Patients with nasal irrigation had a better outcome based on questionnaire score and saccharine transit time. However, there was no difference in outcome between patients who received irrigation with EAW and NS. Conclusion: Our study showed that EWA irrigation did not confer a greater benefit than that of NS irrigation in post-FESS care. (Am J Rhinol Allergy 28, 176 –181, 2014; doi: 10.2500/ajra.2014.28.4015)
N
asal irrigation has become a common adjunctive method for management of allergic rhinitis and chronic rhinosinusitis (CRS).1,2 Its benefit may be because of mechanical clearance of mucus, but other potentially beneficial physiological effects have also been proposed, including improvement in mucus clearance; enhanced ciliary beat activity; removal of antigens, biofilm, or inflammatory mediators; and a protection of sinonasal mucosa.3 Recently, irrigation solutions have been added with antifungal or antibiotic agents to increase the potential to kill microorganisms in the nasal secretion.4,5 Although nasal irrigation has been widely used to manage rhinosinusitis, there is currently no consensus about the optimal salinity, pH, or delivery system.6,7 Electrolyzed acid water (EAW) is generated by the electrolysis of a weak sodium chloride solution.6 During electrolysis, the weak sodium chloride solution dissociates into EAW, which has pH values of 2–3, an oxidation-reduction potential of ⬎1100 mV, and an active chlorine content of 10–90 ppm, and electrolyzed basic water that has a pH of 10–13 and an oxidation-reduction potential of ⫺800 to ⫺900 mV.7 EAW has been recognized to have strong bactericidal activity and has been used as a sanitizer in the food industries of many countries.8,9 The feasibility and safety of EAW irrigation in body cavities has been reported in the literature.8,10,11 However, whether EAW is suitable for nasal irrigation and its efficacy in CRS management has not been investigated. In this study, we investigated the efficacy and adverse effects of EAW nasal irrigation in postoperative care of CRS patients after functional endoscopic sinus surgery (FESS).
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MATERIALS AND METHODS
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From: 1Department of Otolaryngology, Taichung Veterans General Hospital, Taichung, Taiwan, 2School of Medicine, Chung Shan Medical University, Taichung, Taiwan, 3Faculty of Medicine, National Yang-Ming Medical University, Taipei, Taiwan, 4Department of Otolaryngology, Chung Shan Medical University Hospital, and School of 5Speech Language Pathology and Audiology, Chung Shan Medical University, Taichung, Taiwan, 6National Tainan Institute of Nursing, Tainan, Taiwan, and 7 Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan Presented at the 20th International Federation of Oto-Rhino-Laryngological Societies World Congress, Seoul, Korea, June 1–5, 2013 The authors have no conflicts to declare pertaining to this article Address correspondence to Fung-Jou Lu, Ph.D., Institute of Medicine, Chung Shan Medical University, 110, Section 1, Chien-Kuo North Road, Taichung 402, Taiwan E-mail address: [email protected] Copyright © 2014, OceanSide Publications, Inc., U.S.A.
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Subjects
The flowchart and design of this study are shown in Fig. 1. One hundred eighty-five CRS patients who responded poorly to medical treatment and subsequently underwent FESS were enrolled in this study between May 2009 and March 2012. The diagnosis of CRS was based on guidelines of the Sinus and Allergy Health Partnership Task Force in 2002, which included a history of rhinosinusitis for ⬎12 weeks, the findings of nasal endoscopy, and a radiological examination.12 Any patient who had a history of immunodeficiency or a previous sinus surgery was not enrolled. Patients who took antibiotics within a week before bacterial culture were also excluded. This study was approved by the Ethics Committee of Taichung Veterans General Hospital (IRB TCVGH No. C08008). Written consent was obtained from each patient.
Preoperative Assessment Before the FESS procedure, all patients completed a Taiwanese version of the 20-item Sino-Nasal Outcome Test (SNOT-20) questionnaire.13 Patients also received acoustic rhinometry, smell test, saccharine transit test, hearing test, nasal bacterial culture, and an endoscopic examination. Acoustic rhinometry was performed to measure the second minimal cross-sectional area (MCA2) of the nasal cavity. The MCA2 of right and left nasal cavity was averaged to give a mean MCA2 (cm2). The smell function was evaluated by Smell Threshold Test (Sensonics, Inc., Hadden Heights, NJ)14 and a traditional Chinese version of the University of Pennsylvania Smell Identification Test (UPSIT-TC; Sensonics, Inc.).15 Saccharine transit test was performed by putting saccharine granules under the head of the inferior turbinate in the nostril with more severe disease and then measuring the time interval between placement of saccharine granules and sensation of sweetness in the patient’s throat. The hearing test included tympanometry and pure tone audiometry. Bacterial cultures were performed by taking swab specimens from the bilateral middle meatus, using a cotton-tipped stick. The endoscopic appearances were quantified on a 0- to 2-point scale according to the staging system devised by Lund and Mackay.16 Endoscopic appearances included the presence of polyps (0, no polyp; 1, polyps confined to the middle meatus; 2, polyps beyond the mid-
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Figure 1. Flowchart and design of the study.
dle meatus), discharge (0, no discharge; 1, clear, thin discharge; 2, thick, purulent discharge), and edema.
Postoperative Care After surgery, patients were followed up at the outpatient clinic; nasal local treatment was performed to remove crusts and discharge from the nasal cavities. No antibiotic, intranasal or oral antihistamine, and/or intranasal or oral steroid was prescribed. One month after surgery,
patients were randomized into three groups. In group 1, patients irrigated their noses with 250 mL of EAW every day for 2 months. In group 2, patients irrigated their noses with 250 mL of neutral normal saline (NS) every day for 2 months. In group 3, patients did not irrigate their noses. During these 2 months, no medication was given to any patient. Debridement was not performed either. Randomization assignments were generated by an independent statistician. The physicians were blinded for the randomization.
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Table 1 Comparison of preoperative and postoperative clinical characteristics in group 1
SNOT-20 score MCA2 Smell threshold UPSIT-TC score Saccharine transit time Tympanogram Type B Type C Endoscopic score Bacterial culture rate#
Patient No.
Pre-FESS
Post-FESS
p Value
36 35 36 36 28
40.56 ⫾ 15.92* 0.48 ⫾ 0.26 2.90 ⫾ 2.43 20.19 ⫾ 9.36 20.50 ⫾ 9.54 29 3 Ears 6 Ears 6.06 ⫾ 2.01 47.2%
30.83 ⫾ 17.59 0.51 ⫾ 0.25 3.19 ⫾ 2.55 21.17 ⫾ 7.97 19.29 ⫾ 9.04
0.002 0.358 0.536 0.535 0.644
36 36
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6 Ears 5.47 ⫾ 1.99 48.6%
0.081 1.000
*Mean ⫾ SD. #Bacterial culture taken from bilateral middle meatus. SNOT-20 ⫽ 20-item Sino-Nasal Outcome Test; MCA2 ⫽ second minimal cross-sectional area; UPSIT-TC ⫽ traditional Chinese version of University of Pennsylvania Smell Identification Test.
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Table 2 Comparison of preoperative and postoperative clinical characteristics in group 2
SNOT-20 score MCA2 Smell threshold UPSIT-TC score Saccharine transit time Tympanogram Type B Type C Endoscopic score Bacterial culture rate#
Patient No.
Pre-FESS
35 35 35 35 23 27
34.60 ⫾ 19.22* 0.48 ⫾ 0.18 ⫺3.47 ⫾ 2.75 20.69 ⫾ 8.44 19.17 ⫾ 9.14
34 35
T
1 Ear 7 Ears 5.71 ⫾ 2.33 34.3%
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Post-FESS
25.54 ⫾ 20.69 0.52 ⫾ 0.18 ⫺3.83 ⫾ 2.33 22.43 ⫾ 7.84 15.96 ⫾ 8.93
6 Ears 5.15 ⫾ 1.92 68.6%
p Value 0.001 0.162 0.409 0.134 0.272
0.226 ⬍0.001
*Mean ⫾ SD. # bacterial culture taken from bilateral middle meatus. SNOT-20 ⫽ 20-item Sino-Nasal Outcome Test; MCA ⫽ second minimal cross-sectional area; UPSIT-TC ⫽ traditional Chinese version of University of Pennsylvania Smell Identification Test. Table 3 Comparison of preoperative and postoperative clinical characteristics in group 3
SNOT-20 score MCA2 Smell threshold UPSIT-TC score Saccharine transit time Tympanogram Type B Type C Endoscopic score Bacterial culture rate#
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Patient No
Pre-FESS
Post-FESS
p Value
39 37 39 39 28 31
37.59 ⫾ 20.62* 0.42 ⫾ 0.20 ⫺3.48 ⫾ 2.81 21.10 ⫾ 8.79 16.07 ⫾ 9.98
30.82 ⫾ 19.12 0.58 ⫾ 0.25 ⫺4.50 ⫾ 2.78 22.38 ⫾ 8.28 16.39 ⫾ 9.55
0.024 ⬍0.001 0.024 0.335 0.881
2 Ears 4 Ears 5.82 ⫾ 2.42 59.0%
3 Ears 4 Ears 4.54 ⫾ 1.97 48.7%
39 39
0.001 0.261
*Mean ⫾ SD. #Bacterial culture taken from bilateral middle meatus. SNOT-20 ⫽ 20-item Sino-Nasal Outcome Test; MCA2 ⫽ second minimal cross-sectional area; UPSIT-TC ⫽ traditional Chinese version of University of Pennsylvania Smell Identification Test.
Irrigation Device and Preparation of Irrigation Fluid A Sanvic SH903 pulsatile irrigator (Yun-Wang Industrial Co., Tainan, Taiwan) was used to irrigate nasal cavities in this study. The Sanvic SH903 irrigator is a high-volume delivery device. EWA was generated using a Long-Life YS-A717 water ionizer (Yi Shan Electro Industrial Co., Taichung, Taiwan). Two thousand milliliters of tap water was placed into two containers, and 1 g of sodium
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chloride was equally added into two containers. The solution was electrolyzed to produce EWA. The pH value of EWA was measured using a pH meter and was between 2.3 and 2.5. Next, another 9 g of sodium chloride was added into 1000 mL of EWA to achieve an osmolarity of 309 osmol/L. Neutral NS was prepared from neutral water. Neutral water was generated using a Health Control water ionizer (Yi Shan Electro Industrial Co.). The pH value of neutral water was measured using a pH meter and was between
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Table 4 Bacteriology before and 3 mo after FESS Group
1 (72*) Pre-FESS
Species Aerobic and facultative bacteria Gram-positive Coagulase-negative staphylococci Staphylococcus aureus Streptococcus pneumoniae Streptococcus viridans Corynebacterium spp. Moraxella catarrhalis Gram-positive bacillus Gram-positive coccus Gram-negative Haemophilus influenza Klebsiella pneumonia Klebsiella oxytoca Klebsiella ozaenae Pseudomonas aeruginosa Pseudomonas stutzeri Pseudomonas putida Pseudomonas oryzihabitans Enterobacter aerogenes Enterobacter cloacae Citrobacter koseri Citrobacter freundii Escherichia coli Proteus vulgaris Proteus mirabilis Acinetobacter johnsonii Bacillus cereus Bacillus sp. Nonfermentative Gram-negative bacillus Aeromonas hydrophila Shewanella algae Total aerobic and facultative bacteria Anaerobic bacteria Gram-positive Propionibacterium acnes Propionibacterium sp. Peptostreptococcus magnus Gram-negative Fusobacterium nucleatum Nonfermentative Gram-negative bacillus Total anaerobic bacteria Total bacterial isolates
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2 (70)
After FESS
Pre-FESS
3 (78)
After FESS
Pre-FESS
After FESS
11 11 1
8 15 2
No. of Isolates
12 6
4 8 2
8 5
1 5
2 1
3 2
2
2
1 2
7
5
O N 2 44
1
2
2 2 1
O C 2 4
2 2
2 6
1 1
1 2 2 4 3 4 2 1
3 1
2 2 1
1
1
32
22
1 1 1
2
1 1 5 37
1 1
14 1
T
1
1 1
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1 3 2
1 3 1 2 1 1 1
2 1 2 42
4 16
2 24
52
2 53
44
2
0 52
2 55
0 44
*Number of specimens. FESS ⫽ functional endoscopic sinus surgery.
6.8 and 6.9. Next, 9 g of sodium chloride was added into 1000 mL of neutral water to make the osmolarity of 279 osmol/L.
Postirrigation Assessment Three months after surgery, patients completed another SNOT20 questionnaire. Patients also received acoustic rhinometry, smell test, saccharine transit test, hearing test, nasal bacterial culture, and an endoscopic examination. The comfort of nasal irrigation was measured by using a 10-point visual analog scale with 0 representing least comfort and 10 representing most comfort.
Assessment of Potential Adverse Events of Nasal Irrigation The adverse events of nasal irrigation were assessed subjectively and objectively. Patients were asked to report any adverse event relating to nasal irrigation. Whether nasal irrigation affected smell function, mucociliary function, or E-tube function was evaluated by smell test, saccharine transit test, and hearing test.
Sample Size and Statistical Analysis Sample size was calculated with the study design of one-way ANOVA by use of the PASS software Version 12.0.3 (NCSS, LLC,
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Kaysville, UT). The minimum required sample size was driven by the improvement of SNOT-20 score after 2 months of treatment. A minimum of 36 subjects was required in each study arm to have 90% power (␣ ⫽ 0.05) and an improvement of three scores in SNOT-20. A score change of ⱖ3 is believed to be clinically meaningful according to the results of validation of Taiwanese version of SNOT-20.13 All data were presented as mean ⫾ SD. The sex of patients, bacterial culture rate, rate of prolongation in the saccharine transit time and the rate of prolongation in the saccharine transit time, and impairment rate of E-tube function 3 months after FESS were compared among three groups by Pearson chi-square test. The age of patients, SNOT-20 score, mean MCA2, smell threshold, UPSIT-TC score, saccharine transit time, and endoscopic score were compared by AVONA test. The comfort of nasal irrigation was compared between EAW and NS groups by AVONA test. The pre- and post-FESS SNOT-20 scores, mean MCA2, smell threshold, UPSIT-TC score, saccharine transit time, and endoscopic score were compared by paired samples t-test. The pre- and post-FESS bacterial culture rates were compared by Pearson chi-square test. All computations were performed using SPSS Version 17.0 (SPSS, Inc., Chicago, IL). Two-tailed values of p ⬍ 0.05 were considered statistically significant.
Postoperative Clinical Characteristics among the Three Groups There were no significant differences in postoperative SNOT-20 scores, mean MCA2, smell threshold, UPSIT-TC scores, saccharine transit time, and endoscopic scores among the three groups. The bacterial culture rate was significantly higher in group 2 (p ⫽ 0.037). There were seven patients who refused to receive EAW for nasal irrigation because they experienced irritation in their nose during the nasal irrigation instruction. When asked about the comfort level while using nasal irrigation in patients who finished the 2-month irrigation period, those receiving NS irrigation felt greater comfort than those receiving EAW (p ⬍ 0.001).
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RESULTS
Assessment of Potential Adverse Events of Nasal Irrigation
Patients As shown in Fig. 1, 110 patients were included in the final analysis with 36 in group 1, 35 in group 2, and 39 in group 3. There were 25 men and 11 women in group 1. Their ages ranged from 22 to 71 years old with a mean of 44.9 years. There were 23 male and 12 female subjects in group 2. Their ages ranged from 10 to 71 years old with a mean of 42.8 years. There were 27 male and 12 female subjects in group 3. Their age ranged from 15 to 84 years old with a mean of 45.3 years. There were no significant differences in sex and age among the three groups (p ⫽ 0.93 and 0.77, respectively).
There was no significant difference in preoperative SNOT-20 score, mean MCA2, smell threshold, UPSIT-TC score, saccharine transit time, and endoscopic score among the three groups. The bacterial culture rate was significantly lower in group 2 (p ⫽ 0.011).
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Preoperative and Postoperative Clinical Characteristics
The clinical characteristics before FESS and 3 months after FESS in the three groups are shown in Tables 1–3. In patients receiving EAW irrigation, the SNOT score was significantly lower after irrigation. The mean MCA2 and UPSIT-TC score increased after surgery, but the smell threshold, saccharine transit time, and endoscopic score decreased. The bacterial culture rate was almost the same after surgery. In patients receiving NS irrigation, the SNOT score was significantly lower after irrigation. The mean MCA2 and UPSIT-TC score increased after surgery, but the smell threshold, saccharine transit time, and endoscopic score decreased, although not significantly. The bacterial culture rate decreased after surgery. In patients receiving NS irrigation, the SNOT score was significantly lower after irrigation. The mean MCA2 and UPSIT-TC score increased after surgery, but the smell threshold, saccharine transit time, and endoscopic score decreased, although not significantly. However, the bacterial culture rate significantly increased after surgery. In patients without nasal irrigation, the SNOT score was significantly lower after irrigation. The mean MCA2 significantly increased after surgery and UPSIT-TC score also increased, but not significantly. The smell threshold and endoscopic scores significantly decreased. However, the saccharine transit time increased (not significantly) and the bacterial culture rate decreased after surgery.
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Preoperative Clinical Characteristics
Several adverse events have been reported. One patient complained of loss of smell after completing EAW irrigation but found his sense of smell came back later. No patients complained of loss of smell after completing NS irrigation. Five patients withdrew from the EAW irrigation protocol because of adverse events. Among them, two patients felt their smell was impaired after nasal irrigation for a few days, but their smell returned to normal during follow-up. Two other patients suffered from nasal stuffiness after nasal irrigation for a few days. When nasal irrigation was stopped, the feeling of nasal stuffiness disappeared. The fifth patient reported feeling swollen in his legs after nasal irrigation, but the symptom resolved after stopping irrigation. No adverse event occurred in patients receiving NS irrigation. When the results of smell tests and saccharine transit time were compared before and 3 months after FESS among the three groups, EAW nasal irrigation did not impair smell function or prolong saccharine transit time. Saccharine transit time was prolonged in 13 of 28 (46.4%) patients after EAW irrigation, in 10 of 23 (43.5%) patients after NS irrigation, and in 16 (57.1%) of 28 patients without irrigation 3 months after FESS. The rate of prolongation in the saccharine transit time was not significantly different among the three groups (p ⫽ 0.579). Twenty-nine patients who received EAW irrigation underwent a hearing test. Five ears with type A before FESS became type C after irrigation. Twenty-seven patients who received NS irrigation received the hearing test. One ear with type A before FESS changed to type C after irrigation. Thirty-one patients without nasal irrigation underwent the hearing test. One ear with type A before FESS became type C, and two ears with type A before FESS changed to type B 3 months after FESS. The impairment rate of E-tube function 3 months after FESS (type A changing to type B or C) was not significantly different among the three groups (p ⫽ 0.268).
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DISCUSSION The antibacterial activity of EAW has been investigated in several studies. The active factors responsible for the bactericidal effect of EAW are chlorine-related substances, such as chlorine, hypochlorous acid, and hypochlorous ion.17 Its antibiotic activity can reach as high as 50 times that of hypochlorous acid and kills germs in a short time.18 EAW is considered to be safe for human consumption.17 In addition to its strong antibacterial activity, EAW has other advantages as an irrigating solution. It is minimally invasive to tissue because of its low cytotoxicity, is ecological because its breakdown produces only saline and traces of chlorine gas, and is economical because only tap water and a little salt are needed to produce EAW.8 It has also been shown that EAW can be stored for 21 days without significant changes in pH and oxidation-reduction potential values.17 Therefore, it may have potential as a nasal irrigant for management of CRS. In this study, it was shown that FESS effectively improved patients’ symptoms whether or not postoperative nasal irrigation was performed, but SNOT-20 scores decreased more in patients with nasal
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irrigation than without irrigation. The mean scores decreased from 40.56 to 30.83 (p ⫽ 0.002) in patients with EAW irrigation, from 34.6 to 25.54 (p ⫽ 0.001) in patients with NS irrigation, and from 37.59 to 30.82 (p ⫽ 0.024) in patients without irrigation. Furthermore, nasal irrigation seemed to improve mucociliary function. The mean saccharine transit time decreased in patients with EAW and NS irrigation but increased in patients without irrigation, although all changes were not significant. The saccharine transit time decreased in 50% (14/28) of patients receiving EAW irrigation and in 52.2% (12/23) of patients receiving NS irrigation, but decreased only in 28.6% (8/28) of patients without irrigation. However, no difference was found between patients receiving EAW irrigation and those receiving NS irrigation. It has been shown that EAW has good antibiotic activity for Bacillus subtilis, Enterococcus hirae, Staphylococcus aureus, Staphylococcus epidermidis, and Escherichia coli, and a weaker activity against Streptococcus pyogenes and Pseudomonas aeruginosa.18 When the bactericidal activity of EAW was tested on anaerobes isolated from dental root canals, it had a good effect against anaerobes, but the effect against Streptococcus intermedia, Veillonella parvula, Propionibacterium acnes, and Prevotella melanimogenica was weaker.17 In our previous study, the results showed that EAW could effectively inhibit the growth of bacteria isolated from the nasal secretion, and its antibacterial activity was as effective as 70% alcohol, but our results also showed the antibacterial activity of EWA was weaker against anaerobes than against aerobes.19 In this study, postoperative bacteriology showed EAW irrigation did not inhibit the bacterial growth and more anaerobes grew in patients receiving EAW irrigation (Table 4). Interestingly, significantly higher bacterial growth was found in patients receiving NS irrigation. Whether this resulted from the NS fluid being nonsterile requires further investigation. Because EAW, especially at pH values of 2–3, has been shown to be irritating17 it may have potentially deleterious effects when used as a nasal irrigant. Therefore, we investigated its effects on smell function, mucociliary clearance function, and E-tube function. Our results showed that EAW irrigation might impair smell function but this deleterious effect was temporary. However, EAW irrigation was more irritating and uncomfortable than NS irrigation.
CONCLUSION
3.
4.
5.
6.
7.
8.
9. 10.
11.
12.
13.
14.
15.
16. 17.
18.
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Our results showed that post-FESS nasal irrigation resulted in better outcomes with regard to SNOT-20 scores and saccharine transit times, but EWA irrigation did not confer a greater benefit than NS irrigation in post-FESS care. Although EAW irrigation was more irritating and uncomfortable than NS irrigation, it did not have deleterious effects on smell function, mucociliary clearance function, and E-tube function.
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2.
19.
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