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Communications to the Editor |

A Reappraisal of Nasal Saline Solution Use in Chronic Sinusitis FREE TO VIEW

Hanifi Kurtaran; Ahmet Karadag; Ferhat Catal; Zekai Avci
Author and Funding Information

Affiliations: Fatih University Faculty of Medicine Ankara, Turkey,  Chang Gung Children’s Hospital Taoyuan, Taiwan

Correspondence to: Ahmet Karadag, MD, Ceyhun Atif Kansu Cad. 343/11 06460, Balgat Ankara, Turkey; e-mail: kara_dag@hotmail.com



Chest. 2003;124(5):2036-2038. doi:10.1378/chest.124.5.2036
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Published online

To the Editor:

We read with interest the article by Tsao et al1 in the March 2003 issue of CHEST. Although we agree with the idea that the chronic sinusitis that ensues concomitantly in children with mild asthma and allergic rhinitis should definitely be treated, we have some objections to the aggressive treatment methods they have recommended.

First of all, saline solution nasal washing certainly facilitates nasal drainage and cleans the airway from any postnasal discharge24 ; however, it can be effective when applied appropriately. As described in the aforementioned studies, saline solution is applied (five drops in each nostril) at least four times a day (before going to bed, in the morning, and twice before feeding) until the symptomatology subsides. In the study by Tsao et al,1 nasal saline solution was applied once a week, whereas the technique was not designated. At this point, one can reasonably speculate that inappropriate saline solution administration could have a role in the worse treatment outcome when compared to groups of children treated with antibiotics.

There is still much debate on the use of antibiotics in chronic sinusitis treatment; as opposed to Tsao et al,1 there are studies57 that have shown the ineffectiveness of either topical or systemic use of antibiotics in chronic sinusitis. Besides, antibiotics are widely known allergens and can readily cause allergic reactions in this atopic group of asthmatic patients. Asthma exacerbations have been reported during various antibiotic treatments including amoxicillin.89 Moreover, it has also been mentioned that the use of antibiotics can even bring about asthma in early childhood.10 Thus, we strongly underscore the necessity of a delicate decision before utilizing antibiotics in asthmatic children.

Overall, the treatment strategy for asthmatic children with chronic sinusitis has not been established. Antibiotics—with their high costs, possible side effects, disputed treatment outcomes, and likely contribution to asthma pathogenesis—comprise one group of treatment alternatives. However, nasal saline solution—with the evidence of its beneficial effects in the treatment of upper respiratory tract infections and acute sinusitis24— is a cheap and convenient way of treating these patients. We do imply that placebo-controlled cohort trials are obviously awaited for rendering its success in the treatment of concurrent asthma and chronic sinusitis in children.

References

Tsao, CH, Chen, LC, Yeh, KW, et al (2003) Concomitant chronic sinusitis treatment in children with asthma: the effect on bronchial hyperresponsiveness.Chest123,757-764. [CrossRef] [PubMed]
 
Topal, B, Özsoylu, Ş Are antibiotics required for the treatment of acute sinusitis in children?Yeni Tip Dergisi2001;18 (suppl),58-60
 
Karadag, A Nasal saline for acute sinusitis [letter].Pediatrics2002;109,165-928
 
Ozsoylu, S. Nose drops at the common cold [letter]. Eur J Pediatr. 1985;;144 ,.:294. [PubMed]
 
Sykes, DA, Wilson, R, Chan, KL, et al Relative importance of antibiotic and improved clearance in topical treatment of chronic mucopurulent rhinosinusitis: a controlled study.Lancet1986;16,359-360
 
Otten, FW Conservative treatment of chronic maxillary sinusitis in children: long term follow up.Acta Otorhinolaryngol Belg1997;5,173-175
 
Stalman, W, van Essen, GA, van der Graaf, Y, et al Maxillary sinusitis in adults: an evaluation of placebo-controlled double blind trials.Fam Pract1997;14,124-129. [CrossRef] [PubMed]
 
Ventura, MT, Di Corato, R, Dagnello, M, et al Latex and amoxicillin-induced asthma.Allergy2000;55,587-588. [CrossRef] [PubMed]
 
Sastre, J, Quirce, S, Novalbos, A, et al Occupational asthma induced by cephalosporins.Eur Respir J1999;13,1189-1191. [CrossRef] [PubMed]
 
Wickens, K, Pearce, N, Crane, J, et al Antibiotic use in early and the development of asthma.Clin Exp Allergy1999;29,766-771. [CrossRef] [PubMed]
 
To the Editor:

We appreciate the recommendation regarding the method of nasal washing for patients with chronic sinusitis. From the results of our study1 and Oliveria et al,2 nasal saline solution irrigation can be safely used for symptom relief without any influence on bronchial hyperreactivity (BHR) in asthmatic children with concomitant chronic sinusitis; however, we cannot neglect the possibility of a different method of nasal saline solution irrigation influencing the result of our study.

Sinusitis is not uncommon in asthmatic patients. As mentioned by Karadag et al, there is still much debate on antibiotic treatment for chronic sinusitis. However, some studies35 have shown that children with asthma had remarkable improvement of lower airway symptoms and pulmonary function after diagnosis and concomitant treatment of sinusitis. The impressive result of our study1 also reveals a trend. For mild asthmatic children with concomitant chronic sinusitis, if aggressive antibiotic treatment is provided there is significant improvement on symptoms and BHR. From this point of view, for those asthmatic children who show an unpredictable response to appropriate treatment, earlier intervention and treatment for chronic sinusitis will not only lower the cost for unnecessary medications for asthma control but will also resolve the concomitant sinusitis problem.

A marked increase in allergic diseases has been linked to the hygiene environment in early infancy. Infants exposed to more children at home or day-care experienced less frequent wheeze from year 8 through year 13 and were less likely to have elevated serum IgE levels.6 Improved hygiene in industrialized societies and the use of vaccine and antibiotics have been reported to reduced the incidence of infections that would normally stimulate the immune system in some way that mitigates against asthma.7 Whether exposure to endotoxin (lipopolysaccharide), a potent inducer of interleukin-12 and interferon-γ, is protective or harmful is likely to depend on a complex mixture of timing of exposure during the life cycle, environmental cofactors, and genetics. In both animal models and studies in humans, exposure to endotoxin early in life, during the development of the immune system, seems to be most important in providing protection against the development of allergic disease.8 For older children, the use of antibiotics should not bring about increased allergic diseases.

References
Tsao, CH, Chen, LC, Yeh, KW, et al Concomitant chronic sinusitis treatment in children with mild asthma: the effect on bronchial hyperresponsiveness.Chest2003;123,757-764. [CrossRef] [PubMed]
 
Oliveria, CAA, Sole, D, Naspitz, CK, et al Improvement of bronchial hyperresponsiveness in asthmatic children treated for concomitant sinusitis.Ann Allergy Asthma Immunol1997;79,70-74. [CrossRef] [PubMed]
 
Rachelefsky, GS, Katz, RM, Siegel, SC Chronic sinus disease with associated reactive airway disease in children.Pediatrics1984;73,526-529. [PubMed]
 
Friedman, R, Ackerman, M, Wald, E, et al Asthma and bacterial sinusitis in children.J Allergy Clin Immunol1984;74,185-189. [CrossRef] [PubMed]
 
Slavin, RG Relationship of nasal disease and sinusitis to bronchial asthma.Ann Allergy1982;49,76-79. [PubMed]
 
Ball, TM, Holberg, CJ, Martinez, FD, et al Exposure to siblings and day care during infancy and subsequent development of asthma and frequent wheeze.N Engl J Med2000;343,538-543. [CrossRef] [PubMed]
 
Strachan, DP Hay fever, hygiene, and number of siblings.BMJ1989;299,1259-1260. [CrossRef] [PubMed]
 
Weiss, ST Eat dirt: the hygiene hypothesis and allergic diseases.N Engl J Med2002;347,930-931. [CrossRef] [PubMed]
 

Figures

Tables

References

Tsao, CH, Chen, LC, Yeh, KW, et al (2003) Concomitant chronic sinusitis treatment in children with asthma: the effect on bronchial hyperresponsiveness.Chest123,757-764. [CrossRef] [PubMed]
 
Topal, B, Özsoylu, Ş Are antibiotics required for the treatment of acute sinusitis in children?Yeni Tip Dergisi2001;18 (suppl),58-60
 
Karadag, A Nasal saline for acute sinusitis [letter].Pediatrics2002;109,165-928
 
Ozsoylu, S. Nose drops at the common cold [letter]. Eur J Pediatr. 1985;;144 ,.:294. [PubMed]
 
Sykes, DA, Wilson, R, Chan, KL, et al Relative importance of antibiotic and improved clearance in topical treatment of chronic mucopurulent rhinosinusitis: a controlled study.Lancet1986;16,359-360
 
Otten, FW Conservative treatment of chronic maxillary sinusitis in children: long term follow up.Acta Otorhinolaryngol Belg1997;5,173-175
 
Stalman, W, van Essen, GA, van der Graaf, Y, et al Maxillary sinusitis in adults: an evaluation of placebo-controlled double blind trials.Fam Pract1997;14,124-129. [CrossRef] [PubMed]
 
Ventura, MT, Di Corato, R, Dagnello, M, et al Latex and amoxicillin-induced asthma.Allergy2000;55,587-588. [CrossRef] [PubMed]
 
Sastre, J, Quirce, S, Novalbos, A, et al Occupational asthma induced by cephalosporins.Eur Respir J1999;13,1189-1191. [CrossRef] [PubMed]
 
Wickens, K, Pearce, N, Crane, J, et al Antibiotic use in early and the development of asthma.Clin Exp Allergy1999;29,766-771. [CrossRef] [PubMed]
 
Tsao, CH, Chen, LC, Yeh, KW, et al Concomitant chronic sinusitis treatment in children with mild asthma: the effect on bronchial hyperresponsiveness.Chest2003;123,757-764. [CrossRef] [PubMed]
 
Oliveria, CAA, Sole, D, Naspitz, CK, et al Improvement of bronchial hyperresponsiveness in asthmatic children treated for concomitant sinusitis.Ann Allergy Asthma Immunol1997;79,70-74. [CrossRef] [PubMed]
 
Rachelefsky, GS, Katz, RM, Siegel, SC Chronic sinus disease with associated reactive airway disease in children.Pediatrics1984;73,526-529. [PubMed]
 
Friedman, R, Ackerman, M, Wald, E, et al Asthma and bacterial sinusitis in children.J Allergy Clin Immunol1984;74,185-189. [CrossRef] [PubMed]
 
Slavin, RG Relationship of nasal disease and sinusitis to bronchial asthma.Ann Allergy1982;49,76-79. [PubMed]
 
Ball, TM, Holberg, CJ, Martinez, FD, et al Exposure to siblings and day care during infancy and subsequent development of asthma and frequent wheeze.N Engl J Med2000;343,538-543. [CrossRef] [PubMed]
 
Strachan, DP Hay fever, hygiene, and number of siblings.BMJ1989;299,1259-1260. [CrossRef] [PubMed]
 
Weiss, ST Eat dirt: the hygiene hypothesis and allergic diseases.N Engl J Med2002;347,930-931. [CrossRef] [PubMed]
 
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