www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
The
influence
of
standardized
dry
ivy
leaf
extract
on
the
proportion
of
nasal
secretion
after
post-septoplasty
nasal
packing
removal
夽,夽夽
Slobodan
Savovi´
c
a,
Milica
Paut
Kusturica
b,∗,
Vladimir
Kljaji´
c
a,
Maja
Buljˇ
cik ˇ
Cupi´
c
a,
Ljiljana
Jovanˇ
cevi´
c
a,
Vedrana
Pavlovi´
c
c,
Aleksandar
Raˇ
skovi´
c
b aUniversityofNoviSad,FacultyofMedicine,ClinicalCentreofVojvodina,NoviSad,SerbiabUniversityofNoviSad,FacultyofMedicineNoviSad,DepartmentofPharmacologyToxicologyandClinicalPharmacology,Novi Sad,Serbia
cUniversityofBelgrade,FacultyofMedicine,Belgrade,Serbia
Received21December2017;accepted2May2018 Availableonline21June2018
KEYWORDS
Dryivyleafextract; Nasalsecretion; Post-septoplasty nasalpacking removal
Abstract
Introduction:Afterpost-septoplastynasalpackingremoval,acertainproportionofnasal secre-tionoccurs,leadingtolocalandsometimessystemicinfections.
Objective: Theaimwastodetermineifstandardizeddryivyleafextractapplicationafternasal packingremovalinfluencesthereductionofnasalsecretionanddiminishtheoccurrenceoflocal infections.
Methods:Thestudyincluded70post-septoplastypatients(dividedintotwoequalgroups)whose nasal packingwas removedonthethirddayafter theprocedure.GroupIwas treatedwith standardizeddryivyleafextractsyrupalongwithregularnasalirrigationforthefivedaysafter thenasalpackingremovalwhereastheGroupIIhadonlynasallavage.Onthesixthdayafter nasalpacking removal,thequantityofnasalsecretionwasdeterminedusingavisualanalog scaleandnasalendoscopicexamination.
Results:Thegrouptreatedwithstandardizeddryivyleafextractsyruphadsignificantlylesser nasal secretionbothby subjectivepatients’assessment(p<0.001)andby nasalendoscopic examination(p=0.003).Thepost-surgicalfollowupexaminationonthesixthdayafternasal packingremovalshowednodevelopmentoflocalinfectionintheGroupI,whileintheGroup IIalocalinfectionwasevidentinfivepatients(14.29%)andantibiotictherapywasrequired.
夽 Pleasecitethisarticleas:Savovi´cS,PautKusturicaM,Kljaji´cV,Buljˇcik ˇCupi´cM,Jovanˇcevi´cL, Pavlovi´cV,etal.Theinfluenceof
standardizeddryivyleafextractontheproportionofnasalsecretionafterpost-septoplastynasalpackingremoval.BrazJOtorhinolaryngol. 2019;85:685---9.
夽夽PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. ∗Correspondingauthor.
E-mails:milicapaut@yahoo.com,milicakusturica@uns.ac.rs(M.PautKusturica).
https://doi.org/10.1016/j.bjorl.2018.05.005
1808-8694/©2018Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
Conclusion:Theuseofthestandardizeddryivyleafextractafternasalpackingremoval signi-ficantlylowerstheproportionofnasalsecretion.
© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE
Extratodefolhaseca dehera;
Secrec¸ãonasal; Remoc¸ãodetampão nasal
pós-septoplastia
Ainfluênciadoextratodefolhadeherasecanasecrec¸ãonasalapósremoc¸ãode
tampãonasalpós-septoplastia
Resumo
Introduc¸ão:Apósaremoc¸ãodotampãonasalpós-septoplastia,ocorreproduc¸ãodesecrec¸ão nasal,predispondoinfecc¸õeslocaise,porvezes,sistêmicas.
Objetivo:Determinar se aaplicac¸ãodo extratopadronizadode folhasde hera secaapósa remoc¸ãodotampãonasalinfluenciaareduc¸ãodasecrec¸ãonasalediminui aocorrênciade infecc¸õeslocais.
Método: Oestudoincluiu70pacientespós-septoplastia(divididosemdoisgruposiguais)cujo tampãonasalfoiretiradonoterceirodiaapósoprocedimento.OgrupoIfoitratadocomxarope padronizadodeextratodefolhasecadeherajuntamentecomirrigac¸ãonasalregularporcinco diasapósaremoc¸ãodotamponamentonasal,enquantoaogrupoIIfoirecomendadaapenas lavagemnasal.Nosextodiaapósaremoc¸ãodotampãonasal,aquantidadedesecrec¸ãonasal foideterminadapelaescalaEVA(escalavisualanalógica)epeloexameendoscópiconasal. Resultados: Ogrupotratadocomxaropedeextratosecodefolhasdeheraapresentousecrec¸ão nasalsignificativamentemenortantopelaavaliac¸ãosubjetivadospacientes(p<0,001)quanto peloexameendoscópiconasal(p=0,003).Oexamedeacompanhamentopós-cirúrgiconosexto dia após a remoc¸ão do tampão nasal não mostrou desenvolvimento de infecc¸ão local nos pacientesdogrupoI, enquantoquenogrupo IIcincoapresentaram sinaisdeinfecc¸ãolocal (14,29%)comnecessidadedeantibioticoterapia.
Conclusão:Ousodoextratopadronizadodefolhassecasdeheraapósaremoc¸ãodotampão nasalreduzsignificativamenteaproduc¸ãodesecrec¸ãonasal.
© 2018 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Septoplastyisoneofthemostcommonsurgeriesamongall ENT(ear,nose,andthroat)surgeriesintheUS.1
In order to have a better control over post-surgical bleeding, to preventthe occurrence of hematoma of the nasal septum as well as post-surgical adhesion and to maintainnasalseptumstabilizationafterseptoplasty, ante-riornasalpackingisthemostfrequentpractice.However, there are no standardized opinions on the need of the classicnasal packing afterseptoplasty, the typeof mate-rial used as well as its duration.2 Numerous authors do
not recommend nasal packing after septoplasty due to a numberof discomforts during the packingitself, the fear and the pain while packing removal from the nose as wellassomepossiblesystemiccomplications.Also,no sig-nificant difference was found between the patients who underwentnasal packingand the patients whodidnot in terms of post-surgical bleeding, occurrence of nasal sep-tum hematomas and post-surgical adhesions.3---5 Bernardo
etal.concludedthatroutineanteriornasalpackingwasnot beneficialandthatitcanincreasemorbidityandpotential complications.6
Afternasalpacking removal,thepatients usually com-plain about numerous problems, most commonly the presence of excess nasal secretion. This secretion is usu-allytheconsequenceofthenasalpackingwhichhasbeenin directcontactwithnasalmucosa,leadingtoanaugmented secretionproductionandthelossofcilia.7Decreased
num-ber and a weakened function of cilia are followed by a decrease of mucociliar clearance that hardens secretion elimination. When there is secretion in the nasal cavity, localinfection maytrigger anasal septumabscess, which can result in systemic infection complications and life-threateningconditionssuchas:cavernoussinusthrombosis, meningitis,brainabscessandother.8Numerousstudieshave
demonstrated that infections are rare after an elective nose surgeryin otherwisehealthypatients.9 Forexample,
Canielloetal.haveconcludedthatseptoplastyisthe pro-cedurethatdoesnotrequireprophylacticuseofantibiotics due to a very low post-surgical risk of an infection.10 On
theotherhand,Rechtwegetal.havefoundthat66%outof thequeriedotorhinolaryngologistsroutinelyusedantibiotics afteraseptoplastyinordertopreventapost-surgical infec-tionortoavoidatoxicshocksyndrome.11However,theuse
toxicreactionsandenormouscosts.Furthermore,the inci-dence ofan allergic reactionis present in 0.7% to10%of the cases,and deathcan occur in oneout of twenty-five thousandpatients.12
Standardized dry ivy leaf extractis a safe secretolytic that hasbeen in long-term use todecreasesecretion vis-cosityandsecretioneliminationfromrespiratoryairways.13
Also,the dry ivyleaf extractis well-known for its antiin-flammatoryeffect.14
Theaimofthisstudywastoexplorewhethertheuseof secretolytics afterpost-septoplasty nasal packingremoval influences the proportion of nasal secretion, as well as whethertheuseofsecretolyticshasanimpactonlocal infec-tion occurrence of the nose and the paranasal sinuses in thepost-surgicalperiodinwhichtheuseofantibioticswas indicated.
Methods
ThestudywasperformedattheENTClinic,ClinicalCentre ofVojvodinaandapprovedbyEthicalcommitteeofFaculty ofMedicine, NoviSad (11.05---2006).Itwasan open-label, prospectiveand randomizedstudy.The research was per-formedaccordingtotheHelsinkideclarationprinciples.The patientswereinformedabouttheresearchandsignedthe informedconsent after havingunderstood theprocedure. Allthe patientswerefreetoquit theparticipationin the studyatanymoment.
Sample size calculation was based on requirement to revealdifferencesinthesubjectiveandendoscopic assess-ment of the quantity of nasal secretion between two treatmentoptions,usingtheMann---Whitneytest.The suf-ficienttotalsamplesizes providingat least0.8powers,at 0.05significancelevel,torevealanaveragedifferencesin subjective assessment scoreof 2 and endoscopicscoreof 1,were38and42 subjects,respectively.Sample size cal-culationwasconductedusingtheRpackage‘‘WMWssp’’.15
Patientsinvolved intheresearch(47 menand23 women) ranged in age from18 to56. All thepatients included in the study had undergone a septoplasty due tonasal sep-tum deformity and were diagnosed on the basis of their case histories,anteriorrhinoscopy,nasalendoscopy, ante-riorrhinomanometryandacousticrhinometry.Thepatients with allergicrhinitis, chronic rhinosinusitis, nasal polypo-sis,knownimmunodeficientstatusaswellasthosewhohad undergone any kind of nose or paranasal surgeriesin the pastwerenotincludedinthestudy.Also,thepatientswho underwentinferiorturbinoplastywerenotincluded in the study.
Thesurgerieswereperformedundergeneralanesthesia with orotracheal intubation and had anteriornasal pack-inginserted.Septalcartilageinthecollumelarpocketwas fixatedbyVicryl(3---0)suturesinallthepatients,while hemi-transfixion was fixated by silk (2---0) sutures. Silk sutures were removed onthe seventhday after septoplasty. The nasalpackingwasdonewithvaselinegauzedressing.Nasal splintswerenotusedinanypatients.Allthepatientshadthe nasalpackingremovalonthethirdpostsurgicalday. Antibi-oticswerenotadministeredtoanyofthem.Forthepurpose ofthestudy,dryivyleafextractsyrup[Prospan®Syrup (con-taining7mgofdryivyleafextract/mL)]wastakenorally.
The patients were randomly divided into two equal groupsof35patients.Thefirstgroup(GroupI)consistedof 35patients(23menand12women)whousedsalinenasal lavage(5timesaday10mLineachnostril)alongwithtaking standardizeddryivyleaf extractsyrup,for fivedaysafter nasalpackingremoval.They weretreated with105mgof dry ivy leaf extract (15mL of syrups a day) divided into threedosesof5mL(oneteaspooni.e.35mgofdryivyleaf extract).The other group (Group II) consisted of 24 men and11women.Theyhadonlynoselavageforfivedaysafter nasalpackingremoval.Onthesixthday, thepatients esti-matedthe quantity of nasalsecretionafter nasalpacking removalonthe0---10 scale, 0beingsecretionfree and10 beingtotallysecretionobstructed.Also,onthesixth post-nasal packing removalday, nasal endoscopic examination wasdonetodeterminethedegreeofsecretion.
Thesecretionproportionwasassessedonthe0---4scalein which0indicatedtheabsenceofsecretion,1smallamount, 2moderate,3moderatetolargeamount,4massive.10
StatisticalanalysiswasperformedwithIBMSPSSStatistics 21.Resultswerepresentedasarithmeticmean,medianand measuresofvariability(standarddeviationandrange). Stu-dent’st-testandnon-parametricMann---Whitneytestwere usedtotestthedifferencesinnumericalfeaturesbetween twoindependentsamples.Thechisquaretestwasusedto testthedifferencesbetweennominaldata.Spearman cor-relationcoefficientwascomputedtoassesstherelationship betweentwovariables.Allp-values<0.05wereconsidered significant.
Results
Group I (patients who received standardized dry ivy leaf extractsyrupafternasalpackingremovalandnasallavage) consistedof23 menand12 womenof theaverage ageof 32.80,whileGroupII(onlythenasallavage)consistedof24 menand11womenoftheaverageageof30.06.Therewere nosignificantlystatisticaldifferencesin gender(p=0.799) andage(p=0.960)betweenthetwoexaminedgroups.
Significantlyhighervaluesin nasalsecretionsubjective assessmentwere registered onthesixth post-surgicalday inGroupII(receivedonlymedicalnoselavage)in compari-sonwithgroupI(receivedstandardizeddryivyleafextract syrup)(Z=4.188,p<0.001)(Table1).Also,inGroupII sta-tistically significant greater secretion values were found endoscopicallyonthesixthdayafternasalpackingremoval (Z=3.014, p=0.003) in relation tothepatients whowere givenstandardizeddryivyleafextractalongwiththenasal lavage---GroupI(Table2).
Table 1 Subjective assessment of the quantityof nasal secretion.
Group ¯x Median SD Min Max
I 1.34 1.00 1.23 0 5
II 3.29 3.00 2.07 0 8
Total 2.31 2.00 1.95 0 8 GroupI,standardizeddryivyleafextractandnasallavagegroup; GroupII,onlynasallavagegroup.
Table 2 Endoscopic finding of the quantity of nasal secretion.
Group ¯x Median SD Min Max
I 0.69 1.00 0.76 0 2
II 1.46 1.00 1.12 0 4
Total 1.07 1.00 1.03 0 4 GroupI,standardizeddryivyleafextractandnasallavagegroup; GroupII,onlynasallavagegroup.
Positive correlation wasfound between the subjective assessmentandnasalendoscopicfindingsofnasalsecretion in both groups of patients: Group I (=0.956, p<0.001), GroupII(=0.731,p<0.001).
The post-surgical follow up examination on the sixth dayafternasalpackingremovalshowednodevelopmentof localinfectioninGroup Iandnoneed for antibiotic ther-apy, while in Group II a local infection developed in five patients(14.29%)andantibiotictherapywasrequired.This differencewasstatisticallysignificant(x2=5.385,p=0.020).
Systemicinfectionwasnotdevelopedinanyoftheexamined patients.
Discussion
Likeanyother surgicalprocedure, septoplastycanbe fol-lowed by possible complications, such as local infection that can occur in the surgical region or very rarely sys-temicinfections asmeningitis,cavernous sinus trombosis, brainabscess,whichcanbelife-threatening.16Basedonthe
literature data Georgiou et al. concluded that infections occurredveryrarely afterelectivesurgeries inrhinology.9
Duringor afterthe septoplasty, mostauthors didnot find asignificantdifferenceininfectionfrequencybetweenthe patientstreatedwithantibioticsandthosenottreatedwith antbibiotics.10,17,18 Ricci and Ascanio and Caniello et al.
have not revealed any statistically significant difference in the proportion of purulent secretion, which is consid-ered a sign of the local infection, between the patients whowerepost-surgically administeredantibiotics andthe oneswhowerenot.10,19Moderatetolargeormassive
secre-tionquantity (stages3 and4) wasnotobserved in anyof the patients in both groups. However, in the study con-ductedbyLiljaetal.itwasnoticedthattheinfectionwas morefrequent inthe patientswho werenottreated with antibiotics.Inthegroupofsurgicalpatients,3nasalseptum abscesseswerefound,andnoneofthemweretreatedwith antibiotics.18 However,thedifferencebetween thegroups
wasnotstatisticallysignificant,whichcanbeexplainedby a small number of examined patients. Gioacchini et al. have concluded that there was no need for routine use ofantibioticsafterseptoplasty,exceptin somecasessuch as cardiosurgical interventions, immunosuppresive condi-tions and similar procedures.20 In our study, antibiotics
werenotadministeredtoanypatientafterseptoplasty.The vastmajorityofrhinologistsuseclassicnasalpackingafter septoplasty, primarily to prevent the occurrence of post-surgical bleeding, synechiae and hematoma of the nasal septum.20,21
Inourstudy,everypatientunderwentclassicnasal pack-ingwhichwasremovedonthethird post-surgicalday.The patientsoftencomplainedaboutthenasalpackingremoval secretion.Thissecretionismostfrequentlytheconsequence ofpriornasalpackingpresencethatwascloselyconnected to nasal mucosa,leading to mucosal damage,the loss of cilia and increased secretionproduction.7,22 Ohashi et al.
havefoundthatrecoveryafternasalmucosainjuryoccurred afterfivedaysunlessthebasementmembranewasinjured along withthe basal cells.23 Otherwise, the ciliary
appa-ratus willstart regenerationthreeweeks aftertheinjury, andtotalrecoverycanbeexpectedin6weeks.Kulaetal. havenotfoundthatnasalpackingleadstotheciliary appa-ratusofnasalmucosadamage.21However,theexamination
wasperformed6weeksafterthenosesurgerywhennasal mucosawasalreadyfullyrecovered. Thedecreaseofcilia numberandtheirweakenedfunctionresultedindecreaseof mucociliaryclearance,whichhardenedtheincreased secre-tionquantityelimination.Whenthissecretioniseliminated fromnasalcavity,asismentionedbefore,localinfections, nasalseptumabscessesandsomelife-threateningconditions maydevelop.
In the present study, the patients who were adminis-teredstandardizeddryivyleafextractsyrupalongwithnasal lavagereportedastatisticallysignificantlesserquantityof nasalsecretionincomparisontothosewhohadundergone nasal lavageonly. Also,the nasalendoscopic examination onthesixthdayafternasalpackingremovalshowed statis-tically significant lesser quantityof nasal secretionin the patients whowereadministered standardized dry ivyleaf extractsyrupalongwithnasallavage.Inaddition,wefound astatisticallypositivecorrelationbetweensubjectivenasal secretionassessmentbythepatientsthemselvesandnasal endoscopicfindingsinbothgroupsofpatients.Inthegroup that underwent nasal lavage only, five patients required antibiotictherapyonthesixthdayafterthenasalpacking removal.Inthegroupthatreceivedstandardizeddryivyleaf extract, antibiotic therapy was not required. This differ-encewasstatisticallysignificant.Theguidelineforantibiotic therapyintroductionwastheoccurrenceofpurulent secre-tioninthenosealongwithelevatedbodytemperature(over 38◦C)andthefeelingofpainorfacialpressure,especiallyon onesideoftheface.24Similarresultswereobtainedby
Fed-erspil etal.whotreatedacutenon-purulentsinusitiswith secretolytic Myrtolandvasoconstrictorxylometazolinefor 6daysapproximatelyin onegroup,while theother group receivedplacebo along withvasoconstrictor.25 In the
Myr-tolgroup7.3%ofpatientsrequiredantibiotictherapy,while in the placebo group antibiotic therapy was necessary in 12.6%patients.Tarantinoetal.reportedtheadvantageof secretolyticadministrationincomparisontoplaceboin elim-inatingnasalsecretioninpatientswithrhinosinusitis,while Szmejaetal.have confirmedthatsecretolytic administra-tionalong withstandard therapy shortenstheduration of recovery inrhinosinusitispatients.26,27 On theother hand,
Van Bever et al. have not confirmed the advantage of secretolyticadministrationcomparedtosaline administra-tionineliminatingnasalsecretioninjuvenilepatientswith rhinosinusitis.28
Consideringthatthesurgicalprocedurecausesgreateror lesserdamageofmucociliaryclearance,andconsequently greaterorlessernasaldischarge,weareoftheopinionthat
theadministrationof Prospan® wouldbe usefuldue toits secretolyticandanti-inflammatoryeffects,eveninpatients whodidnotundergonasalpackingafterseptoplasty.
Inourstudy,noneofthepatientswhowereadministered standardized dry ivyleaf extractsyrup havereported any gastrointestinalor other sideeffects.These resultsarein confirmation of the studies of other authors and confirm a good tolerance and no digestion problems with herbal secretolytics.13,25
Conclusions
Toconclude,inthepresentresearch,standardizeddry ivy leafextractadministrationafterremovingpost-septoplasty nasalpacking,alongwithstandardnasallavage,significantly decreasestheproportionofnasalsecretionandthus dimin-ishes the possibilityof localinfectionoccurrence and the needforantibiotictherapy.However,despitetheresultsof ourstudy,majorstudiesneedtobeconductedin orderto confirmourfindings.
Funding
This work was supported by the Ministry of Science and TechnologicalDevelopment,RepublicofSerbia,Projectno. 41012.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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