Effectiveness of hypertonic saline irrigation following functional endoscopic sinus surgery: a systematic review and meta-analysis

Abstract

Objectives: This study aimed to clarify the impact of hypertonic solutions on various outcomes, including persistence or reduction of nasal crusts, polypoid edema, and postoperative inflammatory symptoms.

Methods: We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials for studies comparing hypertonic with isotonic saline irrigation after FESS in adult patients with Chronic Rhinosinusitis (CRS). Outcomes were polypoid mucosa, nasal crusts, and variation from the baseline of Sino-Nasal Outcome Test (SNOT) 20/22 and Visual Analog Scale (VAS). For statistical analysis, we used RevMan 5.4.1, and assessed heterogeneity with I² statistics.

Results: We included a total of 479 patients from 7 studies. In the hypertonic saline group, there was a reduction in the nasal crust Risk Ratio (RR) (RR = 0.65; 95% CI 0.49 to 0.87; p = 0.004; I² = 0%) after 30-45 days and severe crusts at 14-21 days (RR = 0.59; 95% CI 0.38 to 0.91; p = 0.02; I² = 0%). Additionally, the persistence of polypoid mucosa was lower in the intervention arm (RR = 0.53; 95% CI 0.43 to 0.65; p < 0.00001; I² = 0%) after 14-21 days. In the symptomatic evaluation hypertonic saline group showed an improvement in postoperative symptoms by a VAS Mean Difference (MD) (MD = -5; 95% CI -5.77 to -4.24; p < 0.00001; I² = 0%) and a SNOT 20/22 Standard Mean Difference (SMD) (SMD = -1.65; 95% CI -2.7 to -0.61; p = 0.002; I² = 93%) reduction from baseline in 30-45 days after the surgery.

Conclusion: Hypertonic saline showed a superior improvement in postoperative evaluation by means of nasal crusting, mucosal healing aspect, and nasal inflammatory symptoms compared with isotonic saline irrigation.

Keywords: Chronic rhinosinusitis; Meta-analysis; Nasal saline solution; Post-operative; Sinus surgery.

Fig. 1

PRISMA flow diagram of study screening and selection.

Fig. 2

(A) The presence of crusts was similar between the hypertonic and isotonic groups after 14‒21 days (p = 0.42). (B) The polypoidal appearance of the mucosa showed a significant risk reduction in the hypertonic solution irrigation group at 14‒21 days (p < 0.00001).

Fig. 3

(A) The presence of crusts showed a significant risk reduction in the hypertonic solution irrigation group at 30‒45 postoperative days (p = 0.004). (B) The polypoidal appearance progressively improved in the hypertonic group after 30‒45 days (p < 0.00001).

Fig. 4

There was a significant improvement in the presence of severe crusts in the hypertonic group after 14‒21 days (p = 0.01).

Fig. 5

The visual analog scale for total nasal symptom score showed a significant reduction from baseline after 14‒21 days (p = 0.0010). The high-pressure/low-volume subgroup did not show significance; the high-volume/low-pressure group exhibited better performance by hypertonic saline in reducing the visual analog scale score.

Fig. 6

The visual analog scale for total nasal symptom score, maintaining a significant reduction from baseline after 30‒45 days (p < 0.00001).

Fig. 7

Sino-Nasal Outcome Test 20/22 after 30‒45 days, maintaining a significant difference compared to the isotonic solution group (p = 0.002).