European Journal of Cardiovascular Medicine

One of major defense mechanisms of nose and paranasal sinuses against infection is the mucociliary system. Normal mucociliary function (MCF) in all areas of the nose except for the most anterior part of the septum and inferior concha is directed to the nasopharynx.¹ Mucociliary dysfunction can be a significant clinical problem and has been reported in many inflammatory diseases of the airway.²

MCF has been evaluated thoroughly by endoscopic studies and has been shown the direction of MCF in each sinus follows a constant and specific method. In recent research, MCF in the site of operation and in the postoperative period did not follow the usual mucus transport pattern.³ Mucociliary stasis is usually localized to ethmoid sinus and it is more common in patients with persistent or recurrent sinusitis after surgery and this issue is caused by a negative local factor such as inflammation, bacterial colonization, and trauma of surgery.⁴

The saccharin test is a simple and effective way of assessing nasal mucociliary clearance. The time is taken from the placement of the saccharin particle on the inferior turbinate until the perception of sweet taste sensation by the patient is recorded in minutes and taken as the mucociliary clearance time. The advantage of measurement of NMCT by the saccharine method is that it is free from observer variations, has no side-effects, simple to carry out and requires no elaborate equipment.  The present study was done to assess the changes in mucociliary transport following nasal surgeries in patients with having nasal obstruction due to various pathologies like deviated nasal septum, nasal polyps, inferior turbinate hypertrophy, and sinusitis.

Present study was single-center, prospective, observational study, conducted in Department of ENT, Government Medical College and hospital Nandurbar, Maharashtra, India. Study duration was of 20 months from Jan 2023 to Aug 2024. Study was approved by institutional ethical committee.

Inclusion criteria

• Patients between age 6 - 65 years age, with symptomatic for nasal obstruction, underwent nasal surgeries, willing to participate in present study

Exclusion criteria

• Patients with age below 6 year and above 65
• Patients having postoperative complications like synechiae, septal perforation within 3 months.
• Craniofacial
• Malignancy of nose and

Study was explained to participants in local language & written informed consent was taken. For all patients, a detailed history was taken regarding complains, history of present illness with a special note of presence or absence of symptoms, like nasal obstruction, headache, nasal discharge, nasal bleeding, loss of smell and other associated manifestations. Detailed general physical examination and ENT examination and diagnostic nasal endoscopy were done on all the patients. All patients underwent routine blood investigations & X-ray paranasal sinus waters view, CT scan paranasal sinus, were done whenever indicated.

Mucociliary transport was evaluated using the saccharin method. The patients were explained about the details of the Procedure and were asked to blow the nose to remove any excessive secretions. No mucolytic agents or topical preparations were used in the nose prior to the measurement of the saccharine time. Saccharin particle (5mg) was placed over the anterior end of the inferior turbinate. The time from the placement of the particle to the time until the perception of sweet taste sensation by the patient was recorded and taken as the clearance time. The subject was asked not to sniff, exhale deeply or sneeze during the test period. After a waiting period of 90 minutes, the same procedure was repeated on the opposite nostril and clearance time was recorded in minutes. Patients who failed to register a sweet taste within 90 minutes were excluded since they were empirically considered to have an impaired sense of taste or not to understand the test procedure.

Patients with symptomatic deviated nasal septum or sinusitis, nasal polyposis, inferior turbinate hypertrophy having complained of nasal obstruction were subjected to surgeries for nasal obstruction relief. All the patients were reviewed postoperatively after 1 week and then at 6 weeks. During this visit, the Patients underwent a rigid nasal endoscopy to assess the postoperative cavity. Postoperative test of mucociliary clearance with saccharine testing was performed during this visit.

Data was collected and compiled using Microsoft Excel,  analysed using SPSS 23.0 version. Statistical analysis was done using descriptive statistics

The study was conducted in patients attending ENT OPD/admitted patients having complaints of nasal obstruction due to deviated nasal septum, inferior turbinate hypertrophy, sinusitis, nasal polyposis in the tertiary care center. The most common Age group in present study was 16-25 years (41.1%) followed by 26- 35 years (25.5%),followed by 36-45 years(17.8%),followed by 46-55 years (6.7%), followed by 56-65 and 5-15 years (4%). There were 65 males and 25 females in the study. M: F ratio- 2.6:1.

Table 1: General characteristics

In present study, Nasal obstruction was the most common presenting complaint (100%) followed by headache (52%) followed by nasal discharge (48.9%) and sneezing (37.8%).

Table 2: Symptoms of patients

In present study, the most common anterior rhinoscopy sign was DNS (60.7%) followed by discharge which was (52.2%). While the least common finding was ITH.

Table 3: Clinical signs on anterior rhinoscopy

In present study, Diagnostic Nasal Endoscopy was done to confirm the findings of anterior rhinoscopy and to know any additional findings that are missed on anterior rhinoscopy. There are 6 posterior DNS and 7 nasal polyps that were additionally diagnosed on DNE. Congested mucosa was present in 88% of patients. On DNE most common findings was DNS (73.3%) followed by discharge (63.3%). In present study, the most common diagnosis was DNS (53.3%) followed by antrochonal polyp (27.8%) while the least patients were having maxillary +ethmoid sinusitis with DNS (3.3%).

Table 4:  Diagnostic nasal endoscopy findings

In present study, the most common surgery done was SMR (53.4%) followed by Polypectomy by FESS for Ac polyp (21.1%).

Table 5: Showing disease and surgeries performed

In present study mean MCT preoperatively was maximum for maxillary+ ethmoid sinusitis with DNS was 23.75 min while the least mean MCT was for AC polyp right 12.14 min. Average MCT postoperative 1 week was maximum for axillary+ethmiod sinusitis with DNS 17.75 min, while the least average, MCT was for AC polyp with DNS 11.85 min. Average MCT postoperative 6 weeks was maximum for maxillary+ethmiod sinusitis with DNS 13.15 min, while the least average, MCT was for AC polyp with DNS 10.16 min.

In present study, there was the maximum improvement in average MCT postoperatively after 1 week in pt of maxillary+ethmiod sinusitis, while the least improvement was in patients with pansinusitis with DNS. There was the maximum improvement in average MCT postoperatively after 6 weeks in patients of maxillary+ethmiod sinusitis, while the least improvement was in patients with pansinusitis with DNS.

Table 6: Comparison of average MCT preoperatively with average MCT post operatively after 1 week and 6 week in minutes

There was 100% improvement in patients having AC polyp right side with DNS, AC polyp left side with DNS, Chronic right maxillary +ethmoid sinusitis, Chronic right maxillary +ethmoid sinusitis with DNS, ethmoidal polyposis, ethmoidal polyposis with DNS. While the least improvement was in Chronic Pansinusitis with DNS, 50% of cases show no improvement while 50% worsening of MCT. While the least improvement was in Chronic Pansinusitis with DNS, 50% of cases show no improvement while 50% worsening of MCT.

Table 7: Final outcome status of each procedure for postoperative 6 week MCT in minutes

Nasal mucociliary clearance of nose and paranasal sinuses is an important defense mechanism that protects them from any physical and biological insults. Any structural abnormalities of the nose like deviated nasal septum, turbinate hypertrophy and polyps can easily damage the mucociliary clearance. Impairment of this defensive mechanism can lead to obstruction of osteomeatal complex and hence rhinosinusitis.

In the present study, 90 patients, 65 were male and 25 were females. The most common age group was 16-25 years. In the present study Male were more as compared to females with M: F ratio 2.6:1. Gender has no effect on nasal mucociliary clearance which was comparable to a study by K Tamilselvan et al.,⁵ In the present study, the most common symptom was nasal obstruction (100%) followed by headache (52%) followed by discharge(48.9%). This can be comparable to Stewert et al.,⁶ P llium et al.,⁷ & Devseren et al.,⁸ DNS was the most common finding in 48 (54.2%) followed by discharge (32%) for patients undergoing nasal surgery which was comparable to study by Y. K. Maru and Y. Gupta⁹ Most common DNE finding was DNS in (63.3%) followed by discharge in middle meatus (29%) for patients undergoing nasal surgery which was comparable to study by Kamal Kishore, et al. . .,¹⁰

In the present study, there were 48 pts who had undergone submucous resection of the septum for DNS while 25 patients were having antrochonal polyp, out of 25, 19 patients were undergone polypectomy by unilateral FESS while rest 6 underwent polypectomy by unilateral FESS with SMR. The normal MCI time varies, some studies quote <20 minutes as being the normal cut off¹¹ while others propose 7-15 minutes (10, 27.30,31,42,46) In the present study, 7-15 minutes was considered the normal range.

In the present study, for SMR operation, The average pre-operative mean MCT was 13.18 min of which minimum MCT 9 min was and Maximum time was 23 min. The average post-operative MCT after 1 week was 12.18 min which is significantly lower than preoperative MCT this is comparable to study by Mustafa Hashmi et al.,¹² In the study by Uslu et al.,¹³ patients with septal deviation have a prolonged mucociliary transit time as compared with post-operative and healthy controls similar result was observed in the present study.

The mean postoperative MCT at 6 weeks was 11.2 min which is significantly lower than the preoperative mean which was 13.18 min. SMR alters mucociliary clearance at the immediate postoperative period. When the entire nasal mucosa was injured mechanically, regenerative stratified epithelium covered the defect in 1 week, new ciliated cells appeared in 3 weeks and complete regeneration was observed at 6 weeks. In the present study, patients showed improvement in the symptoms and improvement in MCT at the end of 6 weeks after surgery. Present study results were comparable to a study by Kamaran and Tek.¹⁴

In the present study out of 48 patients, 43 (89.6%) patients show improvement in MCT as compared to preoperative and postoperative MCT, while 4 (8.4%) shows prolongation in MCT and 1(2.08%) the patient does not show any change in MCT. All patients undergoing SMR were symptomatically improved. The result of the present study was that there was an improvement in nasal mucociliary clearance after nose and sinus surgeries postoperative after 6 weeks.

Nasal obstruction significantly affects the nasal mucociliary clearance time. The present study proves that nasal surgeries like SMR, FESS do affect the mucociliary clearance transient time also the saccharin test for measurement of mucociliary clearance is very useful and easily available tool for evaluating the outcomes of the nasal surgeries and also the predictor for the success of the nasal surgeries. The present study results are comparable to previously published data. However longer follow up, larger sample size can be considered for further studies.

In the present study, we have observed that the patient's symptoms and the nasal mucociliary clearance time by the saccharin method are correlating. All patients who showed improvement in the nasal mucociliary clearance time after surgery also showed improvement in their symptoms (like nasal obstruction, headache, etc.) So we come to the conclusion that the saccharin method is an effective method in measuring the nasal mucociliary clearance time.

Conflict of Interest: None to declare

Source of funding: Nil

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