ArticlePDF AvailableLiterature Review

Nasal Irrigation: An Imprecisely Defined Medical Procedure

Authors:

Abstract and Figures

Nasal irrigation (NI) is an old practice of upper respiratory tract care that likely originated in the Ayurvedic medical tradition. It is used alone or in association with other therapies in several conditions—including chronic rhinosinusitis and allergic rhinitis—and to treat and prevent upper respiratory tract infections, especially in children. However, despite it being largely prescribed in everyday clinical practice, NI is not included or is only briefly mentioned by experts in the guidelines for treatment of upper respiratory tract diseases. In this review, present knowledge about NI and its relevance in clinical practice is discussed to assist physicians in understanding the available evidence and the potential use of this medical intervention. Analysis of the literature showed that NI seems to be effective in the treatment of several acute and chronic sinonasal conditions. However, although in recent years several new studies have been performed, most of the studies that have evaluated NI have relevant methodologic problems. Only multicenter studies enrolling a great number of subjects can solve the problem of the real relevance of NI, and these studies are urgently needed. Methods for performing NI have to be standardized to determine which solutions, devices and durations of treatment are adequate to obtain favorable results. This seems particularly important for children that suffer a great number of sinonasal problems and might benefit significantly from an inexpensive and simple preventive and therapeutic measure such as NI.
Content may be subject to copyright.
International Journal of
Environmental Research
and Public Health
Review
Nasal Irrigation: An Imprecisely Defined
Medical Procedure
Nicola Principi 1and Susanna Esposito 2, *
1Pediatric Highly Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico,
Universitàdegli Studi di Milano, 20122 Milan, Italy; nicola.principi@unimi.it
2Pediatric Clinic, Universitàdegli Studi di Perugia, 06123 Perugia, Italy
*Correspondence: susanna.esposito@unimi.it; Tel.: +39-075-5784417; Fax: +39-075-5784415
Academic Editor: Paul B. Tchounwou
Received: 14 April 2017; Accepted: 9 May 2017; Published: 11 May 2017
Abstract:
Nasal irrigation (NI) is an old practice of upper respiratory tract care that likely originated
in the Ayurvedic medical tradition. It is used alone or in association with other therapies in several
conditions—including chronic rhinosinusitis and allergic rhinitis—and to treat and prevent upper
respiratory tract infections, especially in children. However, despite it being largely prescribed in
everyday clinical practice, NI is not included or is only briefly mentioned by experts in the guidelines
for treatment of upper respiratory tract diseases. In this review, present knowledge about NI and its
relevance in clinical practice is discussed to assist physicians in understanding the available evidence
and the potential use of this medical intervention. Analysis of the literature showed that NI seems to
be effective in the treatment of several acute and chronic sinonasal conditions. However, although in
recent years several new studies have been performed, most of the studies that have evaluated NI
have relevant methodologic problems. Only multicenter studies enrolling a great number of subjects
can solve the problem of the real relevance of NI, and these studies are urgently needed. Methods
for performing NI have to be standardized to determine which solutions, devices and durations of
treatment are adequate to obtain favorable results. This seems particularly important for children
that suffer a great number of sinonasal problems and might benefit significantly from an inexpensive
and simple preventive and therapeutic measure such as NI.
Keywords: allergic rhinitis; chronic rhinosinusitis; nasal irrigation; upper respiratory tract infection
1. Introduction
Nasal irrigation (NI) is an old practice of upper respiratory tract care that likely originated in
the Ayurvedic medical tradition [
1
]. It was adopted by Western medicine in the late 19th century,
and since then, it has continued to gain popularity worldwide [
2
]. It is used alone or in association
with other therapies in several conditions, including chronic rhinosinusitis (CRS) and allergic rhinitis
(AR) [
3
8
]. Moreover, particularly in children, it has been prescribed to treat and prevent upper
respiratory tract infections (URTIs) [
7
]. In general, otolaryngologists and pediatricians consider NI
very effective because its use has been found to be associated with a significant reduction in both the
signs and symptoms of rhinosinusal diseases and the prescription of drugs commonly used in these
conditions [
9
]. However, despite being prescribed in everyday clinical practice, NI is not included or is
only briefly mentioned by experts in the guidelines for treatment of URTIs [1014].
A great number of studies specifically planned to evaluate NI in clinical practice have been
performed [
7
]. However, they frequently enrolled small numbers of patients with different ages and
diseases and, in most of the cases, they had methodological problems leading to debatable results.
Moreover, several aspects of NI, such as the composition of solutions, means of irrigation, mechanism
of action, and safety and tolerability were not completely clarified. In this review, present knowledge
Int. J. Environ. Res. Public Health 2017,14, 516; doi:10.3390/ijerph14050516 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2017,14, 516 2 of 13
about NI and its relevance in clinical practice will be discussed to assist physicians in understanding
the available evidence and the potential use of this medical intervention.
2. Mechanisms of Action of Nasal Irrigation (NI)
The exact mechanisms by which NI works are not known. However, most of the experts think that
it is primarily a mechanical intervention leading to direct cleaning of the nasal mucosa, independent
of the composition of the solution used for nasal washing [
15
]. The mucus lining the nasal cavity
may be softened and dislodged. Moreover, inflammatory mediators—such as prostaglandins and
leukotrienes—and antigens responsible for allergic reactions can be removed favoring resolution of
URTIs and AR [
16
18
]. However, some data seem to indicate that the composition of the solution can
influence some aspects of the NI action. Although the impact of the salt concentration on mucociliary
clearance through a modification of ciliary beating frequency is not defined because data collected
in vitro
and
in vivo
have been contradictory, it has been demonstrated that the composition and
activity of nasal secretions are related to the tonicity of the solution [
19
]. Administration of low-salt
and isotonic solutions has been associated with an immediate, significant reduction in the microbial
antigens and a related decline of microbial burden. In contrast, hypertonic solutions were found to be
only marginally capable of influencing microbial antigen concentrations. Furthermore, lysozyme and
lactoferrin concentrations were found to be increased by approximately 30% at 24 h after NI [20].
The activity of NI seems further increased by the addition to the solution containing ions different
from Na
+
and Cl
because they can exert a relatively positive effect on epithelial cell integrity and
function. Magnesium (Mg) promotes cell repair and limits inflammation by reducing the eicosanoid
metabolism both at the level of the liberation of arachidonic acid and by direct inhibition of the
5-lipoxygenase enzyme [
21
]. Moreover, Mg inhibits exocytosis from permeabilized eosinophils [
22
] and,
together with zinc, reduces apoptosis of respiratory cells [
23
]. Potassium exerts an anti-inflammatory
action and, globally, all these ions seem to increase viability in respiratory cells more than isotonic
saline [
24
,
25
]. Bicarbonate ions reduce mucus viscosity, although the relevance of the addition of pure
bicarbonate to the saline solutions is debated [
26
]. The advantage of the reduced mucous viscosity might
be counterbalanced by the increase in the pH of the solution, which might be a negative factor.
In vitro
studies have shown that acidic pH can reduce the ciliary beat frequency, whereas the opposite occurs
when slightly alkaline solutions were used. However,
in vivo
, use of a solution with pH ranging from
6.2 to 8.4 did not affect mucociliary clearance [27]. Table 1summarizes the mechanisms of action of NI.
Table 1. Mechanisms of action of nasal irrigation (NI).
Mechanism Action
Mechanical intervention Mucus lining dislodgment
Removal of inflammatory mediators
Impact on mucociliary clearance Reduction in microbial antigens level
Decline of microbial burden
Positive effect on epithelial cell integrity and function
in the presence of additional ions
Magnesium promotes cell repair, limits inflammation, limits
exocytosis, and reduces apoptosis of respiratory cells
Zinc reduces apoptosis of respiratory cells
Potassium exerts anti-inflammatory action
Bicarbonate reduces mucus viscosity
3. Composition of Solutions Commonly Used for Nasal Irrigation (NI)
Isotonic saline (0.9%) and hypertonic saline (1.5% to 3%) are the most common commercial
preparations used for NI. Both are acidic, with pH values varying from 4.5 to 7. Solutions with NaCl
concentrations higher than 3% are not recommended, although the emergence of adverse events due
to hypertonicity—such as sensations of pain, blockage, and rhinorrhea—have been demonstrated to be
dose-dependent and occur only when the NaCl concentration is
5.4% [
28
]. Instead of traditional saline
solutions, some physicians prefer Ringer’s lactate, which contains other minerals in addition to NaCl
Int. J. Environ. Res. Public Health 2017,14, 516 3 of 13
and has a pH from 6 to 7.5 [
29
]. To increase the mineral content, several commercial products containing
seawater diluted with distilled water to obtain an isotonic or slightly hypertonic solution with neutral
or slightly alkaline pH are on the market (Libenar
®
, Sterimar
®
, and Marimer
®
). Although diluted, these
products include a greater amount of minerals compared to NaCl and Ringer’s solutions. An even
greater content of ions is present in a product based on electrodialyzed seawater (Physiomer
®
) because
this method of preparation maintains almost all the minerals of the original seawater. Solutions for NI
can also be prepared at home according to the suggestions of several authors and institutions [
19
,
30
32
].
In general, boiled water mixed with table or canning salt is used. In some cases, baking soda is included.
The final tonicity can vary from 0.9% to 3%, and the pH is acidic unless baking soda is added.
4. Means of Nasal Irrigation (NI)
Several methods, including the one based on the old neti pot simply filled with lukewarm water,
can be theoretically used to perform NI [
33
]. However, studies carried out on adults seem to indicate that
among the various methods, the most effective are those that assure large volume irrigation. Moreover,
although the optimal duration of the treatment has not been clarified, greater benefits result when
positive pressure is used. The distribution of solution in nasal and sinus cavities is more exhaustive with
positive pressure than with negative pressure (by sniffing), nebulization, or spray [
34
]. To maximize
the efficacy, large-volume (no less than 100 mL) low-pressure irrigation is preferable to low-volume
high-pressure irrigation [
35
]. Regarding devices, it has been established that, to allow the best irrigation of
the whole nasal cavity and paranasal sinuses, compressible douching systems should be used. In adults,
they should allow a minimum output pressure of 120 mbar, a good connection to the nostril, a possible
insertion into the nasal vestibule, and an irrigation stream directed upwards (45) [36].
In the community, the most often used device is a syringe. Unfortunately, a syringe has several
limitations. First, it does not allow a good connection with the nostril. This reduces the efficacy of the
NI because part of the solution may leak from the nostril before reaching the nasal cavity. Moreover,
pressure can be quite different according to the force applied by the operator and, in some cases, may
be too strong, which causes discomfort or too light, resulting in an ineffective application. Finally,
when high volumes are needed and a relatively small syringe is used, it should be filled several times
with the risk that the operator does not use the correct volume.
Contrary to what has been precisely defined in adults, no evaluation of the most effective means
of treating NI in children is available. This is a problem particularly for neonates, infants, and toddlers
that cannot use compressive douching systems prepared for adults. In these patients, drops, sprays
or disposable syringes are frequently used, although no study has precisely defined the best method,
the right volume of solution, and the optimal duration of treatment to assure effective NI. Uncertainty
surrounding NI in younger children is evidenced by the different types of NI used in children of a
similar age suffering from the same disease. For example, in the study by Garavello et al. in which
children with allergic rhinitis were evaluated, NI consisted of 2.5 mL of solution delivered to each
nostril three times a day for six weeks with a syringe [
37
]. Marchisio et al. [
38
] and Chen et al. [
39
],
treating children with a similar mean age and the same disease, used 20 mL 2 times a day with a
syringe for 4 weeks, and 4–6 sprays twice a day for 12 weeks, respectively. All of these studies showed
that NI was effective but did not document the best way to perform NI.
5. Tolerability and Safety of Nasal Irrigation (NI)
Adults generally have minimal side effects from NI. Transient adverse reactions, such as nasal
irritation, nasal discomfort, otalgia, or pooling of saline in paranasal sinuses with subsequent drainage,
have been described [
31
]. They are more common (10–20% of the cases) when very high volume devices
are used. However, because they are mild in most of the cases, compliance is high [
40
]. Attention
should be paid to the temperature of the solution because solutions that are either too cold or too hot
can cause problems of tolerance. Similar conclusions can be drawn for children, although evaluation
of compliance in these subjects is more difficult, particularly in the youngest patients. Tolerance is
Int. J. Environ. Res. Public Health 2017,14, 516 4 of 13
judged by parents and the evaluation is mainly derived from the opinion of the operator instead of
the patient’s judgment. A detailed evaluation of tolerance and compliance of NI in pediatrics has
been performed by Jeffe et al., who prescribed NI to 57 children aged 2–16 years after parents were
instructed on how to rinse [
41
]. Each NI consisted of 100 mL of room temperature saline solution
irrigated through each nostril for different periods according to parents’ judgment. Initially, 89% of
children performed NI at least once a day, 7% performed NI one to four times per week, and 4%
performed NI as needed. Parents were contacted between two and four months later and were asked
to complete a questionnaire regarding the child’s experience. It was shown that 25% continued to
use NI
once daily, 5% one to four times per week, and 70% as needed. Compliance was high,
independent of age, and was strictly dependent on initial parental assumption of tolerance. Only two
children did not tolerate NI due to the emergence of adverse events. In six cases, NI was suspended
because the child did not like the treatment, although significant adverse events did not occur. Among
children who tolerated NI, 14% accepted the treatment after the first use, 73% in less than 7 days,
and 11% in a period between 7 and 14 days.
The problem of sterility of the solutions and devices has been debated. Solutions are at risk of
contamination when large volumes of solution based on distilled water, bottled water, or boiled water
are prepared at home, maintained in containers and used each time when NI is needed by withdrawing
the required amount of liquid. Devices can be contaminated when they are continuously used without
adequate cleaning [
42
]. Lee et al. reported that after one and two weeks of use, irrigation bottles used
by adults undergoing endoscopic sinus surgery that were washed with hot soapy water after each
use were found to be contaminated by a large spectrum of bacteria, including Pseudomonas aeruginosa,
Serratia marcescens,Proteus mirabilis, and Staphylococcus aureus [
43
]. Similar findings were reported
by other authors and, because in many cases contaminating bacteria were the same as those that
could cause acute rhinosinusitis, it was suggested that the main source of device colonization was
the sinonasal cavities [
44
,
45
]. The risk of contamination seems independent of the type of device [
46
].
Additionally, the use of a one-way valve irrigation bottle, theoretically capable of reducing the
risk of reflux of contaminated solution in the device, was found to be practically ineffective [
47
].
In contrast, contamination seems to be influenced by the composition of the solution. It was shown
that acidic, isotonic saline solutions were more frequently associated with bacterial contamination
probably because some of the most common contaminants grow optimally in similar environmental
conditions [
48
]. Finally, contamination was found more frequently with longer durations of NI use.
With some exceptions, studies have reported that both bottles and bulb syringes were contaminated
after one to two weeks of use in approximately 25% of the cases and in 45% after four weeks [4851].
Although common and frequently based on potentially dangerous bacteria, contamination is
considered a false problem by some experts [
32
]. They think that the nasal cavity is naturally full of
bacteria and the addition of new pathogens is not clinically relevant. This conclusion seems supported
by the evidence that contamination usually does not modify the disease outcome [
48
51
]. However,
the evidence that replacement of old devices with new clean devices could improve symptom scores
in adult patients with CRS [
49
] and, above all, the report of two primary amebic meningoencephalitis
deaths associated with NI using contaminated tap water support the recommendation to pay attention
to the problem of cleaning and sterilizing solutions and bottles for NI [
52
]. To limit contamination,
several methods have been proposed and studied. Keen et al. compared several measures and found
that rinsing devices with boiling water or disinfectant solutions or use of microwaves could reduce the
degree of contamination in most, although not all, of the devices [
49
]. However, particularly when NI
is performed at home, it seems mandatory to use only sterile, distilled, filtered water and rinse the
device after each use using the same distilled or boiled water [52].
The risk of contamination has been studied practically only in adults. Because children mainly
have sinonasal diseases due to pathogens different from those usually encountered in adults, no firm
conclusions about the risk and type of contamination in pediatrics can be drawn. However, the same
precautions recommended for adults are mandatory. Moreover, the use of sterile solutions delivered
Int. J. Environ. Res. Public Health 2017,14, 516 5 of 13
by spray or nebulization presently on the market and the use of sterile syringes discharged after each
use could probably reduce the risk of contamination and related problems in children. When possible,
nasal douches with warm sacs of premixed solution are recommended [53].
6. Clinical Efficacy
6.1. Acute Upper Respiratory Tract Infections (URTIs)
Acute URTIs, including the common cold and rhinosinusitis, are the most common diseases of
children and are also extremely common in adults. Although mild diseases are observed in the greatest
majority of patients, they significantly impact the health system and quality of life of patients and
their families, especially when they are frequently recurrent, as usually occurs in the first years of life.
To reduce signs and symptoms, antipyretic and decongestant drugs are frequently prescribed [
54
].
Moreover, even if they are mainly due to viruses, frequently they are treated with antibiotics for fear of
superimposed bacterial infections. This leads to the abuse of antibiotics and all the problems related
to the misuse of these drugs [
55
]. To limit the medical, social, and economic impacts of UTRIs and
reduce drug consumption, NI is frequently prescribed by general practitioners, otolaryngologists, and
pediatricians for both prevention and treatment. Several studies were planned to determine NI efficacy
in URTI treatment. As previously reported, only a few had no risk of bias and could be used to draw
reliable conclusions. This is clearly exemplified by a recent Cochrane review in which all the studies
published until August 2014 comparing NI with at least one intervention or placebo for treatment of
URTIs were initially included [
56
]. A total of 360 trials were retrieved, but among them, only five—two
in adults and three in children—were selected for the final analysis because randomized controlled
trials have risks of bias. Unfortunately, clinical characteristics of enrolled patients, prescriptions,
and measures to evaluate treatment efficacy were not uniform and the results could not be pooled.
Moreover, no information could be obtained on the relevance of the solution composition in the
conditioning results. Consequently, firm conclusions could not be drawn. The authors concluded that
NI might be a possible effective system for relieving the symptoms of acute URTIs, although further
studies with greater numbers of participants and with more precise standardization of NI means
and outcome measures are needed to confirm NI efficacy. Studies carried out in adults, enrolling a
total of 205 subjects, reported no differences in nasal symptom scores between treatment and control
groups [
56
,
57
]. A reduction in the time to resolution was evidenced by King et al., who found that the
mean day of well-being for the group receiving isotonic saline solution was lower (7.67 days) than for
the control group (10.48 days), although the difference did not reach statistical significance [56].
The results of pediatric studies were discordant. Bollag et al. enrolled 46 children aged two weeks
to two years with various URTIs and assigned them to two intervention groups (saline nose drops;
medicated nose drops) and a control group (no nose drops) [
58
]. Effectiveness was evaluated only two
days later when it was found that a significant improvement in nasal signs and symptoms had occurred
in all the groups without any advantage of saline drops. In contrast, positive results were reported by
Slapak et al. who enrolled a total of 401 children aged 6–10 years with uncomplicated cold or influenza
who were randomly assigned to two treatment groups, one with standard medication (i.e., antipyretics,
nasal decongestants, and mucolytics) and the other with NI using electrodialyzed seawater solution [
9
].
The effect of treatment was evaluated by measuring the intensity of upper respiratory tract signs and
symptoms after three weeks. The preventive effect of NI was evaluated considering the respiratory
status and incidence of new URTIs together with the consumption of medication, complications,
days off from school, and reported days of illness in the following nine weeks, during which NI was
performed only three times per day compared to six times for the treatment period. It was shown
that, in children with NI, both nasal secretion and nasal obstruction were significantly reduced (mean
scores vs. control group, 1.79 vs. 2.10 and 1.25 vs. 1.58, respectively; p< 0.05 for both) at the end
of the treatment period. Moreover, NI was found to exert a significant prophylactic effect because,
in comparison to children without NI, children receiving NI for more than nine weeks had a lower
Int. J. Environ. Res. Public Health 2017,14, 516 6 of 13
need for using antipyretics (9% vs. 33%), nasal decongestants (5% vs. 47%), mucolytics (10% vs. 37%),
and systemic antibiotics (6% vs. 21%; p< 0.05 for all). Moreover, in the same period, children in the
saline group reported significantly fewer illness days (31% vs. 75%), school absences (17% vs. 35%),
and complications (8% vs. 32%; p< 0.05 for all). A favorable result by Wang et al. was found for the
use of normal saline in children with acute rhinosinusitis [
59
]. These authors enrolled 69 children
aged 3–12 years. All received standard treatment. Thirty were also treated with NI with normal saline
administered one to three times a day for three weeks. The efficacy of nasal treatment was evaluated
considering the nasal peak expiratory flow rate (nPEFR) test, nasal smear examination, radiography
(Water ’s projection), and quality of life. After three weeks, compared to the control group, children
with NI had an improved nPEFR test (p> 0.05) and there was a significant reduction of rhinorrhea,
nasal congestion, throat itching, and cough and sleep quality improved. Similar advantages were also
demonstrated in a subgroup of enrolled children; that is, patients with demonstrated atopy.
After publication of the Cochrane review, some other studies regarding NI and URTIs were
published [
49
]. Among them, Regab et al. seemed to confirm the efficacy of NI in the treatment of
URTIs. Sixty-two children with uncomplicated acute rhinosinusitis were enrolled in a prospective,
randomized, placebo-controlled study [
60
]. The patients were enrolled into two groups, the first
including children receiving amoxicillin and NI with normal saline solution and the second including
patients treated with only NI. The same clinical response and the same middle meatus bacteriological
and cytological changes were evidenced in both groups, suggesting that NI could be as effective
as antibiotic treatment in acute mild rhinosinusitis of children. However, the previously drawn
conclusions by the authors of the Cochrane review remain: the use of NI for URTI treatment is
probably effective but we do not know how well it works, how it should be performed, what the best
solution is for use and how long it has to be used for treatment and for prevention.
6.2. Chronic Rhinosinusitis (CRS)
CRS is diagnosed mainly in adults and it is common in patients with underlying chronic disease
involving the respiratory tract as cystic fibrosis or primary ciliary dyskinesia [
61
,
62
]. Most of the
studies carried out to evaluate NI in this disease have been carried out in adult patients. To simplify
treatment, usually based on antibiotics and corticosteroids, NI is frequently used. The clinical relevance
of this therapeutic measure was first analyzed by Harvey et al. in a Cochrane review published in 2007,
and it included 8 randomized controlled trials selected among the 64 studies initially retrieved [
63
].
As with the studies on treatment for URTIs, these case studies could not be globally pooled because of
significant differences in patients, method of NI and outcome measures. Some studies included both
pediatric patients and patients with allergic rhinitis. Saline solutions were compared with either no
treatment, a placebo, as an adjunct to other treatments or against treatments. Hypertonic versus isotonic
solutions were also compared. Conclusions were such that NI was capable of reducing symptom
scores, although it was less effective than topical corticosteroids [
63
]. However, it can improve
corticosteroid efficacy when used in combination. Finally, it was demonstrated that hypertonic and
isotonic solutions had similar effects on patient symptoms and the quality of life, whereas hypertonic
solutions were associated with significant improvement of radiological scores. More recently, a new
attempt to evaluate the clinical relevance of NI in the treatment of CRS was made by Rudmik et al. [
5
].
These authors reviewed the studies carried out considering well defined primary clinical end-points
that included only adult patients with disease diagnosed according to published diagnostic criteria.
Randomized clinical trials of higher-quality studies were selected. However, lower-level studies were
also considered if the topic contained insufficient evidence. Global quality was, however, poor. Eight
trials, five performed in pre-surgical patients [
30
,
46
,
64
66
] and three [
67
69
] after endoscopic sinus
surgery, were analyzed. Despite significant differences in the number of enrolled patients, the means
and duration of NI and primary clinical end-points, a positive effect of the treatment, was evidenced
in all the pre-surgical trials. Hypertonic and isotonic solutions were compared and found to be quite
similar in relieving symptoms and improving endoscopy, mucociliary clearance, rhinomanometry,
Int. J. Environ. Res. Public Health 2017,14, 516 7 of 13
and olfactometry by Bachman et al., who treated a total of 40 patients with 200 mL of solution twice
a day for one week [
64
]. However, differences in favor of normal saline were found by Hauptman
and Ryan, who tested 80 patients with a single administration of 1 mL of buffered hypertonic or
normal saline delivered through a metered-dose nasal spray bottle to the more symptomatic side of
the nose [
65
]. Compared to basal conditions, both solutions improved the mucociliary clearance and
symptoms of nasal stuffiness and obstruction. However, only buffered physiological solution could
improve nasal airway patency. Finally, buffered hypertonic saline was more irritating.
Favorable results were also shown by two of the three post-operative studies, although with some
limitations. Liang et al. reported that the addition of NI with isotonic saline solution to post-operative
sinus debridement was effective in improving symptom scores only in patients with mild CRS [
69
].
Freeman et al. studied 23 patients comparing treatment with 2 mL of normal saline solution delivered
via a mucosal atomization device for six weeks with no NI [
68
]. They found that the effect was transient
because improved endoscopic appearance and mucociliary clearance were observed only after three
weeks. In contrast, three months after intervention, only minimal and not significantly different
variations were found with regard to crusting and edema, and there was no difference with adhesions,
discharge and polyps. However, Pinto et al. did not report any advantage in the administration of
both normal and hypertonic saline solutions in patients receiving NI with 30 mL four times a day [
67
].
A recent Cochrane review has confirmed that the quality of available publications regarding the
use of NI in CRS is poor [
70
]. Only two studies were included. One [
30
] was already included in
previous reviews [
63
] and only one new study was added [
71
], without significant improvement of our
knowledge regarding all the problems related to NI use in CRS. In addition, data on different chronic
diseases associated with CRS development are scant and do not permit to draw any conclusion.
6.3. Allergic Rhinitis (AR)
AR is relatively common and it is a global health problem [
72
]. From a theoretical point of
view, avoidance of allergens is the best measure to face AR, but it is often not feasible. To relieve
acute signs and symptoms, anti-histamines and topical steroids are usually suggested [
72
]. However,
all these drugs only help with the symptoms and do not provide long-term effects once treatment is
suspended. Moreover, for some of them, long-term use can be followed by relevant adverse events.
To overcome these problems at least partially, NI has been considered and several studies were planned
to evaluate its real efficacy. A systematic review and meta-analysis of the studies published until
2010 [
73
] selected 10 trials [
37
,
74
82
], 7 of which were randomized and controlled studies. Three
studies included children. However, once again, studies varied considerably with regard to many
aspects involving patients, NI and evaluation of efficacy. Moreover, in some cases, a high risk of bias
was evident. In general, NI was considered effective. Nasal symptom scores that were analyzed in
eight of the studies improved in all the studied patients with variation from 3% to 70% in comparison
to the baseline. Only pregnant women did not benefit from the treatment. Consumption of drugs
was reduced, whereas mucociliary clearance times were improved. Comparison of isotonic versus
hypertonic solutions led to discordant results. However, hypertonic solutions, with the exception
of those based on special salts, such as Salsomaggiore or seawater gel [
75
] and the one used in the
study by Garavello et al. [
37
], were associated with a mild worsening mucociliary clearance time
and with a lower improvement of studied parameters in comparison to isotonic solution. However,
the results of some studies carried out after the end of those included in the cited meta-analysis
seemed to lead to different conclusions. The effectiveness of NI in reducing the signs and symptoms of
AR was not always confirmed, whereas in some cases hypertonic solutions were found to be more
effective. De Souza Campos Fernanades et al. compared 40 children with AR corticosteroid nasal
spray administration to NI irrigation with isotonic saline solution [
83
]. Efficacy was measured through
peak nasal inspiratory flow (PNIF) curves and a clinical score during the eight weeks of treatment
and two weeks afterward. Corticosteroid administration was found to be significantly effective with
increased PNIF percentages and lower clinical scores in most of the treated patients. In contrast,
Int. J. Environ. Res. Public Health 2017,14, 516 8 of 13
NI was only marginally effective: PNIF curves were not modified and the mean clinical symptom
score was reduced by only 18%. Unsatisfactory results were also reported by Chen et al. [
39
]. These
authors compared nasal corticosteroids with NI and with a combination of nasal steroids and NI.
For NI, a physiological seawater solution was used. Treatment was given for 12 weeks and efficacy
was measured through a score of nasal signs and symptoms and eosinophil quantification via a nasal
smear. Combined treatment was the most effective, but NI alone was less effective than corticosteroids
alone. Practically, in children with NI, nasal scores decreased only 10% and the eosinophil count was
only marginally reduced. The use of a hypertonic solution was significantly more effective in the study
carried out by Marchisio et al. [
38
], who confirmed what Garavello et al. had previously reported [
37
].
Marchisio et al. evaluated whether children with seasonal grass pollen-related AR could benefit from
NI with normal saline solution or hypertonic solution (2.7% NaCl solution) by assessing the effects
on nasal signs and symptoms, on middle ear effusion and on adenoidal hypertrophy [
38
]. Treatment
lasted four weeks and, as in control patients, a group of children with similar clinical characteristics
without NI was enrolled. Two hundred and twenty children (normal saline: 80; hypertonic saline: 80;
no treatment: 60) completed the study. After four weeks, all the considered items were significantly
reduced in the group receiving hypertonic saline (p< 0.0001), whereas in the group receiving normal
saline, only rhinorrhea (p= 0.0002) and sneezing (p= 0.002) were significantly reduced. There was no
significant change in any of the items in the control group. The duration of oral antihistamines was
significantly lower in children receiving hypertonic saline than in those treated with normal saline or
in controls [38].
In conclusion, regarding AR, the data did not allow firm conclusions to be drawn, although the
high frequency of positive results seems to suggest a possible use of the NI in the treatment of AR.
7. Conclusions
Table 2summarizes the main solutions, means of irrigation and indications of NI. Despite only
one adequate study being carried out, and therefore being left unable to evaluate the preventive
efficacy of NI [
9
], NI seems to be effective in the treatment of several acute and chronic sinonasal
conditions. However, although in recent years several new studies have been performed, scientific
evidence remains poor because most of the studies that have evaluated NI have relevant methodologic
problems. This is demonstrated by the very small number of studies that were specifically performed
to evaluate the impact of NI for the most common clinical conditions included in the Cochrane reviews.
Only multicenter studies enrolling a great number of subjects, including those with chronic diseases as
cystic fibrosis or primary ciliary dyskinesia, can determine the real relevance of NI, and these studies
are urgently needed. Methods for performing NI have to be standardized to determine which solution,
device, and duration of treatment are adequate to obtain favorable results. This seems particularly
important for children that suffer from a great number of sinonasal problems and might benefit
significantly from an inexpensive and simple preventive and therapeutic measure such as NI.
Table 2. Main solutions, means of irrigation, and indication of nasal irrigation (NI).
Mechanism Action
Most common composition Isotonic saline (0.9%) or hypertonic saline (1.5–3%)
pH varying from 4.5 to 7
Optimal means of irrigation
Large volume
Positive pressure
Compressible douching system
Indication
Acute upper respiratory tract infections
Chronic rhinosinusitis
Allergic rhinitis
Int. J. Environ. Res. Public Health 2017,14, 516 9 of 13
Acknowledgments:
This review was supported by grants from the Italian Ministry of Health (Fondazione IRCCS
Ca’ Granda Ospedale Maggiore Policlinico, Progetto ricerca corrente 2017 850/02).
Ethics, Approval and Consent to Participate: Not applicable for this type of publication.
Author Contributions:
Nicola Principi and Susanna Esposito co-wrote the manuscript and approved its
final version.
Conflicts of Interest: The authors declare no conflict of interest.
References
1.
Rama, S.; Ballentine, R.; Hymes, A. Science of Breath: A Practical Guide; Himalayan Institute Press: Honesdale,
PA, USA, 1998.
2. Burns, J.L. Nasal lavage. J. Otholaryngol. 1992,21, 83.
3. Sur, D.K.; Plesa, M.L. Treatment of allergic rhinitis. Am. Fam. Physician 2015,92, 985–992. [PubMed]
4.
Benninger, M.S.; Holy, C.E.; Trask, D.K. Acute rhinosinusitis: Prescription patterns in a real-world setting.
Otolaryngol. Head Neck Surg. 2016,154, 957–962. [CrossRef] [PubMed]
5.
Rudmik, L.; Hoy, M.; Schlosser, R.J.; Harvey, R.J.; Welch, K.C.; Lund, V.; Smith, T.L. Topical therapies in
the management of chronic rhinosinusitis: An evidence-based review with recommendations. Int. Forum
Allergy Rhinol. 2013,3, 281–298. [CrossRef] [PubMed]
6.
Beswick, D.M.; Ramadan, H.; Baroody, F.M.; Hwang, P.H. Practice patterns in pediatric chronic rhinosinusitis:
A survey of the American Rhinologic Society. Am. J. Rhinol. Allergy
2016
,30, 418–423. [CrossRef] [PubMed]
7.
Marchisio, P.; Picca, M.; Torretta, S.; Baggi, E.; Pasinato, A.; Bianchini, S.; Nazzari, E.; Esposito, S.; Principi, N.
Nasal saline irrigation in preschool children: A survey of attitudes and prescribing habits of primary care
pediatricians working in northern Italy. Ital. J. Pediatr. 2014,40, 47. [CrossRef] [PubMed]
8. Sobol, S.E.; Samadi, D.S.; Kazahaya, K.; Tom, L.W. Trends in the management of pediatric chronic sinusitis:
Survey of the American Society of Pediatric Otolaryngology. Laryngoscope
2005
,115, 78–80. [CrossRef]
[PubMed]
9.
Slapak, I.; Skoupá, J.; Strnad, P.; Horník, P. Efficacy of isotonic nasal wash (seawater) in the treatment and
prevention of rhinitis in children. Arch. Otolaryngol. Head Neck Surg.
2008
,134, 67–74. [CrossRef] [PubMed]
10.
Rosenfeld, R.M.; Piccirillo, J.F.; Chandrasekhar, S.S.; Brook, I.; Kumar, K.A.; Kramper, M.; Orlandi, R.R.;
Palmer, J.N.; Patel, Z.M.; Peters, A.; et al. Clinical Practice Guideline (Update): Adult sinusitis executive
summary. Otolaryngol. Head Neck Surg. 2015,152, 598–609. [CrossRef] [PubMed]
11.
Chow, A.W.; Benninger, M.S.; Brook, I.; Brozek, J.L.; Goldstein, E.J.; Hicks, L.A.; Pankey, G.A.; Seleznick, M.;
Volturo, G.; Wald, E.R.; et al. Infectious Diseases Society of America: IDSA clinical practice guideline
for acute bacterial rhinosinusitis in children and adults. Clin. Infect. Dis.
2012
,54, e72–e112. [CrossRef]
[PubMed]
12.
Wald, E.R.; Applegate, K.E.; Bordley, C.; Darrow, D.H.; Glode, M.P.; Marcy, S.M.; Nelson, C.E.;
Rosenfeld, R.M.; Shaikh, N.; Smith, M.J.; et al. American academy of pediatrics: Clinical practice guideline
for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics
2013
,
132, e262–e280. [CrossRef] [PubMed]
13.
Roberts, G.; Xatzipsalti, M.; Borrego, L.M.; Custovic, A.; Halken, S.; Hellings, P.W.; Papadopoulos, N.G.;
Rotiroti, G.; Scadding, G.; Timmermans, F.; et al. Paediatric rhinitis: Position paper of the European academy
of allergy and clinical immunology. Allergy 2013,68, 1102–1116. [CrossRef] [PubMed]
14.
Bousquet, J.; Schunemann, H.J.; Fonseca, J.; Samolinski, B.; Bachert, C.; Canonica, G.W. MACVIA: ARIA
sentinel network for allergic rhinitis (MASK-rhinitis): The new generation guideline implementation. Allergy
2015,70, 1372–1392. [CrossRef] [PubMed]
15.
Bastier, P.L.; Lechot, A.; Bordenave, L.; Durand, M.; de Gabory, L. Nasal irrigation: From empiricism to
evidence-based medicine. A review. Eur. Ann. Otorhinolaryngol. Head Neck Dis.
2015
,132, 281–285. [CrossRef]
[PubMed]
16.
Georgitis, J.W. Nasal hyperthermia and simple irrigation for perennial rhinitis: Changes in inflammatory
mediators. Chest 1994,106, 1487–1492. [CrossRef] [PubMed]
17.
Carothers, D.G.; Graham, S.M.; Jia, H.P.; Ackermann, M.R.; Tack, B.F.; McCray, P.B., Jr. Production of
β
-defensin antimicrobial peptides by maxillary sinus mucosa. Am. J. Rhinol.
2001
,15, 175–179. [CrossRef]
[PubMed]
Int. J. Environ. Res. Public Health 2017,14, 516 10 of 13
18.
Ghafouri, B.; Stahlbom, B.; Tagesson, C.; Lindahl, M. Newly identified proteins in human nasal lavage fluid
from non-smokers and smokers using two-dimensional gel electrophoresis and peptide mass fingerprinting.
Proteomics 2002,2, 112–120. [CrossRef]
19.
Talbot, A.R.; Herr, T.M.; Parsons, D.S. Mucociliary clearance and buffered hypertonic saline solution.
Laryngoscope 1997,107, 500–503. [CrossRef] [PubMed]
20.
Woods, C.M.; Tan, S.; Ullah, S.; Frauenfelder, C.; Ooi, E.H.; Carney, A.S. The effect of nasal irrigation
formulation on the antimicrobial activity of nasal secretions. Int. Forum Allergy Rhinol.
2015
,5, 1104–1110.
[CrossRef] [PubMed]
21.
Ludwig, P.; Petrich, K.; Schewe, T.; Diezel, W. Inhibition of eicosanoid formation in human polymorphonuclear
leukocytes by high concentrations of magnesium ions. Biol. Chem. 1995,376, 739–744. [CrossRef]
22.
Larbi, K.Y.; Gomperts, B.D. Complex pattern of inhibition by Mg
2+
of exocytosis from permeabilised
eosinophils. Cell Calcium 1997,21, 213–219. [CrossRef]
23.
Tesfaigzi, Y. Roles of apoptosis in airway epithelia. Am. J. Respir. Cell Mol. Biol.
2006
,34, 537–547. [CrossRef]
[PubMed]
24.
Trinh, N.T.N.; Privé, A.; Maillé, E.; Noël, J.; Brochiero, E. EGF and K
+
channel activitycontrol normal and
cystic fibrosis bronchial epithelia repair. Am. J. Physiol. Lung Cell. Mol. Physiol.
2008
,295, L866–L880.
[CrossRef] [PubMed]
25.
Buchanan, P.J.; McNally, P.; Harvey, B.J.; Urbach, V. Lipoxin A4-mediated KATP potassium channel activation
results in cystic fibrosis airway epithelial repair. Am. J. Physiol. Lung Cell. Mol. Physiol.
2013
,305, L193–L201.
[CrossRef] [PubMed]
26.
Chusakul, S.; Warathanasin, S.; Suksangpanya, N.; Phannaso, C.; Ruxrungtham, S.; Snidvongs, K.;
Aeumjaturapat, S. Comparison of buffered and nonbuffered nasal saline irrigations in treating allergic
rhinitis. Laryngoscope 2013,123, 53–56. [CrossRef] [PubMed]
27.
England, R.J.; Anthony, R.; Homer, J.J.; Martin-Hirsch, D.P. Nasal pH and saccharin clearance are unrelated
in the physiologically normal nose. Rhinology 2000,38, 66–67. [PubMed]
28.
Baraniuk, J.N.; Ali, M.; Yuta, A.; Fang, S.Y.; Naranch, K. Hypertonic saline nasal provocation stimulates
nociceptive nerves, substance P release, and glandular mucous exocytosis in normal humans. Am. J. Respir.
Crit. Care Med. 1999,160, 655–662. [CrossRef] [PubMed]
29.
PubChem. Open Chemistry Database. Ringer-Lactate. Available online: https://pubchem.ncbi.nlm.nih.
gov/compound/6335487#section=Top (accessed on 3 March 2017).
30.
Rabago, D.; Zgierska, A.; Mundt, M.; Barrett, B.; Bobula, J.; Maberry, R. Efficacy of daily hypertonic saline
nasal irrigation among patients with sinusitis: A randomized controlled trial. J. Fam. Pract.
2002
,51,
1049–1055. [PubMed]
31.
Tomooka, L.T.; Murphy, C.; Davidson, T.M. Clinical study and literature review of nasal irrigation.
Laryngoscope 2000,110, 1189–1193. [CrossRef] [PubMed]
32.
Brown, C.L.; Graham, S.M. Nasal irrigations: Good or bad? Curr. Opin. Otolaryngol. Head Neck Surg.
2004
,12,
9–13. [CrossRef] [PubMed]
33.
Ho, E.Y.; Cady, K.A.; Robles, J.S. A case study of the Neti pot’s rise, americanization, and rupture as
integrative medicine in U.S. media discourse. Health Commun. 2016,31, 1181–1192. [CrossRef] [PubMed]
34.
Wormald, P.J.; Cain, T.; Oates, L.; Hawke, L.; Wong, I. A comparative study of three methods of nasal
irrigation. Laryngoscope 2004,114, 2224–2227. [CrossRef] [PubMed]
35.
Salib, R.J.; Talpallikar, S.; Uppal, S.; Nair, S.B. A prospective randomised single-blinded clinical trial
comparing the efficacy and tolerability of the nasal douching products Sterimar
and Sinus Rinse
following functional endoscopic sinus surgery. Clin. Otolaryngol. 2013,38, 297–305. [CrossRef] [PubMed]
36.
Campos, J.; Heppt, W.; Weber, R. Nasal douches for diseases of the nose and the paranasal sinuses—A
comparative in vitro investigation. Eur. Arch. Otorhinolaryngol. 2013,270, 2891–2899. [CrossRef] [PubMed]
37.
Garavello, W.; Romagnoli, M.; Sordo, L.; Gaini, R.M.; Di Berardino, C.; Angrisano, A. Hypersaline
nasal irrigation in children with symptomatic seasonal allergic rhinitis: A randomized study.
Pediatr. Allergy Immunol. 2003,14, 140–143. [CrossRef] [PubMed]
38.
Marchisio, P.; Varricchio, A.; Baggi, E.; Bianchini, S.; Capasso, M.E.; Torretta, S.; Capaccio, P.; Gasparini, C.;
Patria, F.; Esposito, S.; et al. Hypertonic saline is more effective than normal saline in seasonal allergic rhinitis
in children. Int. J. Immunopathol. Pharmacol. 2012,25, 721–730. [CrossRef] [PubMed]
Int. J. Environ. Res. Public Health 2017,14, 516 11 of 13
39.
Chen, J.R.; Jin, L.; Li, X.Y. The effectiveness of nasal saline irrigation (seawater) in treatment of allergic
rhinitis in children. Int. J. Pediatr. Otorhinolaryngol. 2014,78, 1115–1118. [CrossRef] [PubMed]
40.
Barham, H.P.; Harvey, R.J. Nasal saline irrigation: Therapeutic or homeopathic. Braz. J. Otorhinolaryngol.
2015,81, 457–458. [CrossRef] [PubMed]
41.
Jeffe, J.S.; Bhushan, B.; Schroeder, J.W., Jr. Nasal saline irrigation in children: A study of compliance and
tolerance. Int. J. Pediatr. Otorhinolaryngol. 2012,76, 409–413. [CrossRef] [PubMed]
42.
Brook, I. Bacterial contamination of saline nasal spray/drop solution in patients with respiratory tract
infection. Am. J. Infect. Control 2002,30, 246–247. [CrossRef] [PubMed]
43.
Lee, J.M.; Nayak, J.V.; Doghramji, L.L.; Welch, K.C.; Chiu, A.G. Assessing the risk of irrigation bottle and
fluid contamination after endoscopic sinus surgery. Am. J. Rhinol. Allergy
2010
,24, 197–199. [CrossRef]
[PubMed]
44.
Psaltis, A.J.; Foreman, A.; Wormald, P.J.; Schlosser, R.J. Contamination of sinus irrigation devices: A review
of the evidence and clinical relevance. Am. J. Rhinol. Allergy 2012,26, 201–203. [CrossRef] [PubMed]
45.
Kofonow, J.M.; Bhuskute, A.; Doghramji, L.; Palmer, J.N.; Cohen, N.A.; Chiu, A.G. One-way valve bottle
contamination rates in the immediate post-functional endoscopic sinus surgery period. Am. J. Rhinol. Allergy
2011,25, 393–396. [CrossRef] [PubMed]
46.
Heatley, D.G.; McConnell, K.E.; Kille, T.L.; Leverson, G.E. Nasal irrigation for the alleviation of sinonasal
symptoms. Otolaryngol. Head Neck Surg. 2001,125, 44–48. [CrossRef] [PubMed]
47.
Foreman, A.; Wormald, P.J. Can bottle design prevent bacterial contamination of nasal irrigation devices?
Int. Forum Allergy Rhinol. 2011,1, 303–307. [CrossRef] [PubMed]
48.
Williams, G.B.; Ross, L.L.; Chandra, R.K. Are bulb syringe irrigators a potential source of bacterial
contamination in chronic rhinosinusitis? Am. J. Rhinol. 2008,22, 399–401. [CrossRef] [PubMed]
49.
Keen, M.; Foreman, A.; Wormald, P.J. The clinical significance of nasal irrigation bottle contamination.
Laryngoscope 2010,120, 2110–2114. [CrossRef] [PubMed]
50.
Welch, K.C.; Cohen, M.B.; Doghramji, L.L.; Cohen, N.A.; Chandra, R.K.; Palmer, J.N.; Chiu, A.G. Clinical
correlation between irrigation bottle contamination and clinical outcomes in post-functional endoscopic
sinus surgery patients. Am. J. Rhinol. Allergy 2009,23, 401–404. [CrossRef] [PubMed]
51.
Lewenza, S.; Charron-Mazenod, L.; Cho, J.J.; Mechor, B. Identification of bacterial contaminants in sinus
irrigation bottles from chronic rhinosinusitis patients. J. Otolaryngol. Head Neck Surg.
2010
,39, 458–463.
[PubMed]
52.
Yoder, J.S.; Straif-Bourgeois, S.; Roy, S.L.; Moore, T.A.; Visvesvara, G.S.; Ratard, R.C.; Hill, V.R.; Wilson, J.D.;
Linscott, A.J.; Crager, R.; et al. Primary amebic meningoencephalitis deaths associated with sinus irrigation
using contaminated tap water. Clin. Infect. Dis. 2012,55, e79–e85. [CrossRef] [PubMed]
53.
Gelardi, M.; Taliente, S.; Piccininni, K.; Silvestre, G.; Quaranta, N.; Ciprandi, G. Nasal irrigation with Nasir
®
in children: A preliminary experience on nasal cytology. J. Biol. Regul. Homeost. Agents
2016
,30, 1125–1130.
[PubMed]
54.
Fashner, J.; Ericson, K.; Werner, S. Treatment of the common cold in children and adults. Am. Fam. Physician
2012,86, 153–159. [PubMed]
55.
De Luca, M.; Donà, D.; Montagnani, C.; Lo Vecchio, A.; Romanengo, M.; Tagliabue, C.; Centenari, C.;
D’Argenio, P.; Lundin, R.; Giaquinto, C.; et al. Antibiotic prescriptions and prophylaxis in Italian children. Is
it time to change? Data from the ARPEC Project. PLoS ONE 2016,11, e0154662. [CrossRef] [PubMed]
56.
King, D.; Mitchell, B.; Williams, C.P.; Spurling, G.K. Saline nasal irrigation for acute upper respiratory tract
infections. Cochrane Database Syst. Rev. 2015,4. [CrossRef]
57.
Adam, P.; Stiffman, M.; Blake, R.L., Jr. A clinical trial of hypertonic saline nasal spray in subjects with the
common cold or rhinosinusitis. Arch. Fam. Med. 1998,7, 39–43. [CrossRef] [PubMed]
58.
Bollag, U.; Albrecht, E.; Wingert, W. Medicated versus saline nose drops in the management of upper
respiratory infection. Helv. Paediatr. Acta 1984,39, 341–345. [PubMed]
59.
Wang, Y.H.; Yang, C.P.; Ku, M.S.; Sun, H.L.; Lue, K.H. Efficacy of nasal irrigation in the treatment of acute
sinusitis in children. Int. J. Pediatr. Otorhinolaryngol. 2009,73, 1696–1701. [CrossRef] [PubMed]
60.
Ragab, A.; Farahat, T.; Al-Hendawy, G.; Samaka, R.; Ragab, S.; El-Ghobashy, A. Nasal saline irrigation with or
without systemic antibiotics in treatment of children with acute rhinosinusitis. Int. J. Pediatr. Otorhinolaryngol.
2015,79, 2178–2186. [CrossRef] [PubMed]
Int. J. Environ. Res. Public Health 2017,14, 516 12 of 13
61.
Satdhabudha, A.; Utispan, K.; Monthanapisut, P.; Poachanukoon, O. A randomized controlled study
comparing the efficacy of nasal saline irrigation devices in children with acute rhinosinusitis. Asian Pac. J.
Allergy Immunol. 2016. [CrossRef]
62.
Tugrul, S.; Dogan, R.; Eren, S.B.; Meric, A.; Ozturan, O. The use of large volume low pressure nasal saline
with fluticasone propionate for the treatment of pediatric acute rhinosinusitis. Int. J. Pediatr. Otorhinolaryngol.
2014,78, 1393–1399. [CrossRef] [PubMed]
63.
Harvey, R.; Hannan, S.A.; Badia, L.; Scadding, G. Nasal saline irrigations for the symptoms of chronic
rhinosinusitis. Cochrane Database Syst. Rev. 2007,3. [CrossRef]
64.
Bachmann, G.; Hommel, G.; Michel, O. Effect of irrigation of the nose with isotonic salt solution on adult
patients with chronic paranasal sinus disease. Eur. Arch. Otorhinolaryngol.
2000
,257, 537–541. [CrossRef]
[PubMed]
65.
Hauptman, G.; Ryan, M.W. The effect of saline solutions on nasal patency and mucociliary clearance in
rhinosinusitis patients. Otolaryngol. Head Neck Surg. 2007,137, 815–821. [CrossRef] [PubMed]
66.
Pynnonen, M.A.; Mukerji, S.S.; Kim, H.M.; Adams, M.E.; Terrell, J.E. Nasal saline for chronic sinonasal
symptoms: A randomized controlled trial. Arch. Otolaryngol. Head Neck Surg.
2007
,133, 1115–1120.
[CrossRef] [PubMed]
67.
Pinto, J.M.; Elwany, S.; Baroody, F.M.; Naclerio, R.M. Effects of saline sprays on symptoms after endoscopic
sinus surgery. Am. J. Rhinol. 2006,20, 191–196. [PubMed]
68.
Freeman, S.R.; Sivayoham, E.S.; Jepson, K.; de Carpentier, J. A preliminary randomised controlled trial
evaluating the efficacy of saline douching following endoscopic sinus surgery. Clin. Otolaryngol.
2008
,33,
462–465. [CrossRef] [PubMed]
69.
Liang, K.L.; Su, M.C.; Tseng, H.C.; Jiang, R.S. Impact of pulsatile nasal irrigation on the prognosis of
functional endoscopic sinus surgery. J. Otolaryngol. Head Neck Surg. 2008,37, 148–153. [PubMed]
70.
Chong, L.Y.; Head, K.; Hopkins, C.; Philpott, C.; Glew, S.; Scadding, G.; Scadding, G.; Burton, M.J.;
Schilder, A.G. Saline irrigation for chronic rhinosinusitis. Cochrane Database Syst. Rev. 2016,4. [CrossRef]
71.
Cassandro, E.; Chiarella, G.; Cavaliere, M.; Sequino, G.; Cassandro, C.; Prasad, S.C.; Scarpa, A.; Iemma, M.
Hyaluronan in the treatment of chronic rhinosinusitis with nasal polyposis. Indian J. Otolaryngol. Head
Neck Surg. 2015,67, 299–307. [CrossRef] [PubMed]
72.
World Allergy Organization. Rhinitis. Available online: http://www.worldallergy.org/professional/
allergic_diseases_center/rhinitis/rhinitissynopsis.php (accessed on 3 March 2017).
73.
Hermelingmeier, K.E.; Weber, R.K.; Hellmich, M.; Heubach, C.P.; Mösges, R. Nasal irrigation as an adjunctive
treatment in allergic rhinitis: A systematic review and meta-analysis. Am. J. Rhinol. Allergy
2012
,26,
e119–e125. [CrossRef] [PubMed]
74.
Barbieri, M.; Salami, A.; Mora, F.; Casazza, A.; Sovatzis, A.; Teglia, R.; Cordone, M.P.; Mora, R. Behavior
of serum IgE and IgA in patients with allergic rhinitis treated with iodine bromide thermal water.
Acta Otorhinolaryngol. Ital. 2002,22, 215–219. [PubMed]
75.
Cingi, C.; Unlu, H.H.; Songu, M.; Yalcin, S.; Topcu, I.; Cakli, H.; Bal, C. Seawater gel in allergic rhinitis:
Entrapment effect and mucociliary clearance compared with saline. Ther. Adv. Respir. Dis.
2010
,4, 13–18.
[CrossRef] [PubMed]
76.
Cordray, S.; Harjo, J.B.; Miner, L. Comparison of intranasal hypertonic Dead Sea saline spray and intranasal
aqueous triamcinolone spray in seasonal allergic rhinitis. Ear Nose Throat J. 2005,84, 426–430. [PubMed]
77.
Garavello, W.; Di Berardino, F.; Romagnoli, M.; Sambataro, G.; Gaini, R.M. Nasal rinsing with hypertonic
solution: An adjunctive treatment for pediatric seasonal allergic rhinoconjunctivitis. Int. Arch.
Allergy Immunol. 2005,137, 310–314. [CrossRef] [PubMed]
78.
Garavello, W.; Somigliana, E.; Acaia, B.; Gaini, L.; Pignataro, L.; Gaini, R.M. Nasal lavage in pregnant
women with seasonal allergic rhinitis: A randomized study. Int. Arch. Allergy Immunol.
2010
,151, 137–141.
[CrossRef] [PubMed]
79.
Klimek, L.J.V.; Hundorf, F.; Hommel, G.; Hormann, K. Lässt sich der medikamentenverbrauch bei patienten
mit saisonaler rhinitis allergica durch nasenspülbehandlungen mit isoosmotischer emser salziosung
reduzieren? Allergologie 2001,24, 309–315.
80.
Li, H.; Sha, Q.; Zuo, K.; Jiang, H.; Cheng, L.; Shi, J.; Xu, G. Nasal saline irrigation facilitates control of allergic
rhinitis by topical steroid in children. ORL J. Otorhinolaryngol. Relat. Spec.
2009
,71, 50–55. [CrossRef]
[PubMed]
Int. J. Environ. Res. Public Health 2017,14, 516 13 of 13
81.
Rogkakou, A.; Guerra, L.; Massacane, P.; Baiardini, I.; Baena-Cagnani, R.; Zanella, C. Effects on symptoms
and quality of life of hypertonic saline nasal spray added to antihistamine in persistent allergic rhinitis—A
randomized controlled study. Eur. Ann. Allergy Clin. Immunol. 2005,37, 353–356. [PubMed]
82.
Ural, A.; Oktemer, T.K.; Kizil, Y.; Ileri, F.; Uslu, S. Impact of isotonic and hypertonic saline solutions on
mucociliary activity in various nasal pathologies: Clinical study. J. Laryngol. Otol.
2009
,123, 517–521.
[CrossRef] [PubMed]
83.
De Souza Campos Fernandes, S.; de Andrade, C.R.; da Cunha Ibiapina, C. Application of peak nasal
inspiratory flow reference values in the treatment of allergic rhinitis. Rhinology
2014
,52, 133–136. [CrossRef]
[PubMed]
©
2017 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).
... In Yogic practices, different nasal cleansing techniques are used as part of a wider range of body-cleansing procedures. Vedic texts describe several techniques called "neti" [1,2], with "jala neti" [3,4] corresponding to today's concept of nasal cavity irrigation. In the neti techniques, copperware is used for irrigation (to prevent contamination of the solution), the solution is heated to body temperature and an exact salt concentration in the preparation of the solution is specified. ...
... Additional ionic constituents of seawater show other effects, such as increased cell viability and inflammation reduction ( Figure 1 and Table 2). [3,20]. ...
... In our paper, we presented a comprehensive body of evidence regarding the beneficiary effects of nasal irrigation solutions in general as well as for a wide variety of clinical indications, such as infectious diseases of the upper respiratory tract, allergic rhinitis, postoperative care, etc. All information mentioned above, especially the data in Table 2 [3,20], clearly favours seawater preparations over saline. However, a definitive recommendation can be given only after the careful evaluation of EBM levels for each of the papers discussed. ...
Article
Full-text available
The history of saline nasal irrigation (SNI) is indeed a long one, beginning from the ancient Ayurvedic practices and gaining a foothold in the west at the beginning of the 20th century. Today, there is a growing number of papers covering the effects of SNI, from in vitro studies to randomized clinical trials and literature overviews. Based on the recommendations of most of the European and American professional associations, seawater, alone or in combination with other preparations, has its place in the treatment of numerous conditions of the upper respiratory tract (URT), primarily chronic (rhino)sinusitis, allergic rhinitis, acute URT infections and postoperative recovery. Additionally, taking into account its multiple mechanisms of action and mounting evidence from recent studies, locally applied seawater preparations may have an important role in the prevention of viral and bacterial infections of the URT. In this review we discuss results published in the past years focusing on seawater preparations and their use in clinical and everyday conditions, since such products provide the benefits of additional ions vs. saline, have an excellent safety profile and are recommended by most professional associations in the field of otorhinolaryngology.
... Nasal irrigation is recommended as an adjunctive treatment for ENT disorders. Nasal lavage with hypertonic saline/seawater was shown to have a favorable effect in the management of sinonasal conditions and symptoms [1,2]. Among different hypertonic solutions, seawater solutions of 2.3% NaCl are frequently used in adult and pediatric populations [3][4][5]. ...
... Nasal irrigation is recommended as an adjunctive treatment for ENT disorders. Nasal lavage with hypertonic saline/seawater was shown to have a favorable effect in the management of sinonasal conditions [1,2]. Nasal obstruction is one of the most cumbersome symptoms. ...
Article
Full-text available
Limited real-world data exist on the clinical benefits of medical devices for cleansing and decongesting the nasal mucosa. To that end, a user survey study with a hypertonic seawater nasal irrigation solution comprising algal and herbal ingredients (HSS-Plus) was conducted in patients with ENT disorders. One hundred patients who experienced otorhinolaryngological (ENT) symptoms were recruited in private outpatient settings. Patients were advised to perform nasal irrigations with this medical device according to the products' instructions for use over a period of up to two weeks. At the end of the evaluation period, scores of symptom improvement, nasal cleansing, duration of symptoms and total effectiveness, safety and ease of product use were recorded in questionnaires using Visual Analog Scale (VAS) scores. A high score of 8.4/10 was assigned by patients regarding the product's ability to improve nasal cleansing. Enhanced decongestive action (score 8.2/10) and faster symptom improvement (score 8.0/10) was perceived by the product users. Patients were very satisfied with the product giving a high score of 24.7/30 on product's total effectiveness. The medical device had a high safety profile with few minor adverse events noted. These results support adjunctive treatment of HSS-Plus for symptomatic relief in patients with ENT disorders.
... This guideline is intended to promote more active use of nasal irrigation to treat CRS, improve treatment outcomes, and enhance the doctor-patient relationship. Nasal cavity mucociliary function [13]. Nasal saline irrigation in CRS after ESS has been proven to clean the nasal cavity and promote the restoration of mucosal function [14][15][16]. ...
Article
The Korean Society of Otorhinolaryngology-Head and Neck Surgery and Korean Rhinologic Society appointed a guideline development group (GDG) to establish a clinical practice guideline, and the GDG developed a guideline for nasal irrigation for adult patients with chronic rhinosinusitis (CRS). The guideline focuses on knowledge gaps, practice variations, and clinical concerns associated with nasal irrigation. Nasal irrigation has been recommended as the first-line treatment for CRS in various guidelines, and its clinical effectiveness has been demonstrated through a number of studies with robust evidence. However, no guidelines have presented a consistent nasal irrigation method. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. The committee developed 11 evidence-based recommendations. This guideline focuses on the evidence-based quality improvement opportunities deemed the most important by the GDG. Moreover, the guideline addresses whether nasal lavage helps treat CRS, what type of rinsing solution should be used, and the effectiveness of using additional medications to increase the therapeutic effect.
... More recently, the use of distilled or bottled water has even been recommended due to the increased risk of bacterial contamination with a boiled solution [21]. At least 37% of parents and 20% of physicians did not comment on which volume would be the best to use regarding each age category, reflecting the current gap in the literature on this topic [12]. Pediatric studies mentioned volumes ranging from a few drops [22] to 20 mL in children around 5 years or age [23]. ...
Article
Background : Nasal irrigation is widely used in infants to relieve nasal obstruction. However, the nasal irrigation technique has not been standardized, and nasal irrigation practice habits (NIPH) in infants have not been investigated. Our objective was to provide an overview of NIPH in infants among parents, childcare workers, and healthcare professionals living in Belgium. Methods : Parents, childcare workers, physiotherapists, nurses, pharmacists, and physicians were invited to fill in an electronic survey questioning their NIPH in infants. The survey was disseminated through social networks, practitioners’ associations, and creches. Results : The questionnaire was fully completed by 359 participants. A ready-made solution was used by 93% of participants, of whom 92% used physiological saline. The prophylactic use of nasal irrigation was considered appropriate or very appropriate by 65% of all participants. The irrigation frequency was particularly heterogeneous among participants. The optimal solution propulsion speed and solution volume to be used depended on the group of participants being interviewed. At least 37% of parents and 20% of physicians did not take a stand on the optimal irrigation volume to use in each age category. On average, 83% of participants described performing nasal irrigation by lying the infant on one side and delivering the solution through the top nostril. Finally, 74% of respondents declared that no risk was associated with this technique. Conclusion : Although some common NIPH viewpoints among the surveyed participants were identified, several disagreements were reported, reflecting the absence of a standardized method of nasal irrigation.
... It improves the mucociliary function, which should decrease nasal symptoms and enhance the effects of intranasal corticosteroids. 4 Evidence of saline treatment in ARS is inconclusive due to multiple factors that may impact its effectiveness. Previous meta-analyses assessed patients with upper respiratory tract infection, including pharyngitis, otitis media, and tonsillitis. ...
Article
Background Although nasal saline treatments are widely used in treating acute rhinosinusitis (ARS), the evidence in adult patients is inconclusive. Our objective was to assess the add-on benefits of saline treatment in adult with ARS. Methods Literature searches were performed (updated May 9th, 2021). Randomized controlled trials studying the effects of nasal saline treatment in adults with ARS were included. Data were pooled for meta-analysis. Outcomes were composite symptoms score (CSS), disease-specific quality of life (DS-QoL) score, individual symptom score, endoscopy score, saccharin transit time, cure rate, days to resolution, and adverse events. Results Eleven studies (718 patients) were included. Nasal discharge was the only symptom improved [standardized mean difference (SMD) -0.36, 95% confidence interval (CI) -0.66 to -0.05]. Saline as an add-on treatment brought no benefits in: CSS and DS-QoL score at both time points (3-10 days and at the end of the study). Other outcomes also showed no benefits of saline, including endoscopy score, saccharin transit time, cure rate, days to resolution, and adverse events. Subgroup analyses showed improvement in viral ARS patients in CSS (SMD -0.60, 95% CI -1.12 to -0.08) and DS-QoL score (mean difference -15.90, 95% CI -31.78 to -0.02), and patients using large-volume saline in CSS (SMD -0.42, 95% CI -0.78 to -0.06). Conclusions Nasal saline as an add-on treatment improved rhinorrhea. There was no improvement in CSS and DS-QoL except the subgroup of viral ARS when using large-volume saline. There were no differences in adverse events between the saline and non-saline treatments. This article is protected by copyright. All rights reserved
Chapter
The microbiome is the indigenous microbial population (microbiota) and the host environment in which it lives, and it is revolutionising how doctors think about germs in human health and illness. The understanding that most microbes in human bodies perform vital ecosystem functions that benefit the whole microbial host system is perhaps the most basic development. The microbiome is a collection of varied and numerous bacteria that live in the gastrointestinal system. Generally, this ecosystem comprises billions of microbial cells that play a vital role in human health control. Immunity, nutrition absorption, digestion, and metabolism have all been linked to the microbiome. Researchers have discovered that changes in the microbiome are linked to the development of diseases including obesity, inflammatory lung disease, and CVS diseases, carcinoma in recent times. A change in the microbial population of the intestine has a big impact on human health and disease aetiology. These changes are caused by a combination of factors, including lifestyle and the existence of an underlying illness. Dysbiosis makes the host more susceptible to infection, the type of which varies depending on the anatomical location. The distinct metabolic processes and roles of these bacteria inside each bodily location are accounted for by the inherent variety of the human microbiota. As a result, it is critical to comprehend the human microbiome’s microbial makeup and behaviours as they relate to health and illness.
Article
Background and Objectives We aimed to compare the efficacy of a novel powered irrigation system with that of the manual bottle-squeeze method for postoperative healing after endoscopic sinonasal surgery (ESS).Subjects and Method In this prospective randomized clinical trial, 29 patients were enrolled for nasal irrigation (NI) with either NOSSHA® (Womens Care Co., Ltd.) powered irrigation system (NOSSHA® group, n=14) or manual irrigation (control group, n=15). Objective findings were evaluated using the modified Lund-Kennedy scores. Subjective outcomes were assessed using the total nasal endoscopic score (TNES), total nasal symptom score (TNSS), visual analog scale (VAS), and quality of life (QOL) questionnaires in each group at baseline, and 1, 2, 4, 6, and 8 weeks after ESS. We compared the postoperative changes between both groups.Results The mean TNES of patients were significantly higher in the NOSSHA® group than in the control group (p=0.015); however, the improvement in TNES was achieved 2 weeks earlier in the NOSSHA® group. The improvement in TNES (p<0.001) and TNSS (p<0.001) was statistically significant in both groups. The improvement in QOL was statistically significant in the NOSSHA® (p<0.001) and control group (p=0.007). The improvement in the TNSS and QOL was earlier in the NOSSHA® group by 4 and 7 weeks, respectively; no early improvement occurred in the NOSSHA® group for the VAS score.Conclusion We validated the usefulness of postoperative NI using a powered device, which may be useful for patients who cannot tolerate manual NI.
Chapter
Evidence suggests that the microbiome of the upper respiratory tract (URT) contributes to health and disease. The URT has gained more attention with ongoing consideration within the “unified airway,” and may serve as a model for the lower airway in host–microbial interactions. As we learn more about the role that microbiota play in URT disease development or as a disease modifier, novel approaches can be developed to modify these potential targets. Recent epidemiologic studies reveal an association between environmental exposures which alter the microbiota, and development of allergic rhinitis and chronic rhinosinusitis. In fact, samples from the upper respiratory tract reveal distinct microbiotas compared to healthy controls, with microbial changes (dysbiosis) preceding or coinciding with the development of disease. Mechanistic studies have confirmed that microbes can either promote gut and airway health by strengthening barrier integrity or they can damage gut and airway epithelium through dysregulation of local immune processes. In this chapter, we discuss recent studies that reveal the link between the microbiota and upper airway disease and potential ways to alter the dysbiosis associated with URT disease.
Article
Full-text available
Objective: To evaluate the efficacy of positive pressure nasal irrigation and the incidence of bacterial colonization found in the irrigation device utilized for nasal saline irrigation in children with acute sinusitis. Methods: We performed a randomized, prospective, controlled study of 80 children with acute sinusitis, aged 3-15 years. Each participant was randomized into one of two groups, one treated with a squeezable bottle and the other group treated with a syringe. A 5S-score and satisfactory score were then assessed. All patients utilized 1.25% buffered hypertonic solution for nasal irrigation twice daily for 2 weeks and received amoxicillin or amoxicillin-clavulanic acid. During this period, all participants recorded a 5S-score, a satisfaction score, resultant side effects and antihistamine use. Parents were instructed to clean the device with soap after each use. Nasal irrigation devices were sent to the microbiological laboratory for bacterial identification. Results: At week two visits, both groups had improvement in their 5S-score and satisfaction score compared to baseline visits. Patients in the squeezable bottle group significantly improved in their 5S-score and satisfaction score compared to those in the syringe group. There were few complaints reported, and side effects were seen equally in both groups. The overall rate of bacterial contamination was found to be around 80%, but this did not translate into higher rates of infection amongst patients. Nasal irrigation with the use of a squeezable bottle was associated with improvement in 5S-score and satisfaction scores when compared to syringe use in children with acute sinusitis. There was no significant difference in bacterial contamination.
Article
Full-text available
Background Antimicrobials are the most commonly prescribed drugs. Many studies have evaluated antibiotic prescriptions in the paediatric outpatient but few studies describing the real antibiotic consumption in Italian children’s hospitals have been published. Point-prevalence survey (PPS) has been shown to be a simple, feasible and reliable standardized method for antimicrobials surveillance in children and neonates admitted to the hospital. In this paper, we presented data from a PPS on antimicrobial prescriptions carried out in 7 large Italian paediatric institutions. Methods A 1-day PPS on antibiotic use in hospitalized neonates and children was performed in Italy between October and December 2012 as part of the Antibiotic Resistance and Prescribing in European Children project (ARPEC). Seven institutions in seven Italian cities were involved. The survey included all admitted patients less than 18 years of age present in the ward at 8:00 am on the day of the survey, who had at least one on-going antibiotic prescription. For all patients data about age, weight, underlying disease, antimicrobial agent, dose and indication for treatment were collected. Results The PPS was performed in 61 wards within 7 Italian institutions. A total of 899 patients were eligible and 349 (38.9%) had an on-going prescription for one or more antibiotics, with variable rates among the hospitals (25.7% - 53.8%). We describe antibiotic prescriptions separately in neonates (<30 days old) and children (> = 30 days to <18 years old). In the neonatal cohort, 62.8% received antibiotics for prophylaxis and only 37.2% on those on antibiotics were treated for infection. Penicillins and aminoglycosides were the most prescribed antibiotic classes. In the paediatric cohort, 64.4% of patients were receiving antibiotics for treatment of infections and 35.5% for prophylaxis. Third generation cephalosporins and penicillin plus inhibitors were the top two antibiotic classes. The main reason for prescribing antibiotic therapy in children was lower respiratory tract infections (LRTI), followed by febrile neutropenia/fever in oncologic patients, while, in neonates, sepsis was the most common indication for treatment. Focusing on prescriptions for LRTI, 43.3% of patients were treated with 3rd generation cephalosporins, followed by macrolides (26.9%), quinolones (16.4%) and carbapenems (14.9%) and 50.1% of LRTI cases were receiving more than one antibiotic. For neutropenic fever/fever in oncologic patients, the preferred antibiotics were penicillins with inhibitors (47.8%), followed by carbapenems (34.8%), aminoglycosides (26.1%) and glycopeptides (26.1%). Overall, the 60.9% of patients were treated with a combination therapy. Conclusions Our study provides insight on the Italian situation in terms of antibiotic prescriptions in hospitalized neonates and children. An over-use of third generation cephalosporins both for prophylaxis and treatment was the most worrisome finding. A misuse and abuse of carbapenems and quinolones was also noted. Antibiotic stewardship programs should immediately identify feasible targets to monitor and modify the prescription patterns in children’s hospital, also considering the continuous and alarming emergence of MDR bacteria.
Article
Full-text available
Background: The use of nasal irrigation for the treatment of nose and sinus complaints has its foundations in yogic and homeopathic traditions. There has been increasing use of saline irrigation, douches, sprays and rinsing as an adjunct to the medical management of chronic rhinosinusitis. Treatment strategies often include the use of topical saline from once to more than four times a day. Considerable patient effort is often involved. Any additional benefit has been difficult to discern from other treatments. Objectives: To evaluate the effectiveness and safety of topical saline in the management of chronic rhinosinusitis. Search methods: Our search included the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4 2006), MEDLINE (1950 to 2006) and EMBASE (1974 to 2006). The date of the last search was November 2006. Selection criteria: Randomised controlled trials in which saline was evaluated in comparison with either no treatment, a placebo, as an adjunct to other treatments or against treatments. The comparison of hypertonic versus isotonic solutions was also compared. Data collection and analysis: Trials were graded for methodological quality using the Cochrane approach (modification of Chalmers 1990). Only symptom scores from saline versus no treatment and symptom and radiological scores from the hypertonic versus isotonic group could be pooled for statistical analysis. A narrative overview of the remaining results is presented. Main results: Eight trials were identified that satisfied the inclusion criteria. Three studies compared topical saline against no treatment, one against placebo, one as an adjunct to and one against an intranasal steroid spray. Two studies compared different hypertonic solutions against isotonic saline. There is evidence that saline is beneficial in the treatment of the symptoms of chronic rhinosinusitis when used as the sole modality of treatment. Evidence also exists in favour of saline as a treatment adjunct. No superiority was seen when saline was compared against a reflexology 'placebo'. Saline is not as effective as an intranasal steroid. Some evidence suggests that hypertonic solutions improve objective measures but the impact on symptoms is less clear. Authors' conclusions: Saline irrigations are well tolerated. Although minor side effects are common, the beneficial effect of saline appears to outweigh these drawbacks for the majority of patients. The use of topical saline could be included as a treatment adjunct for the symptoms of chronic rhinosinusitis. © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Article
Full-text available
Background: This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Nasal saline irrigation is commonly used to improve patient symptoms. Objectives: To evaluate the effects of saline irrigation in patients with chronic rhinosinusitis. Search methods: The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 9); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 30 October 2015. Selection criteria: Randomised controlled trials (RCTs) with a follow-up period of at least three months comparing saline delivered to the nose by any means (douche, irrigation, drops, spray or nebuliser) with (a) placebo, (b) no treatment or (c) other pharmacological interventions. Data collection and analysis: We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the commonest adverse event - epistaxis. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of local irritation and discomfort. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. Main results: We included two RCTs (116 adult participants). One compared large-volume (150 ml) hypertonic (2%) saline irrigation with usual treatment over a six-month period; the other compared 5 ml nebulised saline twice a day with intranasal corticosteroids, treating participants for three months and evaluating them on completion of treatment and three months later. Large-volume, hypertonic nasal saline versus usual careOne trial included 76 adult participants (52 intervention, 24 control) with or without polyps.Disease-specific HRQL was reported using the Rhinosinusitis Disability Index (RSDI; 0 to 100, 100 = best quality of life). At the end of three months of treatment, patients in the saline group were better than those in the placebo group (mean difference (MD) 6.3 points, 95% confidence interval (CI) 0.89 to 11.71) and at six months there was a greater effect (MD 13.5 points, 95% CI 9.63 to 17.37). We assessed the evidence to be of low quality for the three months follow-up and very low quality for the six months follow-up. Patient-reported disease severity was evaluated using a "single-item sinus symptom severity assessment" but the range of scores is not stated, making it impossible for us to determine the meaning of the data presented.No adverse effects data were collected in the control group but 23% of participants in the saline group experienced side effects including epistaxis. General HRQL was measured using SF-12 (0 to 100, 100 = best quality of life). No difference was found after three months of treatment (low quality evidence) but at six months there was a small difference favouring the saline group, which may not be of clinical significance and has high uncertainty (MD 10.5 points, 95% CI 0.66 to 20.34) (very low quality evidence). Low-volume, nebulised saline versus intranasal corticosteroidsOne trial included 40 adult participants with polyps. Our primary outcome of disease-specific HRQL was not reported. At the end of treatment (three months) the patients who had intranasal corticosteroids had less severe symptoms (MD -13.50, 95% CI -14.44 to -12.56); this corresponds to a large effect size. We assessed the evidence to be of very low quality. Authors' conclusions: The two studies were very different in terms of included populations, interventions and comparisons and so it is therefore difficult to draw conclusions for practice. The evidence suggests that there is no benefit of a low-volume (5 ml) nebulised saline spray over intranasal steroids. There is some benefit of daily, large-volume (150 ml) saline irrigation with a hypertonic solution when compared with placebo, but the quality of the evidence is low for three months and very low for six months of treatment.
Article
Full-text available
In a period of only one decade in the United States, the neti pot shifted from obscure Ayurvedic health device to mainstream complementary and integrative medicine (CIM), touted by celebrities and sold widely in drug stores. We examine the neti pot as a case study for understanding how a foreign health practice became mainstreamed, and what that process reveals about more general discourses of health in the United States. Using discourse analysis of U.S. popular press and new media news (1999–2012) about the neti pot, we trace the development of discourses from neti’s first introduction in mainstream news, through the hype following Dr. Oz’s presentation on Oprah, to 2011 when two adults tragically died after using Naegleria fowleri amoeba-infested tap water in their neti pots. Neti pot discourses are an important site for communicative analysis because of the pot’s complexity as an intercultural artifact: Neti pots and their use are enfolded into the biomedical practice of nasal irrigation and simultaneously Orientalized as exotic/magical and suspect/dangerous. This dual positioning as normal and exotic creates inequitable access for using the neti pot as a resource for increasing cultural health capital (CHC). This article contributes to work that critically theorizes the transnationalism of CIM, as the neti pot became successfully Americanized. These results have implications for understanding global health practices’ incorporation or co-optation in new contexts, and the important role that popularly mediated health communication can play in framing what health care products and practices mean for consumers.
Article
Allergic rhinitis (AR) and upper airway respiratory infections are frequent in children, and both have a relevant impact on some social aspects, including school attendance and performance, sleep, quality of life (also of the parents), and costs. Saline nasal irrigation is widely employed to reduce nasal congestion and mucopurulent secretion, to stimulate cleansing of the nasal and paranasal cavities, and to induce restoration of mucociliary clearance. The present study evaluated the effects of nasal irrigation on nasal cytology, using the new device Nasir® in 66 children (40 males, 26 females, mean age 7.31Ü.7 years, age range 4-17 years) with allergic rhinitis. The patients were treated with nasal irrigation with warm (36°C) Nasir® (250 mL sacs of premixed solution): one sac twice daily for 12 days. Nasal irrigation significantly reduced the neutrophilic infiltrate (baseline median value 2.8±0.7; post treatment value 2±0.5; p<0.05). In addition, there was a reduction of eosinophil infiltrate (T0= 3.2±1.1; Tl= 2.6±1.2; p= <0.05). There was no significant change with regard to bacteria (T0= 2.7±0.9; Tl= 2.3±1.02; p= 0.17). In conclusion, this pilot study reports that nasal irrigation with Nasir® might be useful to attenuate upper airway inflammation.
Article
Background: Fractional exhaled nitric oxide (FENO) level is directly correlated with airway inflammation in asthma patients. The objective of this study was to define normal FENO levels in healthy Thai volunteers. Methods: This prospective cohort study was conducted in healthy Thai volunteers aged ≥5 years. Demographic and clinical data were recorded and pulmonary function test (PFT) was performed. FENO was measured using a chemiluminescence nitric oxide analyzer. Results: Seventy-nine healthy Thai volunteers with normal lung function test were included. Mean age of participants was 13 (6-47) years and 58.2% were female. All subjects had no history of allergic respiratory diseases. Mean FENO level increased with age, and the differences between age groups were statistically significant (p=0.001). The highest mean FENO level was 13.6 ppb in the 11-15 year age group, and then the FENO level gradually declined with age. The highest mean FENO level was found in the 18-24.9 body mass index (BMI) group. Significant differences were observed for FENO levels between different height groups (p=0.005) but not between different BMI groups (p=0.46). Fair correlations between FENO levels and body weight, height, FEV1, and FVC were observed. A fair correlation between FENO level and age, FENO level and FEF25%-75% was found only in volunteers ≤15 years of age. Conclusion: FENO level in healthy Thais increased with age until reaching maximum level (mean FENO 13.6 ppb) in the 11-15 year age group. Significant differences were observed for FENO levels between different age groups and different height groups.
Article
Background: The management of pediatric chronic rhinosinusitis (PCRS) is evolving. Objective: To assess current practice patterns of members of the American Rhinologic Society (ARS) in managing PCRS. Methods: A 27-item Web-based survey on treatment of PCRS was electronically distributed to the ARS membership. Results: The survey was completed by 67 members, 40% of whom had completed a rhinology fellowship. The most frequently used medical therapies as part of initial treatment for PCRS were nasal saline solution irrigation, (90%), topical nasal steroids (93%), oral antibiotics (52%), and oral steroids (20%). For initial surgical therapy, 90% performed adenoidectomy; in addition, 31% also performed sinus lavage, 17% performed balloon catheter dilation (BCD), and 17% performed endoscopic sinus surgery (ESS). Sixty percent performed adenoidectomy before obtaining computed tomography imaging. When initial surgical treatment failed, 85% performed traditional ESS. In patients with pansinusitis, 50% of the respondents performed frontal sinusotomy and 70% performed sphenoidotomy. BCD was not frequently used; overall, 66% never or rarely used it, 20% sometimes used it, 12% usually used it, and 3% always or almost always used BCD. Conclusions: Most aspects of PCRS management among ARS members were aligned with published consensus statements. Adenoidectomy was almost always included as part of first-line surgical treatment but was also combined with adjunctive surgical procedures with moderate frequency. ESS was performed by a minority of rhinologists as a primary procedure for medically refractory PCRS but was favored when previous surgery failed. BCD was uncommonly used in PCRS.
Article
Objective: Understand real-world prescription patterns for patients presenting with a first diagnosis of ARS and evaluate adherence to published medical guidelines. Study design: Retrospective administrative database analysis. Setting: US-based outpatient settings. Methods: From a US claims database (MarketScan), 99,033 patients were identified with acute rhinosinusitis (ARS) in 2012 ("index"), with a complete medical and prescription history for 12 months preindex and 18 months postindex and no diagnoses of asthma or chronic rhinosinusitis. Of these, a random 10,000-patient sample was generated matched for age and sex to the initial cohort. Prescriptions and procedures at index, as well as complications up to 12 months postindex, were analyzed. Results: Nearly 90% of all patients received a prescription at index. Antibiotics were prescribed for 84.8% patients, followed by antitussives (16.2% for adults, 6.2% for pediatrics), nasal corticosteroids (15.5% adults, 7.5% for pediatrics), and systemic corticosteroids (10.3% for adults, 5.5% for pediatrics), with 49% adults and 29% children receiving >1 medication at first visit. Macrolides were the most frequently prescribed antibiotics (35.6% adults, 28.6% pediatrics), followed by amoxicillin/clavulanate and amoxicillin. Within 12 months of index, 3 patients presented with meningitis and 3 with orbital cellulitis. Conclusion: Significant variability in ARS treatment was observed, highlighting the need for heightened awareness of existing guidelines.
Article
Allergic rhinitis is a common and chronic immunoglobulin E mediated respiratory illness that can affect quality of life and productivity, as well as exacerbate other conditions such as asthma. Treatment should be based on the patient's age and severity of symptoms. Patients should be educated about their condition and advised to avoid known allergens. Intranasal corticosteroids are the most effective treatment and should be first-line therapy for persistent symptoms affecting quality of life. More severe disease that does not respond to intranasal corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies such as nasal irrigation. Subcutaneous or sublingual immunotherapy should be considered if usual treatments do not adequately control symptoms and in patients with allergic asthma. Evidence does not support the use of mite-proof impermeable mattresses and pillow covers, breastfeeding, air filtration systems, or delayed exposure to solid foods in infancy or to pets in childhood. Copyright (C) 2015 American Academy of Family Physicians.