Nasal Irrigation is a Longstanding Treatment for Sinonasal Disease

8/12/2019 Nasal Irrigation is a Longstanding Treatment for Sinonasal Disease

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Three key elements are important to the normal physiologic functioning of paranasal sinuses:(1) the patency of the ostium, (2) the function of the ciliary apparatus, and (3) the quality ofsecretions.Impaired drainage and retention of secretions in the paranasal sinuses is usuallycaused by one or more of the following factors: obstruction of the ostium, reduction in thenumber of cilia or an impairment of their function, and overproduction of secretions or a changein the viscosity of secretions.

Shoseyov D, Bibi H, Shai P, Shoseyov N, Shazberg G, Hurvitz H. Treatment with hypertonicsaline versus normal saline nasal wash of pediatric chronic sinusitis. J Allergy Clin Immunol1998;101:602-5

The nasal cilia are covered by a blanket of mucus containing bacteria and other irritants, andthis is constantly being moved to the sinus ostia and the nasopharynx. Patients with paranasalsinus disease often have decreased mucociliary clearance. Not only the ciliary beat frequencybut also other factors are responsible for the stagnation of dust, crusts, and bacteria in the areaof the mucous membrane. Therefore both mucociliary function and the mucous membrane areimportant factors with regard to recovery in cases of chronic sinusitis. Endonasal irrigations aidthe clearance of intranasal irritants. There is evidence that irrigations employing a salt solution

improve mucociliary clearance.

Talbot et al. found that a buffered hypertonic saline nasal irrigation improves the mucociliaryclearance time of saccharine whereas buffered normal saline has no such effect in healthysubjects. In a randomized double-blind study Shoseyov et al. compared the effect of hypertonic(3.5%) with normal saline (0.9%) nasal wash on pediatric cases of chronic sinusitis. Bothtreatment options were effective, and the hypertonic saline solution showed an additionalimprovement. Not only the postnasal drip score but also the cough and radiological scoresshowed a significant improvement in both groups.

Several research groups have investigated the effect of salt solutions on mucociliary function interms of osmolarity, pH, and buffer capacity. An investigation by van den Donk et al. revealed

that an acidic or alkaline solution with a pH value of 710 did not affect the tracheal ciliary beatfrequency in chicken embryos, but that lower or higher pH values decreased the frequency.

Also, both hypertonic and hypotonic sodium chloride solutions showed a similar negative effecton the ciliary beat frequency. Messerklinger has shown that the Gleichenberger salt solution hasa more beneficial effect on mucociliary motion than sodium chloride solution. TheGleichenberger salt solution, such as the Ems salt solution, has a high hydrogen carbonateconcentration. No other substances are known which can improve mucociliary clearance.Guaifenesin, a compound reported to enhance airway mucus clearance, had no significanteffect on the saccharin transit time in a double-blind study

Bachmann G, Hommel G, Michel O. Effect of irrigation of the nose with isotonic salt solution onadult patients with chronic paranasal sinus disease. Eur Arch Otorhinolaryngol2000;257:537-

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Chronic sinusitis is a commonly encountered condition that places a substantial burden not onlyon the healthcare system, but also on the quality of life of chronic sufferers. Since recurrentantibiotic use, intranasal steroid administration, and surgery may not be the most desirabletherapeutic options for this condition, nasal saline sprays offer a simple and convenient way toreduce symptoms.


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Yeung DF. Efficacy of Nasal Saline Sprays to Relieve Symptoms of Chronic Sinusitis. UTMJ2011;88(2):84-87

Nasal mucociliary clearance is an essential function required to defend and preserve the healthof the nose. Between 20 and 40 ml of mucus are secreted from the normal resting nose dailyfrom 160 cm2of nasal mucosa. This mucus provides a confluent lining for the nasal cavity onto

which inhaled particles can impact. Eighty percent of particles larger than 12.5 g are filteredfrom the air before they reach the pharynx. The blanket of mucus can be moved by thecoordinated waves of cilia from the anterior nose to the nasopharynx, where it can be eitherexpectorated or swallowed.Mucociliary transport depends on interactions between the cilia(number, structure, and beating rhythm) and a two-layered system of mucus with certainviscoelastic properties.The cilia beat within the lubricating periciliary layer fluid.This layer isanatomically continuous with, but functionally distinct from, the outer, more viscous mucus layer.Saccharin, and other soluble materials, can dissolve and be transported within the periciliarylayer. Particles may be transported through this layer more effectively than in the layer of mucusabove.The nasal mucociliary system is sensitive to drying; however, under usual conditionsmucociliary transport rate varies only slightly due to the humidifying and warming functions ofthe nose.

Boatsman JE, Calhoun KH, Ryan MW. Relationship between Rhinosinusitis Symptoms andMucociliary Clearance Time. OtolaryngologyHead and Neck Surgery2006;134:491-493

Nasal irrigation is performed by instilling saline into one nostril and allowing it to drain out of theother nostril, bathing the nasal cavity. Saline nasal irrigation can be performed with low positivepressure from a spray or squirt bottle, or with gravity-based pressure using a vessel with a nasalspout, such as a neti pot. Both are available over the counter.

Rabago D, Zgierska A. Saline Nasal Irrigation for Upper Respiratory Conditions. AmericanFamily Physician2009;80(10):1117-1118

Chronic rhinosinusitis (CRS) is a common disease resulting from inflammation of the sinonasalmucosa. The underlying cause of the inflammation is multifactorial, with both genetic andenvironmental contributions. Guidelines published by the AAOHNS in 2007 and a Cochranereview by Harvey et al. published in 2009 have clearly established the benefits of nasal salineirrigation for patients with CRS. Benefits include improved mucociliary function, decreased nasalmucosal edema, and mechanical removal of infectious debris, allergens, mucus, and bacteriafrom the sinus and nasal cavities. Irrigation may also reduce reliance on other sinusmedications, the number and frequency of acute exacerbations of CRS, and symptoms relatedto CRS. Side effects of saline irrigation are minimal and self-limiting, mostly related to localirritation or ear symptoms.

Nasal Irrigation has also been recognized as a potential route for topical drug administration intoparanasal sinuses due to ease of use and direct drug effects on the sinonasal mucosa


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Nasal irrigation has been practiced in India for centuries as part of the purification routinesperformed in preparation for yoga . It has been used as an adjunctive therapy for sinonasaldiseases (including acute and chronic sinusitis) and allergic rhinitis. Several published articlesreported it also improves clinical sinus symptoms. Nasal irrigation is an inexpensive, patient-

controlled therapy that flushes the nasal cavity with saline solution, facilitating a wash of thestructures within. Benefits from nasal irrigation may accrue from removal of nasal discharge andcrusts, mucus thinning [10], and enhanced mucociliary clearance of nasal secretions. Nasalirrigation also may decrease mucosal inflammation osmotically.

The purpose of this study is toevaluate the effectiveness of normal saline nasal irrigation in themanagement of acute sinusitis in children. This study shows that nasal irrigation is effective indecreasing symptoms of nasal disease. The mechanism by which this improvement is effectedis unclear. It has been hypothesized that nasal irrigation promotes improvement of nasalsymptoms via (1) improving mucociliary function, (2) decreasing mucosal edema, (3) decreasinginflammatory mediators, and (4) mechanically clearing inspissated mucus.

Wang YH, Yang CP, Ku MS, Sun HL, Lue KH. Efficacy of nasal irrigation in the treatment ofacute sinusitis in children. International Journal of Pediatric Otorhinolaryngology2009;73:16961701

Rhinosinusitis is one of the most common chronic diseases, with prevalence as high as orhigher than many other chronic conditions such as allergy and asthma. Patients with chronicrhinosinusitis (CRS) visit primary care clinicians twice as often as those without the disorder,and have 5 times as many prescriptions filled.1 Moreover, they experience substantial negativehealth impact because of their disease, which adversely affects mood, physical functioning, andsocial functioning

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 CRS. Treatment strategiesoften include the use of topical saline from once to more than 4 times a day. Considerablepatient effort is often involved. Any additional benefit has been difficult to discern from othertreatments.

Burton MJ, Eisenberg LD, Rosenfeld RM. Extracts from The Cochrane Library: Nasalsaline irrigations for the symptoms of chronic rhinosinusitis. Otolaryngology Head andNeck Surgery2007;137:532-534

In chronic rhinosinusitis, the normal adult nasal mucosa (composed of ciliated cells, striate cells,muciparous goblet cells, and basal cells) tends to change, the chronic inflammatory response

gradually disrupting nasal mucosa integrity. An altered number and appearance of therespiratory epithelial cells have been found in chronic rhinosinusitis; and the epithelium maygradually become metaplastic, progressing as a proliferative process with rising numbers ofmuciparous goblet cells.

Ottaviano G, Marioni G, Staffieri C, Giacomelli L, Ragona RM, MD, Bertolin A et al. Effects ofsulfurous, salty, bromic, iodic thermal water nasal irrigations in nonallergic chronic rhinosinusitis:


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a prospective, randomized, double-blind, clinical, and cytological study. American Journal ofOtolaryngologyHead and Neck Medicine and Surgery2011;32:235239

Rhinosinusitis is a common clinical problem with significant morbidity and often refractorysymptoms that accounts for approximately 26.7 million office and emergency room visits andresults in 5.8 billion dollars spent in direct costs in the United States each year. The impact of

sinonasal disease on a patients quality of life is significant in both the adult and pediatricpopulation

Nasal saline irrigation are a personal hygiene practice in which mucus and debris is flushedfrom the nasal cavity. This is typically performed using a commercially available neti pot orflexible plastic bottle and warm saline solution. Nasal saline irrigation has long been a mainstayof treatment for sinonasal disease in the adult population because of its economy, safety andapparent efficacy. While the literature suggests a benefit to nasal irrigation in the treatment ofchildren with seasonal allergies, acute sinusitis, and chronic sinusitis

While the exact mechanism of action is unknown, both isotonic and hypertonic rinses have beendemonstrated to improve mucociliary clearance, and isotonic saline rinses have further been

shown to increase nasal patency [10]. A recent Cochrane review provides evidence that nasalsaline irrigation is beneficial not only when used as a treatment adjunct, but also when used asthe sole modality of treatment.This review also provides evidence that routine use of nasalsaline irrigation is associated with decreased use of antibiotics. Nasal saline irrigation is welltolerated in the adult population. While minor side effects such as nasal burning, irritation andnausea are reported, there have been no documented severe adverse effects

Jeffe JS, Bhushan B, Schroeder JW. Nasal saline irrigation in children: A study of complianceand tolerance. International Journal of Pediatric Otorhinolaryngology2012;76:409413

In a recent study, Rabago et al. performed a randomized, controlled trial looking at patients withtwo episodes of acute sinusitis or one episode of chronic sinusitis per year for 2 consecutive

years. Fifty-two patients received hypertonic saline, whereas 24 patients did not receive anyirrigations. When using hypertonic nasal irrigations, improvements in quality-of-life and overallsymptom severity scores were statistically significant. Steroid nasal spray use was alsodecreased.

SafetyNasal irrigations have been shown to be safe. Side effects encountered are minimal. Localirritation, itching, burning, otalgia, and pooling in sinuses with subsequent drainage have beenreported. This pooling, with delayed discharge in some head positions, is most commonly seenin patients who have undergone previous sinus surgery.

Brown CL, Graham SM. Nasal irrigations: good or bad? Curr Opin Otolaryngol Head Neck Surg

2004;12:913

Nasal saline irrigations are recognized as beneficial in reducing common symptoms of chronicrhinosinusitis. In addition to empiric evidence of its benefits, many scientific studies have beenpublished proving its beneficial effects on clearing secretions, as well as its positive effects onthe elimination of symptoms and its improving the quality of life for its users.

Nasal irrigations have been used for centuries by otolaryngologists and rhinologists in thetreatment of patients with allergic rhinitis and chronic rhinosinusitis. Recently, it has also been


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used in the postoperative care of patients with endoscopic sinus surgery.Although the exactmechanism of action by which these nasal irrigations improve nasal function is not properlyunderstood, most theories suggest that nasal irrigations: 1) improve the mucociliary function ofthe respiratory mucosa; 2) decrease the mucosal edema; 3) help to clear static secretions;4)rinse infective debris; 5) remove the source of allergen; and 6) minimize crusting, which mayobstruct normal sinonasal drainage or lead to adhesions

Friedman M, Vidyasagar R, Joseph N. A Randomized, Prospective, Double-Blind Study on theEfficacy of Dead Sea Salt Nasal Irrigations. Laryngoscope2006;116:878882

The use of nasal irrigation dates back centuries. One of the earliest examples is the use ofnasal irrigation with a hypertonic solution as part of purification routines in preparation for yoga.Western medicine had adopted this practice by the 19th century.

Garrett Hauptman and Matthew W. Ryan. The effect of saline solutions on nasal patency andmucociliary clearance in rhinosinusitis patients. OtolaryngologyHead and Neck Surgery2007;137:815-821

The new and more specific Task Force definition is as follows: Chronic rhinosinusitisis a groupof multifactorial diseases characterized by inflammation of the mucosa of the nose andparanasal sinuses, with a history of at least 12 weeks of persistent symptoms and signs, despitemaximum medical therapy. Chronicrhinosinusitis has been reported to affect a varyingpercentage of the population. According to the National Health Interview Survey in the UnitedStates, the rate of chronic rhinosinusitis ranges from 14% to 16%. However, current prevalencemay often be exaggerated

Nasal mucosa produces about half a liter of mucus per 24 hours, which contains 2% mucin and1%-2% salt, pH 6.5-7.2. The use of hypertonic solution may reduce the need of nasaldecongestives, thus avoiding the risk of side effects due to the overstimulation of adrenergicreceptors in the nasal mucosa

The destruction of the ciliary epithelium, due to long-lasting nasal mucosa colonization withpathogenic microorganisms, is another cause of reduced nasal mucociliary clearance in chronicrhinosinusitis patients. It is manifested as a decreased frequency of ciliary movements, whichincreases with long-term antibiotic therapy

ulig J, Leppe M1, Veva, Djanic D. Efficiency of hypertonic and isotonic seawater solutionsin chronic rhinosinusitis. Med Glas Ljek komore Zenicko-doboj kantona2010; 7(1):116-123

Chronic rhinosinusitis (CRS) is an increasingly common health care challenge affecting adults.Sinuses rarely get infected without the nose being involved, so the term rhinosinusitis is usedinstead of sinusitis. In 2009, the Centers for Disease Control and Prevention (CDC) reported

that more than 14% of the United States adult population was affected by this disorder. Theacute form of the disease may last up to 28 days and is considered chronic once the symptomshave persisted for 12 weeks or longer. Approximately $3.4 billion can be attributed annually tothe treatment of CRS that accounts for over 20 million primary care office visits each year. Thecost of CRS is enormous in lost work and productivity, surgeries, and medicines and cannegatively affect patientsquality of life. The financial burden and increasing prevalence of CRSunderscores the importance of evidence- based treatment and prevention options.


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Adults suffering from CRS may use a variety of prescription and over-the-counter (OTC)medications for relief of symptoms. These treatments range from avoidance of environmentalirritants to short- and long-term antibiotic treatments. Although most CRS is caused by viruses,antibiotics are frequently prescribed for this diagnosis. In fact, CRS is the third most prevalentdiagnosis for antibiotic use. This overuse of antibiotics is especially problematic because itcontributes to the increase in more potent and drug-resistant bacteria.

Thornton K, Alston M, Dye H, Williamson S. Are Saline Irrigations Effective in Relieving ChronicRhinosinusitis Symptoms? A Review of the EvidenceThe Journal for Nurse Practitioners2011;7(8):680-686

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Nasal Irrigation is a Longstanding Treatment for Sinonasal Disease