Nasal Saline Irrigations for the Symptoms of Acute and Chronic Rhinosinusitis
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- Achilles, N. & Mösges, R. Curr Allergy Asthma Rep (2013) 13: 229. doi:10.1007/s11882-013-0339-y
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The use of saline nasal irrigation (SNI) in the treatment of nasal and sinus disorders has its roots in the yoga tradition and homeopathic medicine. In recent years, SNI has been increasingly observed as concomitant therapy for acute (ARS) and chronic rhinosinusitis (CRS). Various devices are employed, such as nasal douches, neti pots or sprays. The saline solutions used vary in composition and concentration. This article gives a current overview of literature on the clinical efficacy of SNI in the treatment of ARS and CRS. It then answers frequent questions that arise in daily clinical routine (nasal spray vs. nasal irrigation, saline solution composition and concentration, possible risks for patients). SNI has been an established option in CRS treatment for many years. All large medical associations and the authors of systematic reviews consistently conclude that SNI is a useful addition for treating CRS symptoms. SNI use in ARS therapy, however, is controversial. The results of systematic reviews and medical associations’ recommendations show the existing but limited efficacy of SNI in ARS. For clinical practice, nasal douches are recommended—whatever the form of rhinosinusitis—along with isotonic and hypertonic saline solutions in CRS (in ARS to a limited extent). To prevent infections, it is essential to clean the nasal douche thoroughly and use the proper salt concentration (2−3.5 %). Conclusive proof of the efficacy of SNI in the treatment of ARS is still pending. In CRS, SNI is one of the cornerstones of treatment.
KeywordsSaline nasal irrigationNasal douchingAcute rhinosinusitisChronic rhinosinusitisNasal washingNasal lavage
American Academy of Allergy Asthma and Immunology
American Academy of Otolaryngology Head and Neck Surgery
British Society for Allergy and Clinical Immunology
The European Position Paper on Rhinosinusitis and Nasal Polyps
Saline nasal irrigation
Is saline nasal irrigation preferable to nasal sprays?
Which salt concentration should safe and effective nasal irrigation have? Are there differences depending on the indication (ARS or CRS)?
What possible risks does the use of saline nasal irrigation pose to the patient?
Clinical Picture of Rhinosinusitis
Clinical definition of rhinosinusitis
Rhinosinusitis is an inflammation of the nose and the paranasal sinuses characterized by two or more symptoms:
• nasal blockage/obstruction/congestion
• nasal discharge (anterior/posterior nasal drip)
• facial pain/pressure
• reduction or loss of smell
endoscopic signs of nasal polyps, mucopurulent discharge primarily from middle meatus and/or edema/mucosal obstruction primarily in middle meatus
CT changes as mucosal changes within the ostiomeatal complex and/or sinuses
Rhinosinusitis consensus research definitions
Type of rhinosinusitis
CRS without nasal polyposis
CRS with nasal polyposis
Criteria for diagnosis
Pattern of symptoms
• Symptoms present for a minimum of 10 days up to a maximum of 28 days
Symptoms present for ≥12 weeks
• Severe disease (presence of purulence for 3−4 days with high fever)
• Worsening disease (symptoms that initially regress but worsen within first 10 days)
Symptoms for diagnosis
Requires ≥2 of the following symptoms
• Anterior and/or posterior purulent drainage plus
• Anterior and/or posterior mucopurulent drainage
• Nasal obstruction or
• Nasal obstruction
• Facial pain/pressure/fullness
• Facial pain/pressure/fullness
Therapy of Rhinosinusitis
The therapy of rhinosinusitis is generally distinguished between a conservative and an operative approach. Among conservative treatments are pharmacotherapy with analgesics, antibiotics, decongestants, and topical and oral glucocorticosteroids, as well as other pharmacological (mucolytics, antihistamines) and non-pharmacological treatment approaches (among others: phytotherapy, homeopathy, SNI) [3•].
Therapy recommendation for rhinosinusitis
In allergic rhinitis
In allergic rhinitis
The German Society of Oto-Rhino-Laryngology, Head and Neck Surgery strongly recommends the use of topical glucocorticosteroids in both ARS and CRS. However, it disapproves of the systemic application of glucocorticosteroids, because the risk of relapse in CRS is too high [3•]. The Society thus agrees with the recommendations made in the European guidelines [5•].
In everyday clinical practice, many patients have reservations about taking medicine, especially glucocorticosteroids. In 2008, Kaschke published an article which indicated that approx. 64 % of patients suffering from seasonal allergic rhinitis developed “cortisone phobia,” and therefore only about 31 % of the patients decided in favor of the long-term application of local glucocorticosteroids . It appears absolutely feasible to transfer this “cortisone phobia” to the clinical picture of rhinosinusitis, since the side effects of glucocorticosteroids can occur independent of the patient’s disease. More and more often it is observed that a multitude of patients inquire about non-medicinal therapy approaches in the treatment of rhinosinusitis. One of these possible approaches is the use of SNI.
Saline Nasal Irrigation
Various kinds of nasal douches or neti pots can be used for nasal irrigation. Their capacities range from 30 to 500 ml, and the amount of solution used per procedure averages from 200 to 250 ml. This volume is considered appropriate by adult patients . Introducing saline solutions into the nose by means of pump spray bottles is also called nasal irrigation in the literature [11, 12••, 13••]. Saline solutions are most often employed in nasal irrigation. Table salt (iodized and non-iodized), sodium chloride, and natural brines can be used. The solutions can be isotonic, hypotonic or hypertonic and are available in buffered or unbuffered form [14, 15]. The general mechanism of action of these various solutions is based upon the liquefaction of nasal secretion and the resulting improvement in mucociliary clearance. A vasoconstrictive and thereby decongestive effect is also assumed .
Saline Nasal Irrigation in ARS
The presently available evidence for the application of SNI in ARS is controversial. In a Cochrane Review published in 2010, the authors Kassel et al. criticized that “the included trials were too small and had too high risk of bias to be confident about the possible benefits to nasal saline irrigation in acute upper respiratory tract infections.” They substantiated their claim based on three included randomized, controlled clinical trials with a total of 618 patients. The results of these studies showed that there were no statistically significant differences with respect to therapy with SNI and to the control groups (no treatment , phenylephrine nose drops , standard treatments only ). In just one study by Adam et al. could a statistically insignificant superiority of SNI be shown in terms of −0.3 days of fewer symptoms and time off work . The authors of the Cochrane Review thus called for larger randomized, controlled clinical trials to be able to make an evidence-based assessment of the use of SNI in the treatment of ARS and to recommend it to patients without hesitation [13••].
The authors of the EPOS also confirmed the limited efficacy of SNI in adult patients suffering from ARS symptoms [5•]. They justified their recommendation based on the Cochrane Review by Kassel et al. and the articles considered therein [13••] on the one hand, and based on the publications by Axelsson et al.  and Hildenbrand et al. [12••] on the other hand. Axelsson et al. observed in their clinical trial that SNI combined with 10-day antibiotic treatment offered no statistically significant benefits to the patients in overcoming their symptoms . The systematic review by Hildenbrand et al. published in German in 2011 confirmed that SNI has an existing but limited efficacy in adults with ARS [12••]. The authors also refer to the above Cochrane Review by Kassel et al. published in 2010 [13••]. In addition, they ascribe a preventive effect to SNI in cases of increased susceptibility to infection and support this assertion with articles by Rabago et al. (2002, 2005) and Tano et al. (2004) [20–22].
The authors of the German S2 Guidelines for Rhinosinusitis subscribe to the European position. Neither isotonic nor hypertonic nasal irrigation or sprays has an alleviating effect on symptoms of ARS. An effect of SNI could not be verified and thus “no certain recommendation can be made” [3•]. To a large part, the authors reference the research results published by Adam et al. . In the BSACI  as well as AAAAI  guidelines, no advice or recommendations can be found for the use of SNI in ARS.
No current articles on the application of SNI in ARS (appearing after publication of EPOS and the German-language review by Hildenbrand et al.) are available according to a literature search in the US National Library of Medicine.
Saline Nasal Irrigation in CRS
The use of SNI in the therapy of CRS, however, is established and evidence-based. In their 2007 Cochrane Review “Nasal saline irrigations for the symptoms of chronic rhinosinusitis,” Harvey et al. come to the clear conclusion that SNI possesses a beneficial effect for the majority of patients despite rarely observed side effects. This procedure is also characterized by good clinical tolerability. SNI therefore represents a useful addition in the treatment of CRS symptoms . In their meta-analysis, the authors take a total of eight studies into consideration. Three clinical trials compared nasal irrigation to no intervention [21, 24, 25]: one compared it to placebo , one investigated saline nasal spray as concomitant medication together with an intranasal steroid , and one compared a nasal spray to an intranasal steroid as a control substance . Two clinical trials examined the differences between hypertonic and isotonic saline solutions [29, 30]). A current systematic review by Adappa et al. from 2012 confirms the results of the Cochrane Reviews [31•].
In the EPOS from 2012, SNI is also described as beneficial in the treatment of CRS symptoms on the basis of the above Cochrane Review by Harvey et al. The authors of the European guidelines, however, voice their concern that Harvey et al. did not consider the occurrence of nasal polyps when making their recommendation. Moreover, it was unclear whether the patients had previously undergone paranasal sinus surgery. For this reason, Fokkens et al. recommend SNI only to CRS patients who have no nasal polyps and have had no previous paranasal sinus surgery. They broaden their recommendation to include the postinterventional use of SNI (e.g., after paranasal sinus surgery) [5•].
The German S2 Guidelines for Rhinosinusitis mention the local application of saline solutions as follows: “Nasal irrigation or sprays with hypertonic buffered solutions in chronic rhinosinusitis disorders lead at the least to symptom relief” [3•]. The authors make references to: the above Cochrane Review by Harvey et al. ; two case−control studies that prove the efficacy of 2 and 3.5 % hypertonic solution, respectively [26, 32]; and a clinical trial that describes positive long-term effects lasting 6 months for the use of buffered 2 % hypertonic saline solution .
The BSACI also expresses a recommendation for SNI as a safe and inexpensive treatment option for CRS . In contrast, the AAAAI national guidelines do not discuss the application of SNI as an additional therapy option for CRS . The American Academy of Otolaryngology, Head and Neck Surgery, AAO-HNO), however, recommends SNI following paranasal surgery and for secondary CRS prophylaxis .
Saline Nasal Irrigation in Clinical Practice
Both doctors and patients are very interested in getting answers to the following questions about SNI frequently asked in daily clinical practice:
Is Saline Nasal Irrigation Preferable to Sprays?
The EPOS from 2012 indicates that the effect of SNI depends, among other things, on the mode of application [5•]. In a clinical trial from 2004, Wormald et al. examined the efficacy of three different application forms of SNI with regard to their distribution in the nasal cavity and the paranasal sinuses. The three application forms were “metered nasal spray, nebulization with RinoFlow, and nasal douching while kneeling with the head on the floor.” The authors concluded that nasal douches caused a greater distribution of saline in the paranasal structures and should therefore be the method of choice . In another clinical trial, Olson et al. likewise compared three different techniques for applying saline solutions. The methods they used were “irrigation using positive-pressure irrigation, irrigation using negative-pressure irrigation, and irrigation using a nebulizer.” It became evident that only nasal irrigation forms with positive-pressure or negative-pressure were effective. The use of nebulizers, however, is an inadequate procedure for alleviating patient symptoms . The research conducted by Pynnonen 3 years later confirmed the results of Olson et al. A large rinsing volume—delivered under low pressure—appeared to be superior to the use of nasal spray . Moreover, two other randomized, controlled clinical trials from Italy proved that special irrigation systems (e.g., nasal douche and neti pot) have an advantage over a conventional application with pump spray or syringe. The authors presume better intranasal distribution in using nasal douches and neti pot, respectively [37, 38].
Based on the previously described clinical studies, the delivery of saline solutions via a nasal douche or neti pot is clearly recommended.
Which Salt Concentration Should Safe and Effective Nasal Irrigation Have? Do Differences Exist Depending on the Indication (ARS or CRS)?
The question as to the concentration and saline composition used in nasal irrigation depending on the indication (ARS or CRS) has often been investigated and discussed in the medical literature.
The authors of the EPOS from 2012 make no clear recommendation for the use of isotonic or hypertonic saline solutions in ARS, since SNI generally possesses only limited efficacy in ARS symptoms and therefore symptom relief for patients is not necessarily to be expected [5•]. Some American authors, however, prefer the use of hypertonic saline solutions. They thereby refer to research conducted by Talbot et al. that showed a statistically significant improvement in nasal mucociliary clearance when hypertonic saline solutions were applied by patients suffering from ARS and CRS . Ural et al. also examined the influence of SNI (isotonic vs. hypertonic saline composition) on mucociliary clearance depending on the clinical picture. They demonstrated that mucociliary clearance could be improved with hypertonic saline solution in CRS and with isotonic saline solution in ARS. Therefore, they recommended adapting therapy with SNI to the clinical picture .
The German S2 Guidelines for Rhinosinusitis distinguish between the clinical pictures of ARS and CRS, while according to Adam et al. , neither isotonic nor hypertonic saline solutions are to be preferred in ARS, 2−3.5 % hypertonic saline solutions [21, 26, 32] can be applied for CRS symptoms [3•]. Another study on the clinical picture of CRS confirms the use of hypertonic saline solutions . Also, isotonic saline solutions (Emser) [30, 36, 40] and Dead Sea salt  possess a proven effect as a supplement to standard therapy.
It is also necessary to take great care in choosing the correct saline solution concentration. In CRS, 2−3.5 % hypertonic saline solutions can be used [3•]. Other solution concentrations (hypotonic or very hypertonic, 6 % or stronger) can have harmful effects on mucociliary clearance and result in severe irritation [42–46]. Baraniuk et al. even describe side effects that can occur at a 6-times greater concentration. Such effects include rhinorrhea, an increase in the sensation of nasal pain, and nasal obstruction among others . Not only highly hypertonic saline solutions but also untreated tap water can pose a threat to the patient’s health in rare cases .
Based on the clinical studies described previously, isotonic and hypertonic saline solutions are to be recommended in CRS. In ARS, however, no clear recommendation can be made due to the controversial study evidence. Hypertonic saline solutions appear to be more appropriate for patients.
What Risks Does the Use of Saline Nasal Irrigation Pose to the Patient?
In 2009, an abstract submitted by the American allergist Nsouli at the Annual Meeting of the American College of Allergy Asthma and Immunology gave rise to great uncertainty. He and his colleagues maintained that long-term, daily nasal irrigation performed by healthy patients frequently leads to rhinosinusitis infections. Their assertion was based on the constant weakening of the primary defense mechanisms of the nasal mucosa (loss of immunoglobulin A, lactoferrin, and lysozyme) . In a systematic review, Hildenbrand et al. criticize Nsouli and his colleague’s interpretation of the study results. They point out, among other weaknesses, an inadequate study design (no randomized cross-over design and lack of a randomized comparison group concept) [11, 12••, 13••]. Moreover, the article by Nsouli et al. is the only clinical study to date that describes increased susceptibility to infection caused by the daily use of SNI.
In contrast, a multitude of clinical trials report the statistically significant reduction of susceptibility to infection resulting from long-term application of SNI: 10-week application in the study by Tano et al. , 3 months by Schmidt et al. , and 18 months by Rabago et al. .
The EPOS 2012 points out that thorough cleaning of the nasal douche or neti pot is indispensable to prevent dangerous bacterial contamination [5•]. Lee et al. , Welch et al. , and Williams et al.  indeed affirmed that nasal rinsing systems were contaminated with bacteria, but this did not have an influence on the actual infection rate. Lee et al. and Foremann et al. stress that patients must be instructed to clean their rinsing systems regularly in order to minimize the risk of infection and thereby protect their own health [50, 53]. Psaltis et al. also holds the prescribing physicians responsible for carefully explaining the correct and safe use of nasal irrigation systems to their patients .
When the procedure is performed correctly (i.e., the nasal douche or neti pot is thoroughly cleaned, and the solution has the recommended concentration), a higher susceptibility to infections and thus the patient’s actual risk of having a relapse of rhinosinusitis can be virtually ruled out.
This systematic review shows that SNI has been established in the therapy of CRS for many years. The main scientific article that demonstrates the clinical efficacy of SNI coupled with good tolerability is the Cochrane Review by Harvey et al. published in 2007 . The authors arrive at the clear conclusion that the application of SNI represents a useful supplement for treating CRS symptoms. All large European specialist societies [3•, 5•, 6] as well as the authors of the present systematic review expressly agree with this recommendation.
In the treatment of ARS, however, the use of SNI continues to be controversial and could not yet be substantiated. In their Cochrane Review, Kassel et al. cannot conclusively prove the clinical effect of SNI. The authors therefore call for further randomized, controlled clinical trials with sufficient patient numbers to be able to recommend the use of SNI without risk to patients [13••]. In the EPOS from 2012 [5•], in the German S2 Guidelines for Rhinosinusitis [3•], and in the systematic review by Hildenbrand et al. [12••], SNI is in fact attested as being effective in the therapy of ARS, although to a limited extent. Therefore, this review can also make no clear recommendation for SNI as a treatment option in ARS.
The authors would like to thank Gena Kittel for her editorial assistance.
Dr. Mösges has received a speaker honorarium from NeilMed Ltd. UK. Dr. Achilles reported no potential conflicts of interest relevant to this article.