Nasal Saline Irrigations for the Symptoms of Acute and Chronic Rhinosinusitis


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.

This is a preview of subscription content, log in to check access.



American Academy of Allergy Asthma and Immunology


American Academy of Otolaryngology Head and Neck Surgery


Acute rhinosinusitis


British Society for Allergy and Clinical Immunology


Chronic rhinosinusitis


The European Position Paper on Rhinosinusitis and Nasal Polyps


Saline nasal irrigation


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    Brown CL, Graham SM. Nasal irrigations: good or bad? Curr Opin Otolaryngol Head Neck Surg. 2004;12(1):9–13.

    PubMed  Article  Google Scholar 

  2. 2.

    Rabago D, Zgierska A. Saline nasal irrigation for upper respiratory conditions. Am Fam Physician. 2009;80(10):1117–9.

    PubMed  Google Scholar 

  3. 3.

    • Stuck BA, Bachert C, Federspil P, Hosemann W, Klimek L, Mosges R, et al. Rhinosinusitis guidelines of the German Society for Otorhinolaryngology, Head and Neck Surgery. 2011. This is the current update of the Rhinosinusitis guidelines of the German Society for Otorhinolaryngology, Head and Neck Surgery from 2011. This paper considers a high number of publication about ARS and CRS and recommends saline irrigations in the therapy of CRS. For ARS symptoms, neither isotonic nor hypertonic nasal irrigation or sprays has an alleviating effect.

  4. 4.

    Nsouli TM, Schluckebier CD, McSorley-Gerard EJ, Chabal N, Burke I. Long-term use of nasal saline irrigation: harmful or helpful? 2009 Annual Meeting of the American College of Allergy, Asthma and Immunolgy; Miami, Florida (USA): Ann Allergy Asthma Immunol 2009; 2009.

  5. 5.

    • Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl. 2012;(23):3 p preceding table of contents, 1–298. This is the current update of the European Position Paper on Rhinosinusitis and Nasal Polyps from 2012. In the EPOS from 2012, nasal saline irrigation is described as beneficial in the treatment of CRS symptoms. The authors also confirmed the limited efficacy of nasal saline irrigation in adult patients suffering from ARS symptoms.

  6. 6.

    Scadding GK, Durham SR, Mirakian R, Jones NS, Drake-Lee AB, Ryan D, et al. BSACI guidelines for the management of rhinosinusitis and nasal polyposis. Clin Exp Allergy. 2008;38(2):260–75. doi:10.1111/j.1365-2222.2007.02889.x.

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    Meltzer EO, Hamilos DL, Hadley JA, Lanza DC, Marple BF, Nicklas RA, et al. Rhinosinusitis: establishing definitions for clinical research and patient care. J Allergy Clin Immunol. 2004;114(6 Suppl):155–212. doi:10.1016/j.jaci.2004.09.029.

    PubMed  Article  Google Scholar 

  8. 8.

    Mösges R, Heubach C. Evidenzbasierte Therapie der Rhinosinusitis. So werden die Nebenhöhlen wieder frei. Der Hausarzt. 2011;48(1):54–5.

    Google Scholar 

  9. 9.

    Kaschke O. Auswirkungen einer Steroidphobie in Deutschland auf die Therapie mit topischen Glukokortikoiden. Med Rep. 2008;31(17):10.

    Google Scholar 

  10. 10.

    Jorissen M. Postoperative care following endoscopic sinus surgery. Rhinology. 2004;42(3):114–20.

    PubMed  Google Scholar 

  11. 11.

    Adam P, Stiffman M, Blake Jr RL. A clinical trial of hypertonic saline nasal spray in subjects with the common cold or rhinosinusitis. Arch Fam Med. 1998;7(1):39–43.

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    •• Hildenbrand T, Weber R, Heubach C, Mosges R. Nasal douching in acute rhinosinusitis. Laryngorhinootologie. 2011;90(6):346–51. doi:10.1055/s-0031-1275317. This German publication is one of a few systematic reviews about nasal douching in acute rhinosinusitis. It has a high level of evidence, and the literature search was performed in PUBMED, Allied and Complementary Medicine (AMED), Cochrane Database of Abstracts of Reviews of Effectiveness (DARE), Cochrane Database of Systematic Reviews (CDSR) and Cochrane Central Register of Controlled Trials.

    PubMed  Article  CAS  Google Scholar 

  13. 13.

    •• Kassel JC, King D, Spurling GK. Saline nasal irrigation for acute upper respiratory tract infections. Cochrane Database Syst Rev. 2010;(3):CD006821. doi:10.1002/14651858.CD006821.pub2. This reference has the highest level of evidence (level 1). Only randomzsed controlled trials comparing topical nasal saline treatment to other interventions in adult and children with clinically diagnosed acute upper respiratory tract infections were included in the systematic review. Two reviewers independently assessed trial quality and extracted data.

  14. 14.

    Michel O. [Nasal irrigation in case of rhinosinusitis]. Laryngorhinootologie. 2006;85(6):448–58. doi:10.1055/s-2005-921110. quiz 59–60.

    PubMed  Article  CAS  Google Scholar 

  15. 15.

    Weber R. Nasenspülungen - Wirksamkeit und Indikationen. Eine Literaturübersicht. HNO Kompakt. 2010;18:151–64.

    Google Scholar 

  16. 16.

    Talbot AR, Herr TM, Parsons DS. Mucociliary clearance and buffered hypertonic saline solution. Laryngoscope. 1997;107(4):500–3.

    PubMed  Article  CAS  Google Scholar 

  17. 17.

    Bollag U, Albrecht E, Wingert W. Medicated versus saline nose drops in the management of upper respiratory infection. Helv Paediatr Acta. 1984;39(4):341–5.

    PubMed  CAS  Google Scholar 

  18. 18.

    Slapak I, Skoupa J, Strnad P, Hornik P. Efficacy of isotonic nasal wash (seawater) in the treatment and prevention of rhinitis in children. Arch Otolaryngol Head Neck Surg. 2008;134(1):67–74. doi:10.1001/archoto.2007.19.

    PubMed  Article  Google Scholar 

  19. 19.

    Axelsson A, Grebelius N, Jensen C, Melin O, Singer F. Treatment of acute maxillary sinusitis. IV. Ampicillin, cephradine and erythromycinestolate with and without irrigation. Acta Otolaryngol. 1975;79(5–6):466–72.

    PubMed  Article  CAS  Google Scholar 

  20. 20.

    Rabago D, Pasic T, Zgierska A, Mundt M, Barrett B, Maberry R. The efficacy of hypertonic saline nasal irrigation for chronic sinonasal symptoms. Otolaryngol Head Neck Surg. 2005;133(1):3–8. doi:10.1016/j.otohns.2005.03.002.

    PubMed  Article  Google Scholar 

  21. 21.

    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(12):1049–55.

    PubMed  Google Scholar 

  22. 22.

    Tano L, Tano K. A daily nasal spray with saline prevents symptoms of rhinitis. Acta Otolaryngol. 2004;124(9):1059–62. doi:10.1080/00016480410017657.

    PubMed  Article  Google Scholar 

  23. 23.

    Harvey R, Hannan SA, Badia L, Scadding G. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database Syst Rev. 2007;(3):CD006394. doi:10.1002/14651858.CD006394.pub2.

  24. 24.

    Garavello W, Di Berardino F, Romagnoli M, Sambataro G, Gaini RM. Nasal rinsing with hypertonic solution: an adjunctive treatment for pediatric seasonal allergic rhinoconjunctivitis. Int Arch Allergy Immunol. 2005;137(4):310–4. doi:10.1159/000086462.

    PubMed  Article  Google Scholar 

  25. 25.

    Garavello W, Romagnoli M, Sordo L, Gaini RM, Di Berardino C, Angrisano A. Hypersaline nasal irrigation in children with symptomatic seasonal allergic rhinitis: a randomized study. Pediatr Allergy Immunol. 2003;14(2):140–3.

    PubMed  Article  Google Scholar 

  26. 26.

    Heatley DG, McConnell KE, Kille TL, Leverson GE. Nasal irrigation for the alleviation of sinonasal symptoms. Otolaryngol Head Neck Surg. 2001;125(1):44–8. doi:10.1067/mhn.2001.115909.

    PubMed  Article  CAS  Google Scholar 

  27. 27.

    Rogkakou A, Guerra L, Massacane P, Baiardini I, Baena-Cagnani R, Zanella C, et al. 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(9):353–6.

    PubMed  CAS  Google Scholar 

  28. 28.

    Cordray S, Harjo JB, 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(7):426–30.

    PubMed  Google Scholar 

  29. 29.

    Shoseyov D, Bibi H, Shai P, Shoseyov N, Shazberg G, Hurvitz H. Treatment with hypertonic saline versus normal saline nasal wash of pediatric chronic sinusitis. J Allergy Clin Immunol. 1998;101(5):602–5. doi:10.1016/S0091-6749(98)70166-6.

    PubMed  Article  CAS  Google Scholar 

  30. 30.

    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(10):537–41.

    PubMed  Article  CAS  Google Scholar 

  31. 31.

    • Adappa ND, Wei CC, Palmer JN. Nasal irrigation with or without drugs: the evidence. Curr Opin Otolaryngol Head Neck Surg. 2012;20(1):53–7. doi:10.1097/MOO.0b013e32834dfa80. This work also has an importance for our systematic review. It is a current publication from February 2012 and is about nasal irrigations with or without drugs. The results confirm that physiologic saline irrigation is beneficial in the treatment of symptoms of CRS.

    PubMed  Article  Google Scholar 

  32. 32.

    Tomooka LT, Murphy C, Davidson TM. Clinical study and literature review of nasal irrigation. Laryngoscope. 2000;110(7):1189–93. doi:10.1097/00005537-200007000-00023.

    PubMed  Article  CAS  Google Scholar 

  33. 33.

    Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg. 2007;137(3 Suppl):S1–S31. doi:10.1016/j.otohns.2007.06.726.

    PubMed  Article  Google Scholar 

  34. 34.

    Wormald PJ, Cain T, Oates L, Hawke L, Wong I. A comparative study of three methods of nasal irrigation. Laryngoscope. 2004;114(12):2224–7. doi:10.1097/01.mlg.0000149463.95950.c5.

    PubMed  Article  Google Scholar 

  35. 35.

    Olson DE, Rasgon BM, Hilsinger Jr RL. Radiographic comparison of three methods for nasal saline irrigation. Laryngoscope. 2002;112(8 Pt 1):1394–8. doi:10.1097/00005537-200208000-00013.

    PubMed  Article  Google Scholar 

  36. 36.

    Pynnonen MA, Mukerji SS, Kim HM, Adams ME, Terrell JE. Nasal saline for chronic sinonasal symptoms: a randomized controlled trial. Arch Otolaryngol Head Neck Surg. 2007;133(11):1115–20. doi:10.1001/archotol.133.11.1115.

    PubMed  Article  Google Scholar 

  37. 37.

    Gelardi M, Mezzoli A, Fiorella ML, Carbonara M, Di Gioacchino M, Ciprandi G. Nasal irrigation with lavonase as ancillary treatment of acute rhinosinusitis: a pilot study. J Biol Regul Homeost Agents. 2009;23(2):79–84.

    PubMed  CAS  Google Scholar 

  38. 38.

    Passali D, Damiani V, Passali FM, Passali GC, Bellussi L. Atomized nasal douche vs nasal lavage in acute viral rhinitis. Arch Otolaryngol Head Neck Surg. 2005;131(9):788–90. doi:10.1001/archotol.131.9.788.

    PubMed  Article  Google Scholar 

  39. 39.

    Ural A, Oktemer TK, 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(5):517–21. doi:10.1017/S0022215108003964.

    PubMed  Article  CAS  Google Scholar 

  40. 40.

    Wendeler H, Müller J, Dieter R, Helms J. Nasenspülungen mit isoosmotischer Emser-Salz-Lösung bei chronischer Rhinosinusitis. Oto-Rhino-Laryngologia Nova. 1997;7(5–6):254–8.

    Article  Google Scholar 

  41. 41.

    Friedman M, Hamilton C, Samuelson CG, Maley A, Wilson MN, Venkatesan TK, et al. Dead Sea salt irrigations vs saline irrigations with nasal steroids for symptomatic treatment of chronic rhinosinusitis: a randomized, prospective double-blind study. Int Forum Allergy Rhinol. 2012;2(3):252–7. doi:10.1002/alr.21003.

    PubMed  Article  Google Scholar 

  42. 42.

    Boek WM, Keles N, Graamans K, Huizing EH. Physiologic and hypertonic saline solutions impair ciliary activity in vitro. Laryngoscope. 1999;109(3):396–9.

    PubMed  Article  CAS  Google Scholar 

  43. 43.

    Homer JJ, Dowley AC, Condon L, El-Jassar P, Sood S. The effect of hypertonicity on nasal mucociliary clearance. Clin Otolaryngol Allied Sci. 2000;25(6):558–60.

    PubMed  Article  CAS  Google Scholar 

  44. 44.

    Kim CH, Hyun Song M, Eun Ahn Y, Lee JG, Yoon JH. Effect of hypo-, iso- and hypertonic saline irrigation on secretory mucins and morphology of cultured human nasal epithelial cells. Acta Otolaryngol. 2005;125(12):1296–300. doi:10.1080/00016480510012381.

    PubMed  Article  CAS  Google Scholar 

  45. 45.

    Min YG, Lee KS, Yun JB, Rhee CS, Rhyoo C, Koh YY, et al. Hypertonic saline decreases ciliary movement in human nasal epithelium in vitro. Otolaryngol Head Neck Surg. 2001;124(3):313–6. doi:10.1067/mhn.2001.113145.

    PubMed  Article  CAS  Google Scholar 

  46. 46.

    Miwa M, Matsunaga M, Nakajima N, Yamaguchi S, Watanabe K. Hypertonic saline alters electrical barrier of the airway epithelium. Otolaryngol Head Neck Surg. 2007;136(1):62–6. doi:10.1016/j.otohns.2006.08.013.

    PubMed  Article  Google Scholar 

  47. 47.

    Baraniuk JN, Ali M, Yuta A, Fang SY, 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(2):655–62.

    PubMed  CAS  Google Scholar 

  48. 48.

    Sowerby LJ, Wright ED. Tap water or "sterile" water for sinus irrigations: what are our patients using? Int Forum Allergy Rhinol. 2012;2(4):300–2. doi:10.1002/alr.21031.

    PubMed  Article  Google Scholar 

  49. 49.

    Schmidt T, Bitzer E, Dörning H, Lüpsen H, Schwartz F, Robra B. Tägliches Nasenspülen reduziert Atemwegsbeschwerden - eine randomisierte Crossover-Studie. Gesundheitswesen. 2004;66. doi:10.1055/s-2004-833862.

  50. 50.

    Lee JM, Nayak JV, Doghramji LL, Welch KC, Chiu AG. Assessing the risk of irrigation bottle and fluid contamination after endoscopic sinus surgery. Am J Rhinol Allergy. 2010;24(3):197–9. doi:10.2500/ajra.2010.24.3481.

    PubMed  Article  Google Scholar 

  51. 51.

    Welch KC, Cohen MB, Doghramji LL, Cohen NA, Chandra RK, Palmer JN, et al. Clinical correlation between irrigation bottle contamination and clinical outcomes in post-functional endoscopic sinus surgery patients. Am J Rhinol Allergy. 2009;23(4):401–4. doi:10.2500/ajra.2009.23.3338.

    PubMed  Article  Google Scholar 

  52. 52.

    Williams GB, Ross LL, Chandra RK. Are bulb syringe irrigators a potential source of bacterial contamination in chronic rhinosinusitis? Am J Rhinol. 2008;22(4):399–401. doi:10.2500/ajr.2008.22.3193.

    PubMed  Article  Google Scholar 

  53. 53.

    Foreman A, Wormald PJ. Can bottle design prevent bacterial contamination of nasal irrigation devices? Int Forum Allergy Rhinol. 2011;1(4):303–7. doi:10.1002/alr.20047.

    PubMed  Article  Google Scholar 

  54. 54.

    Psaltis AJ, Foreman A, Wormald PJ, Schlosser RJ. Contamination of sinus irrigation devices: a review of the evidence and clinical relevance. Am J Rhinol Allergy. 2012;26(3):201–3. doi:10.2500/ajra.2012.26.3747.

    PubMed  Article  Google Scholar 

Download references


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.

Author information



Corresponding author

Correspondence to Ralph Mösges.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Achilles, N., Mösges, R. Nasal Saline Irrigations for the Symptoms of Acute and Chronic Rhinosinusitis. Curr Allergy Asthma Rep 13, 229–235 (2013).

Download citation


  • Saline nasal irrigation
  • Nasal douching
  • Acute rhinosinusitis
  • Chronic rhinosinusitis
  • Nasal washing
  • Nasal lavage