Indian J Otolaryngol Head Neck Surg. 2019 Nov; 71(Suppl 3): 1718–1726.
Published online 2017 Jan 13. doi:10.1007/s12070-017-1070-0
PMCID: PMC6848701
PMID: 31763232
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Abstract
Nasal irrigations have been used for centuries without any scientific data to determine its efficacy. Despite their widespread use, much confusion exist about the mechanism of action, preparation, indications and therapeutic advantage of nasal irrigations. Anecdotal evidence and poorly controlled studies add to the confusion. Recent evidence provides strong scientific justification of the benefits and advantages of using nasal irrigations in sinonasal symptoms relief. The present review of the evidence based literature highlights its efficacy and clinical applications.
Keywords: Nasal irrigation, Sinonasal symptoms, Efficacy, Applications
Introduction
Nasal irrigation is a simple, inexpensive procedure that has been used to treat sinus and nasal conditions for many years. The procedure involves flushing the nasal cavity with nasal solution such as saline solution which promotes mucociliary clearance by moisturizing the nasal cavity and removing encrusted material [1]. The concept of nasal irrigation has been used for at least 2 centuries. The first description of nasal irrigation appeared in the British Medical Journal in 1895 [2]. Thudicum’s nasal douche was marketed by Dr. Johann L. W. Thudicum’s in the 1800s for cleansing and medicating the nasal passages [3].
Despite of the early discovery of nasal irrigation, it was not well practiced and developed thereafter. It is known in upper respiratory conditions such as acute and chronic rhinosinusitis, viral upper respiratory tract infection (URTI), allergic and non allergic rhinitis are common disorders that pessimistically affects patients quality of life. Nasal irrigation was originally used at the University of California, San Diego after endoscopic sinus surgery and was originally implemented in their Nasal dysfunction Clinic in the late 1990s [4]. Nasal irrigation was given to patients post endoscopic sinus surgery and they reported significant improvement and patients continued to irrigate well beyond the prescribed postoperative period. This result had led to the application of nasal irrigation in the treatment of nasal diseases including allergic rhinitis and chronic rhinosinusitis. Subsequently nasal irrigation has been used as an adjunctive treatment modality in many centres and also by physicians around the world for the treatment of rhinosinusitis, allergic rhinitis and other sinonasal disease [5]. In 2007, a Cochrane review demonstrated that nasal irrigation showed more benefits than placebo and compares favourably to the treatment effect observed in other sinonasal interventions with intranasal corticosteroids and immunotherapy. This large symptom effect underscores its growing popularity [6].
Mechanism of Action
The respiratory tracts are protected from airborne pollution and debris by a mucociliary layer that lines the sinonasal cavity. Thus this layer consists of pseudostratified ciliated columnar epithelial cells and goblet cells bathed in mucus which constitutes one of the body’s first line defences against potential invading organisms. Foreign particles are trapped in the sticky layer of mucus and ciliary action propels the entire mucous layer out of the sinuses towards the nasopharynx [7]. Sinonasal diseases such as rhinosinusitis occur when ciliary transport mechanism fails usually due to viral, bacterial, allergen or irritant effect [8].
Nasal irrigation is defined as a practice of flushing the nasal cavity with a sterile solution through the nostrils [9]. Furthermore the solution may contain antibiotics or steroid medication. The solution can be saline, hypertonic solution such as sea water and alkaline solution (sodium bicarbonate). Despite various studies done in nasal irrigation, the exact mechanism by which nasal irrigation works remains controversial. The following are postulated mode of action of nasal irrigation [10].
Enhance the Ciliary Beating Frequency
The mucus lining the nasal cavity consists of a sol layer and more superficial gel layer. Foreign material such as bacteria, virus, fungi and allergens get entrapped in the mucus. The cilia project from the nasal pseudostratified columnar epithelium into the mucus. The beating cilia which are more predominant on the gel layer sweep the mucus backwards towards the nasopharynx then it is swallowed. Thus nasal irrigation may enhance ciliary transport of mucus towards the nasopharynx which may be through a direct physical effect. [10] Therefore increasing the ciliary beating frequency will result in the increase to the mucociliary clearance [11].
Softening Effect on Thick Secretions
Nasal irrigation is very effective on crusting and thick secretions by softening and dislodging them along with the nasal secretions [12]. Thus the thick tenacious secretion may become less viscous and enhances the clearance of mucus. A study that found forceful irrigation is more effective than gentle washing of the nose gives support to this hypothesis [13].
Removal of Inflammatory Mediators
The nasal mucus contains many inflammatory mediators such as histamines, prostaglandins and leukotrienes. Defensins is an inflammatory mediator which has been isolated from sinus cavity mucus and its concentration appears to increase with inflammation. These inflammatory mediators were activated in respond to the allergens stimulation to the nasal cavity mucosa. Thus nasal irrigation may act by removing these inflammatory mediators and reduces the acute symptoms in patients with allergic rhinitis [14].
Methods and Devices of Nasal Irrigation
The method involves flushing the nasal cavity with sterile solution. Flushing the nasal cavity can be performed by positive pressure from bottle bulb syringes, negative pressure by sniffing solution into nasal cavity, by nebulizers and gravity based pressure using a vessel with a nasal spout such as neti pot [10]. Evidence had shown that pulsating saline irrigation may also remove bacteria [4]. Olson et al. [15], had stated that positive and negative pressure nasal irrigation were more effective than nebulizers solution into ethmoidal and maxillary sinuses. Furthermore a study by Wormald et al. [16] in 2004, had concluded that nasal douching obtained maximum distribution within the nasal cavity and sinuses when compared with metered spray or nebulizer and is suggested as the irrigation method of choice after endoscopic sinus surgery.
A systematic review by van den Berg et al. [17] looked at the efficacy of nasal saline irrigation versus nasal saline spray. The study looked at time to clinical cure, symptom relief and side effects in adult patients with chronic rhinosinusitis. This review suggested that nasal saline irrigation may provide symptom improvement over nasal saline spray. In another review, Dunn et al. [18] found that the use of a high-volume, low-pressure system like a squeeze bottle has the optimal delivery method and is preferable. Elmiyeh et al. [19] compared the use of three commercially available nasal irrigation device (Stérimar Original®, Emcur® and Sinus Rinse™) in a prospective single blind randomised study in adult volunteers. All three devices were saline based, with differences in mineral content and method of administration. There was no difference in effectiveness and preferences of the three systems. The authors concluded that to optimise compliance, clinicians should ideally explain the correct method of device use and tailor the choice of device to the patient’s medical and social circ*mstances. Nonetheless, there is no consensus regarding methods of irrigation. There were no studies, comparative or not, in the literature focusing on syringe administration, despite this being the most widespread method [20].
Safety of Nasal Irrigation
Nasal irrigation has been shown to be safe and effective till today. Nevertheless minimal side effects such as local irritation, itching, burning sensation in nasal cavity, ear fullness or otalgia and pooling sensation in sinuses have been reported [4, 21]. In addition, most of these minor side effects can be ameliorated with technique modification and salinity adjustment [22]. However, nasal irrigation is contraindicated in facial trauma due to potential leak of nasal solution into danger spaces or plane and in neurologic or musculoskeletal diseases such as intention tremor in which there is an increase risk of aspiration [22].
Lin et al. [23] looked at the practice of nasal irrigation in children aged 3–9years with symptoms of chronic rhinosinusitis. The study revealed that compliance was generally good with the use of nasal irrigation of at least once a day and it significantly alleviates chronic sinonasal symptoms and improve their quality of life. The long term use of nasal irrigation is also well established in paediatric patients. Pham et al. [24] enrolled a total of 104 paediatric chronic rhinosinusitis patients with the mean age of 8.0years and median length of follow-up was 48months. The use of once daily nasal irrigation is effective and leads to symptom resolution as well as minimize the need for surgery such as adenoidectomy and endoscopic sinus surgery. There were no safety issues reported for both studies.
It is recommended that the nasal solution should be sterile or the water used can be initially boiled in order to reduce spread of infection from the nasal cavity which is full of micro organisms [10]. However, no studies available in the literature have been able to identify an approach that achieves complete disinfection of the nasal saline rinse bottles with regular use. Nevertheless, no clear association between irrigation bottle contamination and clinical infection has been demonstrated [25].
Solutions Used as Nasal Irrigation
There are a lot of solutions that had been used as nasal irrigation such as isotonic saline, hypertonic nasal saline and buffered or non buffered solution. According to one study in paediatric chronic sinusitis [26] where patients were randomized to receive either hypertonic saline irrigation (3.5%) or normal saline irrigation (0.9%) for 4weeks. The severity of the disease was measured by two clinical scores and a radiology score. Cough score and nasal secretions or postnasal drip scores were measured at the beginning of the study and at the end of the study in the clinic. The hypertonic saline treatment group reported an increase in clear nasal secretions and most of them had improved clinical cough scores, improved postnasal drip or nasal secretion scores and improved sinus radiology scores. The patients treated with normal saline did not report any significant improvement in their coughs and had no significant change in their radiologic scores at the end of the study. However, a significant improvement in the nasal secretion score was observed as postnasal drip or nasal secretions disappeared or became clear in most of the patients [26]. Furthermore, it has been shown that hypertonic nasal irrigation (3%) was more effective than isotonic nasal irrigation in improving mucociliary clearance, in acute bacterial sinusitis [10]. Talbot et al. [12] had also concluded that hypertonic solution was significantly more effective in improving mucociliary clearance.
On the other hand, buffered solution also had been used on several occasions [12]. This solution can be obtained by adding baking soda which is pure bicarbonate. Moreover, it has been established that alkaline state may decrease mucous viscosity in the nasal cavity and there is maximal ciliary beating frequency in pH between 7 and 9 [3, 27]. Additives may also be included into the nasal solution as irrigation substances. Most often antibacterial and antifungal agents were used and the usage of these additives are best guided by cultures [10]. Antibiotic agents such as gentamycin and tobramycin are most frequently used. Furthermore, bactroban ointment can be also mixed as an aid to help to eradicate staphylococci infections. Ponikau et al. [28] used antifungal agent intranasally in the treatment of chronic rhinosinusitis whereby Amphotericin B was dissolved in sterile water and twice daily irrigation was performed for at least 3months. The study had reported that thirty-eight of 51 patients had improvement in their sinusitis symptoms. A recent study by Jiang et al. [29] recruited seventy-seven patients with chronic rhinosinusitis who received endoscopic sinus surgery and randomly assigned them to two groups (normal saline irrigation versus amphotericin B irrigation). Although all the patients reported improvement after irrigation, there was no difference in outcome between patients who received amphotericin B and those who received normal saline solution.
Advantage of Buffered Solution
It is commonly acknowledged that buffered solution such as alkaline nasal solution is a better irrigation than nasal saline solution. Suslu et al. [30] had conducted a prospective randomized study to evaluate the effect of different irrigation solution on mucociliary clearance, nasal patency and to compare the limitation of the solution by a standard visual analog measuring scale. A total of 45 patients had been recruited and were divided into 3 groups. These subjects were post septoplasty patients in which each group was given 2.3% buffered hypertonic seawater, buffered isotonic saline and non buffered isotonic saline respectively, as irrigation solution. This study revealed there was a significant difference in saccharine clearance time (SCT) between the hypertonic buffered seawater group and non buffered isotonic saline in improving the nasal airway patency. The authors concluded that buffered hypertonic solution used after nasal surgery was beneficial for both mucociliary clearance and postoperative decongestion. Thus, postoperative recovery was faster and has less complications.
In contrast, Keojampa et al. [31] had shown that both buffered hypertonic and buffered normal saline spray significantly improved saccharine clearance time (SCT) without affecting nasal airway patency. Furthermore, Hauptman et al. [32] found that both buffered normal saline and buffered hypertonic saline improve mucociliary clearance with nasal airway patency improves by buffered normal saline but no effect of buffered hypertonic saline on airway patency.
Satdhabudha and Poachanukoon [33] had shown that nasal irrigation with buffered hypertonic saline causes a mark improvement in saccharine clearance time (SCT), total nasal symptoms score (TNSS) and quality of life (QoL) as compared to buffered normal saline in children with symptomatic allergic rhinitis. The authors suggested that buffered hypertonic saline is superior to buffered normal saline and hypertonic saline is better than normal saline. The possible explanation is that the hypertonicity causes reduction of mucosal oedema due to osmotic pressure induced water transport through the mucosal epithelial membrane thereby reducing nasal congestion and improving mucociliary clearance [27]. Moreover alkaline pH is also better for ciliary function [27].
Nasal irrigation in rhinosinusitis diseases with buffered solution gives more pleasant feeling during irrigation and provides beneficial effect [34]. Therefore in children, nasal irrigation may avoid antibiotic and reduce nasal steroid decongestant usage.
Advantage of Sea Salt Solution
The ‘Dead Sea’ water has high salt composition which are calcium, magnesium, bromine and potassium and less sodium sulfate and carbonate than any other ocean [35]. The magnesium component which is the dominant cation inhibits histamine release from mast cell and stabilizes eosinophils by inhibiting them from degranulation. Therefore, this process decreases the immune response and produces an anti-inflammatory response. Levine et al. [35] recruited 31 patients with refractive purulent rhinosinusitis and subjected them to treatment with nasal irrigation using ‘Dead Sea’ salt (Oasis; Master Solutions, Tulsa, OK, USA). The study noted that ‘Dead Sea’ salt is an effective irrigation and spray in the treatment of purulent rhinosinusitis in improving the quality of life and rhinosinusitis symptoms. Its effectiveness might be due to the different cation composition from the normal or hypertonic saline.
Nasal saline solution such as ‘Dead Sea’ saline can be an effective alternative in mild to moderate allergic rhinitis, particularly with respect to nasal and eye symptoms [36]. The Dead Sea solution may have a positive effect on the physiology of the nasal mucosa by improving mucociliary clearance. In addition, the dominant cation (magnesium) in the Dead Sea solution probably exerts anti-inflammatory effects on the nasal mucosa and on the systemic immune response. The practice has been used safely for both adults and children with no serious adverse effects.
Chen et al. [37] enrolled 61 children with allergic rhinitis (moderate to severe) with mean age of 6years (range from 2 to 15years) for daily nasal irrigation as an adjunct treatment to their intranasal corticosteroid. Daily nasal irrigation with seawater significantly improved the symptoms of the allergic rhinitis, proving its effectiveness in controlling symptoms and reducing the dose of a nasal corticosteroid. Friedman et al. [38] compared the efficacy of Dead Sea salt irrigations and nasal spray versus saline irrigations and topical nasal steroid spray in the treatment of symptoms of chronic rhinosinusitis. Treatment with Dead Sea salt irrigations and sprays provides significant improvement in symptoms and quality of life for patients with chronic rhinosinusitis and appears to be as effective as using a combination of a topical intranasal steroid and hypertonic saline solution.
Clinical Applications
In most guidelines for the treatment of various nasal pathological conditions nasal irrigation is recommended as a stand-alone or as a supplementary therapy [20, 34, 39].
It is recommended that nasal irrigation should be considered for all patients with chronic rhinitis, rhinitis medicamentosa, atrophic rhinitis, nasopharyngitis and sinusitis [40]. Thus nasal irrigation can be used in the management of acute or chronic rhino sinusitis, allergic and non allergic rhinitis, postnasal drip, septal perforation and postoperative cases. Nasal irrigation has been proven to be effective with neglectable rate of side effects and safe to be used in children and during pregnancy.
Nasal Irrigation Use for Allergic Rhinitis
Nasal irrigation is a simple and inexpensive treatment that relieves the symptoms allergic rhinitis. The use of nasal irrigation also reduces the use of medical resources and may help to minimize antibiotic use and resistance [9].
In a randomized clinical trial by Garavello et al. [41], nasal irrigation with hypertonic saline was used as an adjunctive treatment modality in the management of paediatric allergic rhinitis. The aimed of this study was to determine whether nasal irrigation with hypertonic solution can be routinely used in children with allergic rhino-conjunctivitis. In this study 44 children with seasonal grass pollen rhino conjunctivitis was recruited and divided into 2 groups equally. One group was given hypertonic saline as nasal irrigation 3 times daily for duration of 7weeks and the other was as control group without nasal irrigation. Oral antihistamine was given for both groups. Every week nasal symptoms and ocular symptoms were assessed by mean daily rhino-conjunctivitis score. There were statistically significant improvement in sixth and seventh week of therapy in the nasal irrigation group as compared to the control group. Moreover the study also showed reduction in intake of oral antihistamines in patients allocated to nasal irrigation and there were no reported adverse effect during the study.
Besides reduction of nasal symptoms such as nasal discharge, obstruction and congestion, nasal irrigation also decreases the concentration of nasal leukotriene, C4 (an inflammatory mediator) [9]. Furthermore, the nasal irrigation had a long term effect on mediator production and a useful therapy in allergic rhinitis which was evidenced in a controlled clinical study of 30 subjects with persistent rhinitis [14]. Persistent allergic rhinitis is typically treated with antihistamines and corticosteroids are added if symptoms are severe. Nasal irrigation has been suggested as an adjunct therapy to flush out mucus, crust with irritant and improve the flow of air through the nose [9].
Tomooka et al. [4], reported drastic significant improvement in 23 of the 30 nasal symptoms in patients who had used nasal irrigation for the treatment of sinonasal disease, persistent rhinitis, intermittent rhinitis and post nasal drip. Moreover, Quality of Well Being Scale had been used in this study to assess patients’ symptoms pre and post irrigation. Thus, the authors concluded that nasal irrigation provides better health status by reducing the nasal symptoms. In addition, Nguyen et al. [42] had established that the use of large-volume (240mL), low-positive pressure (NeilMed Sinus Rinse bottles) nasal irrigation with isotonic saline is an effective adjunctive therapy to improve quality of life in patients with allergic rhinitis that had already been on intranasal corticosteroid therapy.
Nasal Irrigation Use for Acute and Chronic Rhinosinusitis
Rhinosinusitis is the mucosal inflammation of the nasal and paranasal sinuses. Rhinosinusitis affects 1 in 8 adults in United States which leads to 30 million individual diagnosed each year and the prevalence is on the rise [39]. The morbidity of chronic rhinosinusitis is also most similar to other chronic diseases such as heart failure, chronic obstructive pulmonary disease and chronic back pain [39, 43].
Heatley et al. [21] had shown that more than 70% of patients suffering from chronic rhinosinusitis showed better improvement of symptoms after nasal irrigation. The study had recruited 150 patients and divided them into 3 groups. Each group was assigned to 1 of 3 treatment group as follows; nasal irrigation with bulb syringe, nasal irrigation with pot and the control treatment for a duration of 4weeks. The results of the study revealed a significant improvement of chronic rhinosinusitis symptoms and a reduction in the usage of nasal medication in those patients with good compliance. The authors concluded that nasal irrigation is simple and effective, and is a good adjunct in the treatment of chronic rhinosinusitis in reducing the symptoms and better quality of life.
Rabago et al. [44] conducted a randomized controlled trial regarding the effectiveness of daily saline nasal irrigation in patients with frequent sinusitis. This study demonstrated that daily saline irrigation improves quality of life, reduces symptoms and decreases usage of medication among the patients and this therapy was recommended to the primary care physicians. Subsequently, in another study the same team using the Rhinosinusitis Disability Index (RSDI), a sinus-symptom severity assessment (SIA), and the Sino-Nasal Outcomes Test (SNOT-20) demonstrated the efficacy of hypertonic saline nasal irrigation in subjects with chronic or recurrent sinonasal symptoms in reducing their symptoms and improved their quality of life after usage of nasal irrigation [45].
Moreover, Rabago et al. [46] had established in another study that hypertonic saline nasal irrigation provides effective long term therapy with minimal training at home and follow up for chronic rhinosinusitis patients. Many participants were enthusiastic and reported improvements with the first or second use. Most participants also confirmed positive long-term effects of nasal irrigation on sinus-related quality of life and noted a deep sense of satisfaction associated with the diminution of their sinus symptoms. In addition, there is strong evidence that hypertonic saline nasal irrigation not only improve symptoms of chronic rhinosinusitis but also improve the concomitant allergic rhinitis, asthma and nasal polyposis [47].
Bachmann et al. [48] recruited 40 subjects in a randomized, controlled, double blind trial to study the effectiveness of nasal irrigation between ‘Ems’ salt solution and sodium chloride solution in the treatment of chronic sinus diseases which showed good results with both solution. In this study the nasal irrigation was done twice daily along with regular nasal spray. The assessment of nasal airway obstruction and duration of improved nasal resistance were done by nasal endoscopy, plain radiography of the paranasal sinuses, olfactometry, anterior rhinomanometry and a saccharin-clearance test (SCT). The results showed no improvement in the nasal air flow but assessment done with endonasal endoscopy and radiography revealed a significant improvement with both solutions. The authors concluded that nasal irrigation proved to be effective in relieving the nasal symptoms such as nasal obstruction in the treatment of chronic sinusitis. Similarly, Scheid and Hamm [49] had supported the previous study by showing that nasal irrigation with hypertonic and normal saline has been beneficial in chronic sinusitis with no serious adverse effects. Achilles et al. [50] had reviewed the nasal irrigation delivery in the form of nasal douches, neti pots or sprays in the treatment of nasal and sinus disorders and concluded that nasal douches are recommended whatever the form of rhinosinusitis along with isotonic and hypertonic saline solutions in acute and chronic sinusitis.
Nasal Irrigation Use for Cold and Flu
Cold and flu are very common presentation seen in the general outpatient clinic. Despite many studies been done in common cold and flu, the use of nasal irrigation is still under utilised. Slapak et al. [51] had conducted a study of nasal irrigation on children age ranging from 6 to 10years with cold and flu and showed good outcome. They had selected 401 children with uncomplicated cold and flu disease and randomized them into 2 groups. Each group was given standard medication with additional modified seawater solution (Physiomer) for nasal irrigation to the study group for 12weeks duration. Patients in the saline group showed significantly lower scores in sore throat, cough, nasal obstruction and secretion. Significantly fewer children in the saline group were using antipyretics, nasal decongestants, mucolytics and systemic anti-infectives. During the same period, children in the saline group also reported significantly fewer illness days, school absences and complications.
Moreover, Tano et al. [52] had found that daily nasal irrigation with saline can prevent nasal symptoms of common cold in a population of otherwise healthy adults. In addition, this study had shown that saline spray has the ability to reduce the symptoms of nasal secretion and/or blocked nose with less episodes of upper respiratory tract infection. A recent Cochrane review [53] demonstrated that the use of nasal irrigation in upper respiratory tract infection (URTI) provides significant reductions in the frequency of symptoms (nasal secretions, sore throat, nasal breathing score and nasal obstruction) as well as reduce use of additional nasal decongestant medications. There was a faster improvement of symptoms and significant improvement in the health status score.
Nasal Irrigation Use for Post-Nasal Surgery Care
Post nasal surgery care is one of the important elements in the management of nasal diseases. In fact, post nasal surgery care is the key to success of the surgery. Thus, nasal irrigation plays a pivotal role in management of the post nasal surgery. Keerl et al. [54] evaluated the effectiveness and acceptance of the cleaning of the nose with saline solution after endonasal sinus surgery. They noted that irrigation of the nose after nasal surgery is judged positively by most of the patients and is integrated well in the daily routine. Subsequently, nasal irrigation had become a popular mode of adjunct therapy following sinonasal surgery. Moreover, in another study by Liang et al. [55] revealed that nasal irrigation is an effective mode in post FESS management in patients with chronic sinusitis.
Low et al. [56] compared the use of normal saline, lactated Ringer’s and hypertonic saline nasal irrigation solution after endoscopic sinus surgery for chronic rhinosinusitis. All groups showed an improvement in their subjective symptoms as well as the nasoendoscopic evaluation. However, irrigation with lactated Ringer’s solution resulted in better symptom improvement compared with irrigation with normal saline or hypertonic saline solutions. Kim et al. [57] evaluated the effect of sinus saline irrigation on the prevention of purulent rhinorrhea, extensive granulation formation, and polyp recurrence after endoscopic sinus surgery. Their findings suggested that saline irrigation may be effective in the prevention of recurrent symptoms post surgery over the long term.
Salib et al. [58] compared the efficacy and tolerability of the nasal douching products low-volume high-pressure Sterimar™ and high-volume low-pressure Sinus Rinse™ following functional endoscopic sinus surgery for chronic rhinosinusitis. Their findings showed patients perceived Sinus Rinse™ to be more effective than Sterimar™ but there was no significant difference in the patients’ preference for either product. When comparing Sterimar™ with SinuRinse™, there was a statistically significant favourable outcome for the side treated with Sinus Rinse™. The authors concluded that high-volume low-pressure saline irrigation is recommended as an efficacious, easy to use and well-tolerated adjunct to endoscopic sinonasal toilet in the early postoperative period following endoscopic sinus surgery.
Nasal Irrigation Use for Post-Irradiation Sinus Care
Rhinosinusitis is one of the common acute post radiotherapy complications in nasopharyngeal carcinoma (NPC). Liang et al. [59] enrolled 107 post irradiated NPC patients and divided them into 2 groups in which one group received nasal irrigation for 6months duration and the other did not. The patients in the irrigation group had significantly better outcome than patients in the non irrigation group. The study showed that nasal irrigation is a safe and effective method for the management of this acute complication.
Nasal Irrigation Use for Occupational Sinonasal Disorders
Occupational rhinitis is one of the common sinonasal disorders. Nasal symptoms such as blocked nose, dry nose, runny nose, nosebleeds and sinusitis are common amongst woodworkers as wood dust is a mucous membrane irritant as well as carcinogenic to the nasal mucosa.
Rabone and Saraswati [60] performed a study to determine the benefit of nasal irrigation among woodworkers. The study showed that nasal symptoms were reduced after nasal irrigation and they concluded that nasal irrigation is an acceptable, effective and inexpensive option with minimal side effects for woodworkers. Another study conducted by Castano et al. [61] found that nasal irrigation method was shown to be significantly useful for the monitoring of the upper airways inflammation during the investigation of occupational rhinitis. Thus nasal irrigation do relieves nasal symptoms and provide better working environment for the occupational rhinitis patients.
Nasal Irrigation Use for Pregnant Women with Seasonal Allergic Rhinitis
Nasal irrigation appears suitable in the management of pregnant women with seasonal allergic rhinitis since no deleterious effects on the fetus are to be expected. Garavello et al. [62] performed a randomized study in which 45 pregnant women with seasonal allergic rhinitis were randomized to intranasal irrigation with hypertonic saline solution 3 times daily versus no local therapy in a 6-week period corresponding to the pollen season. At the end of study duration, rhinitis score was assessed and showed significant improvement in the score among the study sample in all subsequent weeks. Moreover, this study also revealed that there was reduction in the usage of antihistamines after nasal irrigation implemented and there was good compliance from the study subjects. Thus as a conclusion, this study showed that nasal irrigation is a safe, simple and effective treatment as alternative for pregnant women with seasonal allergic rhinitis.
Conclusions
The idea and method of nasal irrigation had existed since old days and had been proven to play a vital role as treatment in sinonasal symptoms. Nasal irrigation is simple to use, well tolerated and inexpensive. Isotonic saline nasal irrigation is one of the oldest and most effective methods used in the treatment. Solutions are easily prepared and inexpensive. However, evidences seem to conclude that hypertonic solutions are more efficacious than isotonic solutions for the treatment of sinonasal symptoms. Reported side effects frequently include a burning or stinging sensation with hypertonic solutions. Serious side effects have not been reported with the use of either hypertonic or normal saline nasal sprays or irrigations. Large-volume irrigation provides good distribution over the sinonasal cavities as a whole and isotonic solution with slightly alkaline pH and a composition close to that of sea-water provides better relief and symptom resolution.
Compliance with Ethical Standards
Conflict of interest
All authors declare that he/she has no conflict of interest.
Ethical Approval
This article does not contain any studies with human participants performed by any of the authors.
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