Saline Lavage for Sinonasal Disease
October 2000; Volume 3; 109-112
By Susan T. Marcolina, MD
Rhinosinus patients likely would resort to "up your nose with a rubber hose,"1 the phrase made famous by Vinnie Barbarino in Welcome Back, Kotter, if they thought it would help relieve their chronic congestion, cough, and postnasal drip (PND). These symptoms significantly impact quality of life and constitute the leading cause of school and work absenteeism in the United States.2
For decades, physicians used physiologic (0.9%) nasal saline irrigations as adjunctive therapy for sinonasal symptom relief. With such common usage of antihistamines, antibiotics, and intranasal steroid sprays and their not uncommon side effects, saline lavage has reappeared as a viable therapeutic option. Indeed, postoperative lavage is used to aid in the clearance of nasal secretions, debris, and intranasal crusts; to reduce the risk of adhesion formation; and to promote patency of the osteomeatal complexes after endoscopic sinus surgery.3
Cost and Prevalence of Sinonasal Disease
Nasal and sinus disorders are among the most common and expensive causes of medical disability. The estimated costs of treating allergic rhinitis are up to $5.9 billion per year.4 The 1997 costs of treating sinusitis were approximately $6.1 billion.5
Sinusitis affects 15% of the population6 and allergic rhinitis up to 30%.7 The prevalence of chronic sinusitis among pediatric patients with respiratory complaints is estimated to be 73% in children 2-6 years of age and 74% in children aged 6-10.8
Pathophysiology
There is a known association between allergic rhinitis, sinusitis, and asthma.
The nasal mucosa epithelium presents a large surface area through the folds of the turbinates that adjusts the temperature and moisture content of inhaled air and filters out particulates. Thick mucoid nasal secretions impair airway patency resulting in mouth breathing with inspiration of drier, colder air causing airway irritability.9
Drainage impairment and stagnation of thick mucoid secretions encourage colonization and bacterial growth.10 Morphologic microscopic changes of the respiratory mucosa in chronic sinusitis show ciliary disorientation with a loss of ciliated cells, shortened abnormal cilia, and metaplasia with submucosal edema.11
Characteristics of the Saline Irrigant
Several studies have used hypertonic saline, buffered with sodium bicarbonate.3 (See Table 1.) This mildly alkaline solution has a pH of 7.6. Alkaline environments cause the nasal mucus to remain in a "sol" state while acidic environments may cause a greater proportion of mucus to remain in a "gel" state, thus increasing viscosity within the nasal cavity and sinuses. Pulsatile saline delivery has been shown to be more effective in bacteria removal than nasal irrigation with a bulb syringe.12
| Table 1-Recipe for buffered hypertonic saline (3.0%) |
| 1. Clean 1-quart glass or plastic jar. |
| 2. Fill jar with bottled water. |
| 3. Add 2-3 teaspoons pickling or canning salt. |
| 4. Add 1 teaspoon baking soda. |
| 5. Store at room temperature; shake before use. |
| Adapted from: Talbot AR, et al. Mucociliary clearance and buffered hypertonic saline solution. Laryngoscope 1997; 107:500-503. |
Devices for Nasal Saline Lavage
Several devices are used to administer nasal saline irrigation.13 Respironics offers the RinoFlow® Micronized Nasal Wash and Sinus System, which instills nebulized saline. The nasal drainage is separated and collected in a different section of the unit.14 The Neti Pot is a traditional porcelain East Indian nasal irrigation device.15 The SinuCleanse® is similar to the Neti Pot but is made of unbreakable plastic.16 A simple bulb syringe can be used to collect and administer the saline. Several choices of irrigation devices are available for attachment to the Teledyne Water Pik® models. The Ethicare Nasal Irrigator can be used with either the Hydro-Flo Solution Delivery System or with certain newer Water Pik models.
Human Clinical Trials
Talbot et al assessed the effects of isotonic saline (0.9%, pH 7.6) and hypertonic saline (3%, pH 7.6) irrigation on mucociliary clearance using the saccharin clearance method in a crossover study of 21 non-smoking volunteers without any history of upper respiratory tract infection symptoms or allergies.3 Study patients served as their own controls prior to the nasal irrigations. The authors found that buffered hypertonic saline nasal irrigation significantly increased saccharin transit times in comparison to control values and after irrigation with isotonic saline.
Subsequently, Shoseyov et al performed a randomized, double-blind study comparing the effects of nasal wash with hypertonic saline (HS) (3.5%) vs. isotonic saline (IS) on 34 children (ages 3-16) with chronic maxillary sinusitis.17 The children had been treated with antibiotics, b2-agonists, nasal steroids, and systemic steroids, all of which had been stopped at least one month prior to enrollment. The patients were randomly divided into two groups, matched for age and severity of disease. Disease severity was measured by cough score and nasal secretion/PND scores as well as a radiology score based on the Water’s projection view. The clinical scores were measured at the beginning of the study, once weekly for four weeks, and one month after study completion. The radiologic score was performed at the beginning of the study and at the study’s end four weeks later.
Fourteen of 15 patients in the HS group had complete resolution of nasal secretions by the third week of therapy. Thirteen of 15 HS patients had improved clinical cough scores and improved PND/nasal secretion scores. Fourteen of 15 HS patients also had improved sinus radiology scores. The 15 patients treated with IS had no significant improvement in coughs nor any significant change in radiologic scores by the end of the study. However, 13 of the 15 IS patients experienced a clearing of nasal secretions. Four patients (three from the HS group and one from the IS group) dropped out within four days with burning nasal and throat sensations.
Davidson et al performed a one-year clinical study of 108 patients with sinonasal disease.18 Sixty-two patients were treated with nasal saline irrigation alone; 46 were treated with nasal irrigation in combination with other therapies. Twenty control patients without sinonasal disease performed twice daily nasal irrigations. The authors found that the saline-only patients reported significant improvements in PND and sleep disturbances. The combination therapy patients also had a significant improvement in PND score, and additional significant improvements in nasal congestion, cleanliness, and smell loss. The control group reported no significant improvement in any of the nasal disease-specific measures.
Most recently, Heatley et al examined the effects of nasal irrigation in a randomized, prospective study of 150 adults with chronic sinusitis (unpublished data, 2000). They found patients treated with hypertonic saline irrigation (3%, pH 7.6) using either bulb syringe irrigation or a Neti Pot had equivalent and significant improvements in quality-of-life symptom scores. The 28 smokers in the study were less likely to show improvement than the non-smokers (58% vs. 76%). Overall, 36% reported decreased usage of sinus medication during the study period.
Desrosiers et al examined the effects of topically administered saline solution and antibiotics delivered by RinoFlow Nasal Wash and Sinus System in a double-blind, placebo-controlled pilot study of 20 subjects with refractory sinusitis who had failed medical therapy, endoscopic sinus surgery, and culture-directed antibiotic therapy.19 The subjects were studied for eight weeks; one group received nasal nebulization with normal saline and the other group nebulization with tobramycin (20 mg/ml). Baseline studies done on both groups included Rhinoconjunctivitis Quality of Life Quotient Scale, Sinonasal Symptomatology (VAS) Scale, and Endoscopic Assessment.20 Saline aerosol therapy was found to be well tolerated and effective in reducing the sinonasal symptoms of pain, congestion, and PND. Endoscopically documented improvement in mucosal edema and secretions, and improved nasal symptoms, non-nasal symptoms, sleep, activity, and emotional well-being also were demonstrated. Addition of tobramycin to the saline solution added no statistically significant benefit.
Davidson et al have shown that pulsatile saline nasal irrigation is an important adjunctive treatment for chronic rhinosinusitis patients with cystic fibrosis after endoscopic surgery.21 He found that the addition of aerosolized tobramycin inhibits the growth and colonization of Pseudomonas organisms in this patient population.
Adverse Effects
Irrigations of hypertonic saline initially can cause nasal irritation, discomfort, otalgia, or pooling of saline in paranasal sinuses. Injury to the nasal mucosa also may occur if irrigant temperatures are extreme.18
Contraindications/Precautions
If instructed carefully in the nasal saline lavage technique, patients tolerate the procedure well and can perform it as part of their daily hygiene. It is well tolerated and safe in pediatric patients, usually after age 6 or 7,17 and in pregnant and lactating women.16
Conclusion
Several studies have shown nasal irrigation with hypertonic saline solution to be a safe, inexpensive method to alleviate sinonasal symptoms. It has been used effectively as adjunctive therapy to reduce the usage of antibiotics and other sinus medications in patients with chronic sinusitis. It is useful after sinus surgery. Aminoglycoside antibiotics have been used effectively as additives in some nasal irrigation protocols, especially in the management of chronic rhinosinusitis in patients with cystic fibrosis.
Recommendation
Nasal saline lavage should be used as part of a comprehensive approach to patients with rhinosinus diseases. The ease of administration, efficacy, and low cost make it universally available. Patients should be instructed in the use of this technique with careful clinical follow up and addition of other therapies as warranted.
Dr. Marcolina is a board-certified internist and geriatrician in Issaquah, WA.
References
1. Welcome Back Kotter! Available at: www.rollanet.org/~khigh/kotter.html. Accessed September 1, 2000.
2. Kaliner M, et al. Sinusitis: Bench to bedside. J Allergy Clin Immunol 1997;99(Pt 3):S829-S848.
3. Talbot AR, et al. Mucociliary clearance and buffered hypertonic saline solution. Laryngoscope 1997;107:500-503.
4. Ray NF, et al. Cost of allergic rhinoconjunctivitis: Estimation by the Delphi method. J Allergy Clin Immunol 1998;101:S44.
5. Ray N, et al. The cost of sinusitis: Estimating by the Delphi consensus method. J Allergy Clin Immunol 1998;107:S177.
6. Benson V, Marano MA. Current estimates from the 1993 National Health Interview Survey. Vital Health Stat 1994;10:1-29.
7. Sly RM. Changing prevalence of allergic rhinitis and asthma. Ann Allergy Asthma Immunol 1999;82:233-248.
8. Nguyen KL, et al. Chronic sinusitis among pediatric patients with chronic respiratory complaints. J Allergy Clin Immunol 1993;92:824-830.
9. Austen KF. Diseases of immediate type hypersensitivity. In: Fauci A, et al, eds. Harrison’s Principles of Internal Medicine. 14th ed. New York: McGraw-Hill Companies, Inc.; 1998:1867-1869.
10. Reimer A, et al. The mucociliary activity of the upper respiratory tract. III. A functional and morphological study of human and animal material with special reference to maxillary sinus diseases. Acta Otolaryngol Suppl 1978;356:1-20.
11. Toskala E, et al. Scanning electron microscopy findings of human respiratory cilia in chronic sinusitis and in recurrent respiratory infections. J Laryngol Otol 1995;109:509-514.
12. Anglen JO, et al. The efficacy of various irrigation solutions in removing slime-producing Staphylococcus. J Orthop Trauma 1994;8:390-396.
13. Nasal irrigation for chronic sinusitis and nasal polyps. Available at: www.nb.simpatico.ca/normap/nasalirrig.htm. Accessed August 14, 2000.
14. Patients: Asthma and allergy. Available at: www.Rinoflow.com. Accessed August 14, 2000.
15. Jala Neti—The yoga practice of saline nasal irrigation. Available at: www.shoal.net.au/~swami/compare.html. Accessed August 14, 2000.
16. SinuCleanse—Relief for nasal congestion, sinusitis, allergies and postnasal drip. Available at: www.sinucleanse.com. Accessed August 14, 2000.
17. Shoseyov D, et al. Treatment with hypertonic saline versus normal saline nasal wash of pediatric chronic sinusitis. J Allergy Clin Immunol 1998;101:602-605.
18. Tomooka LT, et al. Clinical study and literature review of nasal irrigation. Laryngoscope 2000;110:1189-1193.
19. Desrosiers MY, et al. Treatment of chronic sinusitis refractory to other treatments with topical antibiotic therapy delivered via large particle nebuliser: Results of a controlled trial. Presented at: American Academy of Otolaryngology—Head and Neck Surgery; September 1999; New Orleans, LA.
20. Juniper E. Quality of life questionnaires: Does statistically significant = clinically important? J Allergy Clin Immunol 1998;102:16-17.
21. Davidson TM, et al. Management of chronic sinusitis in cystic fibrosis. Laryngoscope 1995;105:354-358.
October 2000; Volume 3; 109-112
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