Nasal Irrigation: An Imprecisely Defined Medical Procedure

Nicola Principi, Susanna Esposito, Nicola Principi, Susanna Esposito

Abstract

Nasal irrigation (NI) is an old practice of upper respiratory tract care that likely originated in the Ayurvedic medical tradition. It is used alone or in association with other therapies in several conditions-including chronic rhinosinusitis and allergic rhinitis-and to treat and prevent upper respiratory tract infections, especially in children. However, despite it being largely prescribed in everyday clinical practice, NI is not included or is only briefly mentioned by experts in the guidelines for treatment of upper respiratory tract diseases. In this review, present knowledge about NI and its relevance in clinical practice is discussed to assist physicians in understanding the available evidence and the potential use of this medical intervention. Analysis of the literature showed that NI seems to be effective in the treatment of several acute and chronic sinonasal conditions. However, although in recent years several new studies have been performed, most of the studies that have evaluated NI have relevant methodologic problems. Only multicenter studies enrolling a great number of subjects can solve the problem of the real relevance of NI, and these studies are urgently needed. Methods for performing NI have to be standardized to determine which solutions, devices and durations of treatment are adequate to obtain favorable results. This seems particularly important for children that suffer a great number of sinonasal problems and might benefit significantly from an inexpensive and simple preventive and therapeutic measure such as NI.

Keywords: allergic rhinitis; chronic rhinosinusitis; nasal irrigation; upper respiratory tract infection.

Conflict of interest statement

The authors declare no conflict of interest.

References

    1. Rama S., Ballentine R., Hymes A. Science of Breath: A Practical Guide. Himalayan Institute Press; Honesdale, PA, USA: 1998.
    1. Burns J.L. Nasal lavage. J. Otholaryngol. 1992;21:83.
    1. Sur D.K., Plesa M.L. Treatment of allergic rhinitis. Am. Fam. Physician. 2015;92:985–992.
    1. Benninger M.S., Holy C.E., Trask D.K. Acute rhinosinusitis: Prescription patterns in a real-world setting. Otolaryngol. Head Neck Surg. 2016;154:957–962. doi: 10.1177/0194599816630310.
    1. Rudmik L., Hoy M., Schlosser R.J., Harvey R.J., Welch K.C., Lund V., Smith T.L. Topical therapies in the management of chronic rhinosinusitis: An evidence-based review with recommendations. Int. Forum Allergy Rhinol. 2013;3:281–298. doi: 10.1002/alr.21096.
    1. Beswick D.M., Ramadan H., Baroody F.M., Hwang P.H. Practice patterns in pediatric chronic rhinosinusitis: A survey of the American Rhinologic Society. Am. J. Rhinol. Allergy. 2016;30:418–423. doi: 10.2500/ajra.2016.30.4373.
    1. Marchisio P., Picca M., Torretta S., Baggi E., Pasinato A., Bianchini S., Nazzari E., Esposito S., Principi N. Nasal saline irrigation in preschool children: A survey of attitudes and prescribing habits of primary care pediatricians working in northern Italy. Ital. J. Pediatr. 2014;40:47. doi: 10.1186/1824-7288-40-47.
    1. Sobol S.E., Samadi D.S., Kazahaya K., Tom L.W. Trends in the management of pediatric chronic sinusitis: Survey of the American Society of Pediatric Otolaryngology. Laryngoscope. 2005;115:78–80. doi: 10.1097/01.mlg.0000150671.45484.87.
    1. Slapak I., Skoupá J., Strnad P., Horník P. Efficacy of isotonic nasal wash (seawater) in the treatment and prevention of rhinitis in children. Arch. Otolaryngol. Head Neck Surg. 2008;134:67–74. doi: 10.1001/archoto.2007.19.
    1. Rosenfeld R.M., Piccirillo J.F., Chandrasekhar S.S., Brook I., Kumar K.A., Kramper M., Orlandi R.R., Palmer J.N., Patel Z.M., Peters A., et al. Clinical Practice Guideline (Update): Adult sinusitis executive summary. Otolaryngol. Head Neck Surg. 2015;152:598–609. doi: 10.1177/0194599815574247.
    1. Chow A.W., Benninger M.S., Brook I., Brozek J.L., Goldstein E.J., Hicks L.A., Pankey G.A., Seleznick M., Volturo G., Wald E.R., et al. Infectious Diseases Society of America: IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin. Infect. Dis. 2012;54:e72–e112. doi: 10.1093/cid/cis370.
    1. Wald E.R., Applegate K.E., Bordley C., Darrow D.H., Glode M.P., Marcy S.M., Nelson C.E., Rosenfeld R.M., Shaikh N., Smith M.J., et al. American academy of pediatrics: Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132:e262–e280. doi: 10.1542/peds.2013-1071.
    1. Roberts G., Xatzipsalti M., Borrego L.M., Custovic A., Halken S., Hellings P.W., Papadopoulos N.G., Rotiroti G., Scadding G., Timmermans F., et al. Paediatric rhinitis: Position paper of the European academy of allergy and clinical immunology. Allergy. 2013;68:1102–1116. doi: 10.1111/all.12235.
    1. Bousquet J., Schunemann H.J., Fonseca J., Samolinski B., Bachert C., Canonica G.W. MACVIA: ARIA sentinel network for allergic rhinitis (MASK-rhinitis): The new generation guideline implementation. Allergy. 2015;70:1372–1392. doi: 10.1111/all.12686.
    1. Bastier P.L., Lechot A., Bordenave L., Durand M., de Gabory L. Nasal irrigation: From empiricism to evidence-based medicine. A review. Eur. Ann. Otorhinolaryngol. Head Neck Dis. 2015;132:281–285. doi: 10.1016/j.anorl.2015.08.001.
    1. Georgitis J.W. Nasal hyperthermia and simple irrigation for perennial rhinitis: Changes in inflammatory mediators. Chest. 1994;106:1487–1492. doi: 10.1378/chest.106.5.1487.
    1. Carothers D.G., Graham S.M., Jia H.P., Ackermann M.R., Tack B.F., McCray P.B., Jr. Production of β-defensin antimicrobial peptides by maxillary sinus mucosa. Am. J. Rhinol. 2001;15:175–179. doi: 10.2500/105065801779954238.
    1. Ghafouri B., Stahlbom B., Tagesson C., Lindahl M. Newly identified proteins in human nasal lavage fluid from non-smokers and smokers using two-dimensional gel electrophoresis and peptide mass fingerprinting. Proteomics. 2002;2:112–120. doi: 10.1002/1615-9861(200201)2:1<112::AID-PROT112>;2-N.
    1. Talbot A.R., Herr T.M., Parsons D.S. Mucociliary clearance and buffered hypertonic saline solution. Laryngoscope. 1997;107:500–503. doi: 10.1097/00005537-199704000-00013.
    1. Woods C.M., Tan S., Ullah S., Frauenfelder C., Ooi E.H., Carney A.S. The effect of nasal irrigation formulation on the antimicrobial activity of nasal secretions. Int. Forum Allergy Rhinol. 2015;5:1104–1110. doi: 10.1002/alr.21604.
    1. Ludwig P., Petrich K., Schewe T., Diezel W. Inhibition of eicosanoid formation in human polymorphonuclear leukocytes by high concentrations of magnesium ions. Biol. Chem. 1995;376:739–744. doi: 10.1515/bchm3.1995.376.12.739.
    1. Larbi K.Y., Gomperts B.D. Complex pattern of inhibition by Mg2+ of exocytosis from permeabilised eosinophils. Cell Calcium. 1997;21:213–219. doi: 10.1016/S0143-4160(97)90045-2.
    1. Tesfaigzi Y. Roles of apoptosis in airway epithelia. Am. J. Respir. Cell Mol. Biol. 2006;34:537–547. doi: 10.1165/rcmb.2006-0014OC.
    1. Trinh N.T.N., Privé A., Maillé E., Noël J., Brochiero E. EGF and K+ channel activitycontrol normal and cystic fibrosis bronchial epithelia repair. Am. J. Physiol. Lung Cell. Mol. Physiol. 2008;295:L866–L880. doi: 10.1152/ajplung.90224.2008.
    1. Buchanan P.J., McNally P., Harvey B.J., Urbach V. Lipoxin A4-mediated KATP potassium channel activation results in cystic fibrosis airway epithelial repair. Am. J. Physiol. Lung Cell. Mol. Physiol. 2013;305:L193–L201. doi: 10.1152/ajplung.00058.2013.
    1. Chusakul S., Warathanasin S., Suksangpanya N., Phannaso C., Ruxrungtham S., Snidvongs K., Aeumjaturapat S. Comparison of buffered and nonbuffered nasal saline irrigations in treating allergic rhinitis. Laryngoscope. 2013;123:53–56. doi: 10.1002/lary.23617.
    1. England R.J., Anthony R., Homer J.J., Martin-Hirsch D.P. Nasal pH and saccharin clearance are unrelated in the physiologically normal nose. Rhinology. 2000;38:66–67.
    1. Baraniuk J.N., Ali M., Yuta A., Fang S.Y., 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;160:655–662. doi: 10.1164/ajrccm.160.2.9805081.
    1. PubChem Open Chemistry Database. Ringer-Lactate. [(accessed on 3 March 2017)]; Available online: .
    1. 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;51:1049–1055.
    1. Tomooka L.T., Murphy C., Davidson T.M. Clinical study and literature review of nasal irrigation. Laryngoscope. 2000;110:1189–1193. doi: 10.1097/00005537-200007000-00023.
    1. Brown C.L., Graham S.M. Nasal irrigations: Good or bad? Curr. Opin. Otolaryngol. Head Neck Surg. 2004;12:9–13. doi: 10.1097/00020840-200402000-00004.
    1. Ho E.Y., Cady K.A., Robles J.S. A case study of the Neti pot’s rise, americanization, and rupture as integrative medicine in U.S. media discourse. Health Commun. 2016;31:1181–1192. doi: 10.1080/10410236.2015.1047145.
    1. Wormald P.J., Cain T., Oates L., Hawke L., Wong I. A comparative study of three methods of nasal irrigation. Laryngoscope. 2004;114:2224–2227. doi: 10.1097/01.mlg.0000149463.95950.c5.
    1. Salib R.J., Talpallikar S., Uppal S., Nair S.B. A prospective randomised single-blinded clinical trial comparing the efficacy and tolerability of the nasal douching products Sterimar™ and Sinus Rinse™ following functional endoscopic sinus surgery. Clin. Otolaryngol. 2013;38:297–305. doi: 10.1111/coa.12132.
    1. Campos J., Heppt W., Weber R. Nasal douches for diseases of the nose and the paranasal sinuses—A comparative in vitro investigation. Eur. Arch. Otorhinolaryngol. 2013;270:2891–2899. doi: 10.1007/s00405-013-2398-z.
    1. Garavello W., Romagnoli M., Sordo L., Gaini R.M., Di Berardino C., Angrisano A. Hypersaline nasal irrigation in children with symptomatic seasonal allergic rhinitis: A randomized study. Pediatr. Allergy Immunol. 2003;14:140–143. doi: 10.1034/j.1399-3038.2003.00021.x.
    1. Marchisio P., Varricchio A., Baggi E., Bianchini S., Capasso M.E., Torretta S., Capaccio P., Gasparini C., Patria F., Esposito S., et al. Hypertonic saline is more effective than normal saline in seasonal allergic rhinitis in children. Int. J. Immunopathol. Pharmacol. 2012;25:721–730. doi: 10.1177/039463201202500318.
    1. Chen J.R., Jin L., Li X.Y. The effectiveness of nasal saline irrigation (seawater) in treatment of allergic rhinitis in children. Int. J. Pediatr. Otorhinolaryngol. 2014;78:1115–1118. doi: 10.1016/j.ijporl.2014.04.026.
    1. Barham H.P., Harvey R.J. Nasal saline irrigation: Therapeutic or homeopathic. Braz. J. Otorhinolaryngol. 2015;81:457–458. doi: 10.1016/j.bjorl.2015.07.002.
    1. Jeffe J.S., Bhushan B., Schroeder J.W., Jr. Nasal saline irrigation in children: A study of compliance and tolerance. Int. J. Pediatr. Otorhinolaryngol. 2012;76:409–413. doi: 10.1016/j.ijporl.2011.12.022.
    1. Brook I. Bacterial contamination of saline nasal spray/drop solution in patients with respiratory tract infection. Am. J. Infect. Control. 2002;30:246–247. doi: 10.1067/mic.2002.119955.
    1. Lee J.M., Nayak J.V., Doghramji L.L., Welch K.C., Chiu A.G. Assessing the risk of irrigation bottle and fluid contamination after endoscopic sinus surgery. Am. J. Rhinol. Allergy. 2010;24:197–199. doi: 10.2500/ajra.2010.24.3481.
    1. Psaltis A.J., Foreman A., Wormald P.J., Schlosser R.J. Contamination of sinus irrigation devices: A review of the evidence and clinical relevance. Am. J. Rhinol. Allergy. 2012;26:201–203. doi: 10.2500/ajra.2012.26.3747.
    1. Kofonow J.M., Bhuskute A., Doghramji L., Palmer J.N., Cohen N.A., Chiu A.G. One-way valve bottle contamination rates in the immediate post-functional endoscopic sinus surgery period. Am. J. Rhinol. Allergy. 2011;25:393–396. doi: 10.2500/ajra.2011.25.3664.
    1. Heatley D.G., McConnell K.E., Kille T.L., Leverson G.E. Nasal irrigation for the alleviation of sinonasal symptoms. Otolaryngol. Head Neck Surg. 2001;125:44–48. doi: 10.1067/mhn.2001.115909.
    1. Foreman A., Wormald P.J. Can bottle design prevent bacterial contamination of nasal irrigation devices? Int. Forum Allergy Rhinol. 2011;1:303–307. doi: 10.1002/alr.20047.
    1. Williams G.B., Ross L.L., Chandra R.K. Are bulb syringe irrigators a potential source of bacterial contamination in chronic rhinosinusitis? Am. J. Rhinol. 2008;22:399–401. doi: 10.2500/ajr.2008.22.3193.
    1. Keen M., Foreman A., Wormald P.J. The clinical significance of nasal irrigation bottle contamination. Laryngoscope. 2010;120:2110–2114. doi: 10.1002/lary.21031.
    1. Welch K.C., Cohen M.B., Doghramji L.L., Cohen N.A., Chandra R.K., Palmer J.N., Chiu A.G. Clinical correlation between irrigation bottle contamination and clinical outcomes in post-functional endoscopic sinus surgery patients. Am. J. Rhinol. Allergy. 2009;23:401–404. doi: 10.2500/ajra.2009.23.3338.
    1. Lewenza S., Charron-Mazenod L., Cho J.J., Mechor B. Identification of bacterial contaminants in sinus irrigation bottles from chronic rhinosinusitis patients. J. Otolaryngol. Head Neck Surg. 2010;39:458–463.
    1. Yoder J.S., Straif-Bourgeois S., Roy S.L., Moore T.A., Visvesvara G.S., Ratard R.C., Hill V.R., Wilson J.D., Linscott A.J., Crager R., et al. Primary amebic meningoencephalitis deaths associated with sinus irrigation using contaminated tap water. Clin. Infect. Dis. 2012;55:e79–e85. doi: 10.1093/cid/cis626.
    1. Gelardi M., Taliente S., Piccininni K., Silvestre G., Quaranta N., Ciprandi G. Nasal irrigation with Nasir® in children: A preliminary experience on nasal cytology. J. Biol. Regul. Homeost. Agents. 2016;30:1125–1130.
    1. Fashner J., Ericson K., Werner S. Treatment of the common cold in children and adults. Am. Fam. Physician. 2012;86:153–159.
    1. De Luca M., Donà D., Montagnani C., Lo Vecchio A., Romanengo M., Tagliabue C., Centenari C., D’Argenio P., Lundin R., Giaquinto C., et al. Antibiotic prescriptions and prophylaxis in Italian children. Is it time to change? Data from the ARPEC Project. PLoS ONE. 2016;11:e0154662. doi: 10.1371/journal.pone.0154662.
    1. King D., Mitchell B., Williams C.P., Spurling G.K. Saline nasal irrigation for acute upper respiratory tract infections. Cochrane Database Syst. Rev. 2015;4 doi: 10.1002/14651858.cd006821.pub3.
    1. Adam P., Stiffman M., Blake R.L., Jr. A clinical trial of hypertonic saline nasal spray in subjects with the common cold or rhinosinusitis. Arch. Fam. Med. 1998;7:39–43. doi: 10.1001/archfami.7.1.39.
    1. Bollag U., Albrecht E., Wingert W. Medicated versus saline nose drops in the management of upper respiratory infection. Helv. Paediatr. Acta. 1984;39:341–345.
    1. Wang Y.H., Yang C.P., Ku M.S., Sun H.L., Lue K.H. Efficacy of nasal irrigation in the treatment of acute sinusitis in children. Int. J. Pediatr. Otorhinolaryngol. 2009;73:1696–1701. doi: 10.1016/j.ijporl.2009.09.001.
    1. Ragab A., Farahat T., Al-Hendawy G., Samaka R., Ragab S., El-Ghobashy A. Nasal saline irrigation with or without systemic antibiotics in treatment of children with acute rhinosinusitis. Int. J. Pediatr. Otorhinolaryngol. 2015;79:2178–2186. doi: 10.1016/j.ijporl.2015.09.045.
    1. Satdhabudha A., Utispan K., Monthanapisut P., Poachanukoon O. A randomized controlled study comparing the efficacy of nasal saline irrigation devices in children with acute rhinosinusitis. Asian Pac. J. Allergy Immunol. 2016 doi: 10.12932/AP0840.
    1. Tugrul S., Dogan R., Eren S.B., Meric A., Ozturan O. The use of large volume low pressure nasal saline with fluticasone propionate for the treatment of pediatric acute rhinosinusitis. Int. J. Pediatr. Otorhinolaryngol. 2014;78:1393–1399. doi: 10.1016/j.ijporl.2014.06.006.
    1. Harvey R., Hannan S.A., Badia L., Scadding G. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database Syst. Rev. 2007;3 doi: 10.1002/14651858.cd006394.
    1. 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;257:537–541. doi: 10.1007/s004050000271.
    1. Hauptman G., Ryan M.W. The effect of saline solutions on nasal patency and mucociliary clearance in rhinosinusitis patients. Otolaryngol. Head Neck Surg. 2007;137:815–821. doi: 10.1016/j.otohns.2007.07.034.
    1. Pynnonen M.A., Mukerji S.S., Kim H.M., Adams M.E., Terrell J.E. Nasal saline for chronic sinonasal symptoms: A randomized controlled trial. Arch. Otolaryngol. Head Neck Surg. 2007;133:1115–1120. doi: 10.1001/archotol.133.11.1115.
    1. Pinto J.M., Elwany S., Baroody F.M., Naclerio R.M. Effects of saline sprays on symptoms after endoscopic sinus surgery. Am. J. Rhinol. 2006;20:191–196.
    1. Freeman S.R., Sivayoham E.S., Jepson K., de Carpentier J. A preliminary randomised controlled trial evaluating the efficacy of saline douching following endoscopic sinus surgery. Clin. Otolaryngol. 2008;33:462–465. doi: 10.1111/j.1749-4486.2008.01806.x.
    1. Liang K.L., Su M.C., Tseng H.C., Jiang R.S. Impact of pulsatile nasal irrigation on the prognosis of functional endoscopic sinus surgery. J. Otolaryngol. Head Neck Surg. 2008;37:148–153.
    1. Chong L.Y., Head K., Hopkins C., Philpott C., Glew S., Scadding G., Scadding G., Burton M.J., Schilder A.G. Saline irrigation for chronic rhinosinusitis. Cochrane Database Syst. Rev. 2016;4 doi: 10.1002/14651858.cd011995.pub2.
    1. Cassandro E., Chiarella G., Cavaliere M., Sequino G., Cassandro C., Prasad S.C., Scarpa A., Iemma M. Hyaluronan in the treatment of chronic rhinosinusitis with nasal polyposis. Indian J. Otolaryngol. Head Neck Surg. 2015;67:299–307. doi: 10.1007/s12070-014-0766-7.
    1. World Allergy Organization Rhinitis. [(accessed on 3 March 2017)]; Available online: .
    1. Hermelingmeier K.E., Weber R.K., Hellmich M., Heubach C.P., Mösges R. Nasal irrigation as an adjunctive treatment in allergic rhinitis: A systematic review and meta-analysis. Am. J. Rhinol. Allergy. 2012;26:e119–e125. doi: 10.2500/ajra.2012.26.3787.
    1. Barbieri M., Salami A., Mora F., Casazza A., Sovatzis A., Teglia R., Cordone M.P., Mora R. Behavior of serum IgE and IgA in patients with allergic rhinitis treated with iodine bromide thermal water. Acta Otorhinolaryngol. Ital. 2002;22:215–219.
    1. Cingi C., Unlu H.H., Songu M., Yalcin S., Topcu I., Cakli H., Bal C. Seawater gel in allergic rhinitis: Entrapment effect and mucociliary clearance compared with saline. Ther. Adv. Respir. Dis. 2010;4:13–18. doi: 10.1177/1753465809358190.
    1. Cordray S., Harjo J.B., Miner L. Comparison of intranasal hypertonic Dead Sea saline spray and intranasal aqueous triamcinolone spray in seasonal allergic rhinitis. Ear Nose Throat J. 2005;84:426–430.
    1. Garavello W., Di Berardino F., Romagnoli M., Sambataro G., Gaini R.M. Nasal rinsing with hypertonic solution: An adjunctive treatment for pediatric seasonal allergic rhinoconjunctivitis. Int. Arch. Allergy Immunol. 2005;137:310–314. doi: 10.1159/000086462.
    1. Garavello W., Somigliana E., Acaia B., Gaini L., Pignataro L., Gaini R.M. Nasal lavage in pregnant women with seasonal allergic rhinitis: A randomized study. Int. Arch. Allergy Immunol. 2010;151:137–141. doi: 10.1159/000236003.
    1. Klimek L.J.V., Hundorf F., Hommel G., Hormann K. Lässt sich der medikamentenverbrauch bei patienten mit saisonaler rhinitis allergica durch nasenspülbehandlungen mit isoosmotischer emser salziosung reduzieren? Allergologie. 2001;24:309–315.
    1. Li H., Sha Q., Zuo K., Jiang H., Cheng L., Shi J., Xu G. Nasal saline irrigation facilitates control of allergic rhinitis by topical steroid in children. ORL J. Otorhinolaryngol. Relat. Spec. 2009;71:50–55. doi: 10.1159/000178165.
    1. Rogkakou A., Guerra L., Massacane P., Baiardini I., Baena-Cagnani R., Zanella C. 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;37:353–356.
    1. Ural A., Oktemer T.K., 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;123:517–521. doi: 10.1017/S0022215108003964.
    1. De Souza Campos Fernandes S., de Andrade C.R., da Cunha Ibiapina C. Application of peak nasal inspiratory flow reference values in the treatment of allergic rhinitis. Rhinology. 2014;52:133–136. doi: 10.4193/Rhin13.158.

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