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Sinusitis: Saline Irrigation Works

Posted by medconsumers on September 1, 2007

An Old Sinusitis Treatment Makes a Comeback: Nasal Saline Irrigation

Sinusitis sends millions of adults and children to the doctor each year. And many receive inappropriate treatment. Though studies show that viruses are by far the most frequent cause of a sinus infection, U.S. physicians reported that they prescribed antibiotics in 82% of visits nationwide for this condition. Despite contradictory results from studies exploring the efficacy of inhaled nasal corticosteroids, these drugs are also prescribed frequently.

These are some of the alarming findings from a study reported early this year in Archives of Otolaryngology. The authors, Hadley J. Sharpe and colleagues at the University of Nebraska Medical Center in Omaha, based their study on physician-generated information from two national surveys of patient data collected during visits for ambulatory care from 1999 to 2002. The misuse of antibiotics is of particular concern because it contributes to the increase in more virulent and drug-resistant bacteria.

“Watchful waiting, lavage with saline solution, and use of decongestants or proper antimicrobial agents are the treatments of choice,” wrote the University of Nebraska research team, referring to the steps doctors should go through in treating acute sinusitis. Acute rhinosinusitis, as it is also called, usually lasts less than four weeks, and a short-term antibiotic regimen can in fact provide relief to a minority with a bacterial infection. But the effects of antibiotics on chronic sinusitis, defined as symptoms lasting 12 weeks or longer, were described by the University of Nebraska researchers as questionable.

Enter Saline Irrigation

This study exposed the poor quality of sinusitis treatment in the U.S. Does it provide an impetus for increased use of a home treatment called nasal irrigation, which involves sending a buffered salt-water solution up one nostril and out the other? “Absolutely,” agreed Otolaryngologist Donald A. Leopold, MD, a co-author of the University of Nebraska study, in a telephone interview.

“90% of my patients are rinsing their noses. It’s so easy and inexpensive, and in many ways, solves the whole problem,” said Dr. Leopold, who is professor and chair of the department of otolaryngology-head & neck surgery at the University of Nebraska Medical Center, Omaha. “It’s the every day, and sometimes twice a day, use of this stuff that makes the difference. It’s something the patients have to do on an ongoing basis, and if they do, they get better.”

Nasal saline irrigation recently received validation from a Cochrane review of all relevant clinical trials. After noting that this treatment has its foundations in yogic and homeopathic traditions, the Cochrane review concluded, “There is evidence that [saline irrigations] relieve symptoms of chronic rhinosinusitis, help as an adjunct to treatment and are well tolerated by the majority of patients.”

Allergies can also be relieved with daily nasal saline irrigation, according to two studies involving children with seasonal allergic rhinitis. Those who were randomly assigned to nasal irrigation had a decrease in symptoms and a reduced intake of antihistamines.

Range of Products Available

In the practice of yoga, nasal irrigation involves the use of a neti pot, which can be purchased at most health food stores and resembles a teapot with a narrow spout. With the head tilted sideways, the salt-water solution is poured into one nostril and, in turn, goes down the other. Today nasal irrigation can be accomplished more conveniently while leaning over the bathroom sink and using one of the over-the-counter variations on a flexible plastic squeeze bottle.

Available at most pharmacies under such brand names as NeilMed Sinus Rinse™ and SinuCleanse,TM the products are sold with packets that combine sodium chloride (salt) and sodium bicarbonate (baking soda). The latter acts as a buffer against the stinging and burning sensation caused by salt water alone. These products make saline irrigation easy for children as well as adults.

Another product called Rhinotip™ is designed to fit over the jet tip end of most dental irrigators.

No independent head-to-head comparison study of these over-the-counter nasal wash products has been conducted to determine which is best in terms of ease of use and the reduction of symptoms and use of medications.

Whatever Works

“It’s up to the individual,” said Dr. Leopold when asked which product he recommends to his patients. “I will typically introduce all the different ideas [for nasal irrigation] and if a patient says, ‘I thought it was uncomfortable pressure,’ then I will switch them from a squeeze bottle to a neti pot, for instance. And some of my patients prefer a power wash with WaterPikR which is inserted a number of inches into the nose,” Dr. Leopold continued “Whatever product makes them comfortable and lets them do it on a regular basis is the one I would like to push. Most feel better after they’ve done it, especially if you have a cold, it’s the best way to make cold go away. A small minority feel irritated by [saline irrigation], but most want to do it all the time.”

The lead author of the Cochrane review about saline irrigation, otolaryngologist Richard Harvey, MD, Royal National Throat Nose and Ear Hospital in London, U.K., was asked by e-mail whether he advises his patients to do regular nasal saline irrigations and if so, which product is recommended. “While this is an area of ongoing research, my clinical judgement and experience from working with world leaders in nose and sinus care, suggests that squeeze bottles, such as NeilMed Sinus RinseTM, and pressurised sprays which can deliver high volumes, such as Physiomer (Goëmar Laboratories, France), under positive pressure are probably the most effective.”

In a telephone interview, K.C. Mehta, MD, the California-based lung specialist who developed NeilMed Sinus RinseTM, explained the importance of “positive pressure” and “high volume” in clearing out the nasal passages. “The key to symptom relief is to physically displace and wash away excess mucous and along with it allergens, such as grass and tree pollen, dust particles, pollutants and bacteria from the nasal passages. This in turn reduces inflammation of the mucosa membrane allowing you to breathe more normally.”

Dr. Mehta says that he suffered for years with sinus infection; had all types of treatments, including surgery; and finally decided that saline irrigation worked the best in terms of controlling symptoms. He went on to develop his own products that overcome the messiness of using the traditional neti pot and introduce the high-volume, positive pressure needed to wash out the excessive mucous and allergens. A step-by-step illustration of how to use the product can be found at http://www.neilmed.com. [Disclosure: The writer of this article has a friend who works for the company that makes NeilMed Sinus RinseTM.]

A Trend in the Works

Saline nasal irrigation appears to be catching on, and it is the ear/nose/throat specialists who are leading the way, rather than primary care physicians. The specialists first recommended the practice as aftercare for people who have had sinus surgery. Now, saline irrigation is becoming day-to-day standard care.

And according to Dr. Leopold, word of mouth from satisfied customers is also driving the trend. “People are becoming missionaries giving saline packets to their friends with sinus problems.” Consumer satisfaction is reflected in the sales of these saline irrigation products which have doubled annually for the last few years, according to the independent market data provided by A. C. Nielsen.

Role of Antibiotics

Given the fact that the University of Nebraska study found misuse of antibiotics to be common in the treatment of rhinosinusitis, Dr. Leopold was asked how people would know when antibiotics are appropriate. “If the person has a high fever, that could be an indication for an antibiotic,” he answered. “And if they have chronic respiratory problems like asthma, I typically tell them to take antibiotics early on. I’m aggressive up front with those folks.”

But the symptoms of a cold should be gone in two or three days in people without chronic respiratory problems who rinse their noses regularly, Dr. Leopold explained, and if they are still clogged up, then an antibiotic may be appropriate. He dismissed as “unreliable” the prevailing notion that greenish-yellow mucous always signals the need for an antibiotic.

The treatment of sinus infection seems to have come full circle where it concerns saline irrigation. “Medicine rolls in trends, just like fashion,” said Dr. Leopold. “Rinsing the nose had been a huge deal around the turn of the last century. There were a lot of articles back then about rinsing solutions and rinsing devices,” he explained, but interest died out once antibiotics, “the miracle drugs,” became available.

Now nasal saline irrigation is making a comeback.

Maryann Napoli, Center for Medical Consumers ©
September 2007

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