Nasal irrigation

Nasal irrigation
Intervention
A woman flushing her nose with a neti pot.
ICD-9-CM	22.0
MeSH	D055556

Nasal irrigation or nasal lavage or nose douche is the personal hygiene practice in which the nasal cavity is washed to flush out excess mucus and debris from the nose and sinuses. The practice is well-tolerated and beneficial with only minor side effects.^[1] Nasal irrigation in a wider sense can also refer to the use of saline nasal spray or nebulizers to moisten the mucus membranes.

The saline solution irrigation promotes good nasal health, and patients with chronic sinusitis including symptoms of facial pain, headache, halitosis, cough, anterior rhinorrhea (watery discharge) and nasal congestion often find nasal irrigation to provide effective relief. In published studies, "daily hypertonic saline nasal irrigation improves sinus-related quality of life, decreases symptoms, and decreases medication use in patients with frequent sinusitis",^[2] and irrigation is recommended as an "effective adjunctive treatment of chronic sinonasal symptoms".^[3][4]

Efficacy and safety

Common nose rinse device available at drug stores

Nasal irrigation is used to treat a wide range of chronic sinus and nasal symptoms; for chronic rhinosinusitis it is an effective adjunctive therapy. It is also an effective measure against chronic sinus symptoms induced by work-place exposure to sawdust.^[5] Further evidence suggests that nasal irrigation causes relief for both hay-fever and the common cold.

Daily nasal irrigation with salt water solution (a mixture of 0.9% non-iodized sodium chloride and either purified or tap water warmed to around 98 degrees F / 37 degrees C, with or without inclusion of a buffering agent such as sodium bicarbonate) is recommended as both an adjunctive^[6] and primary treatment^[7] in such cases and is preferable to the use of corticosteroids except in the most serious cases of acute bacterial sinusitis which should be immediately referred to an otolaryngologist.^[8] Irrigation should be used with caution in infants, as nasal drops are not widely tolerated. ^[9]

Flushing the nasal cavity with salt water has been claimed to promote mucociliary clearance by moisturizing the nasal cavity and by removing encrusted material, although there is no clear evidence to support this.^[7] In proper proportion, nasal salt water solution with slight acidic pH functions as an anti-bacterial irrigant. The flow of salt water through the nasal passage flushes the dirt, airborne allergens (dust and pollen), pollutants and bacteria-filled mucus.

Salt water flushing also loosens and thins the mucus, making it easier to expel. Without this build up of mucus, the tiny cilia, or hairs in the nasal passage are able to function more efficiently, pushing excess mucus either to the back of the throat or to the nose to be expelled.

Potential allergens (such as iodine) or contaminants (algae, etc.) are to be avoided in the sodium chloride, water, or buffering ingredients.^[10] Premanufactured dosages of salt water flushing solutions can be purchased, or the user can mix non-iodized 'kosher' salt, with or without a buffering agent such as sodium bicarbonate or baking soda (table salt frequently is iodized, while sea salt may contain algae or other contaminants). Proponents of nasal irrigation include many allergy and sinus sufferers, some of whom have claimed anecdotally to rely less on other medications and/or fewer doctor visits. Treatment guidelines in both Canada and the United States now advocate use of nasal irrigation for all causes of rhinosinusitis and for postoperative cleaning of the nasal cavity.^[11]

A conference abstract presented in November 2009 indicated that long-term nasal irrigation led to higher rates of sinus infections, which the principal researcher theorized was due to alterations in nasal immunological chemistry brought on by flushing out the protective elements of the mucous membrane of the nose. Note that this study has not been published in any peer-reviewed journal, and that the results may have been affected by the method of selection of test subjects and by the neti pot methods followed by the subjects. No such results were observed for short term use. However, it is of note that efficacy studies in general have not been conducted on groups utilizing this specific treatment, and that claims regarding the efficacy of the technique rely largely on anecdotal evidence.^[12]

While nasal irrigation is generally well-tolerated, one death has been reported from the improper use of a neti pot, when amoebae infected a young man. This sort of infection is extremely rare, and can only occur when using water that is not distilled or otherwise purified (for example, by boiling).^[13]

Methods

Currently, the best nasal irrigation system offers the following features and benefits: The irrigator has the anti-backwash valves, so the dirty solution will not flow back to the nasal cavity. This is particular important for these people with viral or bacterial infections, such as common cold or flu. The irrigator should be held up-straight, like brushing your teeth, not tilt your head side way. The lower side of the ear could have the liquid entered to cause an ear infection.

The simplest method, in that it does not require any equipment, is to snort water from cupped hands. The application of commercially available saline nasal spray is another simple alternative, but it is relatively inefficient for washing away debris although it may suffice for simple rehydration of mucous and tissues.^[14][15]

A simple yet effective technique is to pour salt water solution into one nostril and let it run out through the other while the mouth is kept open to breathe, using gravity as an aid. This is an old yogic technique known as jala neti, and the container used to administer the saline is called a neti pot. (Neti is Sanskrit for "nasal cleansing". A second neti technique known as sutra neti uses a piece of string instead of water.)

Neti pots are traditionally made of metal, glass or ceramic, and rely on gravity alone, along with head positioning and repeated practice in order to rinse the outer sinus cavities. Some users are able to use neti pots without problems, while the sideways positioning of the head can induce vertigo in others. A more advanced variation of the technique (known in yoga as "Vyutkrama Kapalaneti") involves pouring the same salt water solution into one nostril while the other is held closed, so that the solution runs out of the mouth. It is more challenging than the basic version (care must be taken to keep the saline solution out of the throat and to suppress possible vomiting reflex), but it can allow more thorough irrigation of the nasal cavity and the sinuses. Yet another technique (known in yoga "Seethkrama Kapalaneti") is to take the saline into the mouth and - leaning forward - force it out of the nostrils.

The second method of nasal irrigation is to introduce some form of positive pressure to the water introduced into the sinuses and nasal cavities in order to provide a more complete rinsing without resort to special techniques, such as holding the head to one side. Some products available from pharmacist supply retailers are essentially bottles made of flexible plastic with special tips to fit the nostril. These bottles, when filled with warm salt water solution, can be squeezed to exert positive pressure of the water flowing through the sinuses while the mouth is kept open at all times in order to breathe and prevent snorting the liquid down the throat. Even ordinary plastic water bottles can and have been used, as long as the nozzle will adequately fit a person's nostril. However, neither squeeze bottles nor bulb syringes provide the user with any genuine control over the pressure/volume of solution introduced. You need to make sure the pressure cannot be too high to prevent ear pressure or ear infection. The diameter of the hole in the center of the nostril fitting cannot be larger than 3 mm. If too large, a big wave of liquid can be forced to enter any where, such as middle ear, to cause ear pain or even ear infection.

Yet another type of product, the Nasaline irrigator, utilizes an oversized syringe with an injector-type plunger in place of the bulb.^[16] Invented by a group of Swedish ENT specialists, the Nasaline contains a specially designed tip intended to better atomize the salt water through a swirling action at a predetermined, nonadjustable velocity as it is forced through the sinuses by the injector's plunger.^[17]

Irrigation machines that utilize electric motor-driven pumps are also available. These irrigation devices pump salt water solution through a tube, in connection with a nasal adapter tip designed to seal against the nostril. Some of these machines allow adjustment of water volume/speed by use of an adjustment dial which regulates pump speed and volume per minute. Most of these motorized machines use a pulsatile or pulsating water pumping action at a relatively low, predetermined fixed pulse cyclic rate, designed to match the normal wave rate of healthy, unobstructed nasal cilia.^[18] This matched pulse rate is claimed to stimulate the nasal cilia hairs and promote better sinus health, while reducing the severity of allergic reactions.^[19] More sophisticated motorized irrigators have two or more pulse cycle settings that adjust the actual pulse cycle (as opposed to a simple volume/speed control, which does not alter the pulse cyclic rate). This design affords the user the option of using a higher pulse cyclic rate when suffering from partially closed sinuses, as in a typical case of acute sinusitis. The efficacy of all motorized pump irrigators has not yet been tested compared to simpler non-motorized mechanical pressure nasal irrigation methods.^[20]

Solutions used for nasal irrigation

Warm salt water solution is commonly used, often with sodium bicarbonate as a buffering agent.

Nasal irrigation can be carried out using ordinary tap water, but this is generally felt to be uncomfortable because it irritates the mucous membranes. Therefore an isotonic or hypertonic salt water solution is normally used, i.e. water with enough salt to at least match the tonicity of the body cells and blood. Normal saline is essentially isotonic with blood. For the same reason, lukewarm water is preferred over cold water, which in addition to irritating nasal membranes can also exaggerate the gag reflex during irrigation. Similarly, a small amount of baking soda is frequently mentioned as an optional buffering ingredient to adjust the pH value to that of the body.

Many pharmacies stock pre-manufactured sachets of pharmaceutical grade salt and baking soda designed to be used with the volume of water their corresponding device uses. Home recipes for an isotonic solution vary considerably, ranging from 3 tablespoons of non-iodized salt per 1 US gallon of water^{[citation needed]} (roughly one part salt to 86 parts water) to a mere 4 teaspoons of salt per 1 US gallon of water (1/4 teaspoon salt to 1 cup, or roughly 1 part salt to 192 parts water)^[21]. Other proportions include 1 US pint of water and 1 and 1/8 teaspoons salt^{[citation needed]} or 1 litre of water and 12 millilitres of salt (just less than 2 and a half teaspoons)^{[citation needed]}. For a hypertonic solution the amount of salt would be doubled or tripled.^[22]

Medical sources generally agree that iodised table salt is not acceptable^{[citation needed]}, and that pickling salt (or kosher salt, though care is needed to ensure no additives and that it dissolved completely) is preferred because it also does not contain any other additives such as anticaking agents^[7] - baking powder is also not an acceptable substitute for baking soda. Most sources advise that tap water should be boiled for several minutes to ensure sterility before it is cooled and used, but it is not clear whether this is really necessary.^[7]

Sometimes manufactured solutions such as lactated Ringer's solution^{[citation needed]} are used instead of the basic recipe.

Optional additives include xylitol which is claimed to draw water into the sinus regions and helps displace bacteria.^[23] Xylitol is commonly used to prevent acute otitis media in Europe and dental caries in the United States,^[24] but research into xylitol use in the sinus cavities is lacking. Another nasal irrigation additive is aloe extract, which helps to prevent nasal dryness.^{[citation needed]} Sodium citrate and citric acid help not only to balance the pH, also helps to improve the sense of smell.^{[citation needed]}

Mechanism of action

The precise reasons for the efficacy of nasal irrigation are not well understood, although it is clear that the removal of mucus plays an important role.^[7] Damage to the mucociliary transport system is an important factor in the development of sinonasal diseases, leading to a stasis of mucus.^[20] The numerous proteins found in nasal mucus include inflammatory mediators, defensins and many whose function is not understood.^[7] Thus hypotheses include that nasal irrigation may decrease inflammation through the removal of mucus, that it may improve mucociliary clearance, and that it may remove thickened mucus that cannot be handled by the cilia.^[7][20]

In a study with eight healthy volunteers, solution was transported reliably to ethmoid and maxillary sinuses when it was snorted or applied with a squeeze bottle; a nebulizer was significantly less effective. Sphenoid and frontal sinuses were rarely reached, and not at all with the nebulizer.^[15]

Origin of nasal irrigation

The earliest record of nasal irrigation is found in the ancient Hindu practice of Ayurveda whose roots are traced to the Vedas.

The simplest method of nasal irrigation, that is to sniff water from cupped hands and then blowing it out, is also a step in the hygienic practices (Wudu) of Muslims.

See also

• Post-nasal drip
• Jala Neti

References

1. ^ Harvey, R.; Hannan, S. A.; Badia, L.; Scadding, G. (2007). Harvey, Richard. ed. "Nasal saline irrigations for the symptoms of chronic rhinosinusitis". Cochrane database of systematic reviews (Online) (3): CD006394. doi:10.1002/14651858.CD006394.pub2. PMID 17636843.  edit
2. ^ Rabago, D.; Zgierska, A.; Mundt, M.; Barrett, B.; Bobula, J.; Maberry, R. (2002). "Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: A randomized controlled trial". The Journal of family practice 51 (12): 1049–1055. PMID 12540331.  edit
3. ^ Rabago, D.; Pasic, T.; Zgierska, A.; Mundt, M.; Barrett, B.; Maberry, R. (2005). "The Efficacy of Hypertonic Saline Nasal Irrigation for Chronic Sinonasal Symptoms". Otolaryngology - Head and Neck Surgery 133 (1): 3–8. doi:10.1016/j.otohns.2005.03.002. PMID 16025044.  edit
4. ^ Tomooka, L. T.; Murphy, C.; Davidson, T. M. (2000). "Clinical Study and Literature Review of Nasal Irrigation". The Laryngoscope 110 (7): 1189–1193. doi:10.1097/00005537-200007000-00023. PMID 10892694.  edit
5. ^ David Rabago (June 1, 2008). "The Use of Saline Nasal Irrigation in Common Upper Respiratory Conditions". US Pharmacist. http://www.uspharmacist.com/continuing_education/ceviewtest/lessonid/105757/ 
6. ^ Rabago D, Pasic T, Zgierska A, Mundt M, Barrett B, Maberry R (July 2005). "The efficacy of hypertonic saline nasal irrigation for chronic sinonasal symptoms". Otolaryngol Head Neck Surg 133 (1): 3–8. doi:10.1016/j.otohns.2005.03.002. PMID 16025044. 
7. ^ ^{a b c d e f g} Brown CL, Graham SM (February 2004). "Nasal irrigations: good or bad?". Curr Opin Otolaryngol Head Neck Surg 12 (1): 9–13. doi:10.1097/00020840-200402000-00004. PMID 14712112. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=1068-9508&volume=12&issue=1&spage=9. 
8. ^ Sarah-Anne Schumann, John Hickner (July 2008). "Patients insist on antibiotics for sinusitis? Here is a good reason to say “no”" (PDF). The Journal of Family Practice 57 (7). http://www.jfponline.com/pdf%2F5707%2F5707JFP_PURLs.pdf 
9. ^ Kassel, J. C.; King, D.; Spurling, G. K. (2010). King, David. ed. Saline nasal irrigation for acute upper respiratory tract infections. doi:10.1002/14651858.CD006821.pub2. PMID 20238351.  edit
10. ^ Harvey, R.; Hannan, S. A.; Badia, L.; Scadding, G. (2007). Harvey, Richard. ed. "Nasal saline irrigations for the symptoms of chronic rhinosinusitis". Cochrane database of systematic reviews (Online) (3): CD006394. doi:10.1002/14651858.CD006394.pub2. PMID 17636843.  edit
11. ^ Osguthorpe, J.; Hadley, J. (1999). "Rhinosinusitis. Current concepts in evaluation and management". The Medical clinics of North America 83 (1): 27–41, vii–viii. PMID 9927958.  edit
12. ^ "Medical News: ACAAI: Frequent Nose Irrigation May Lead to More Sinus Infections — in Meeting Coverage". ACAAI from MedPage Today. http://www.medpagetoday.com/MeetingCoverage/ACAAI/16870?userid=227287&impressionId=1257836779807&utm_source=mSpoke&utm_medium=email&utm_campaign=DailyHeadlines&utm_content=GroupD. 
13. ^ http://apnews.myway.com/article/20110818/D9P66J183.html. Accessed August 18, 2011.
14. ^ Pynnonen, M. A.; Mukerji, S. S.; Kim, H. M.; Adams, M. E.; Terrell, J. E. (2007). "Nasal Saline for Chronic Sinonasal Symptoms: A Randomized Controlled Trial". Archives of Otolaryngology - Head and Neck Surgery 133 (11): 1115–1120. doi:10.1001/archotol.133.11.1115. PMID 18025315.  edit
15. ^ ^{a b} Olson, D. E. L.; Rasgon, B. M.; Hilsinger, R. L. (2002). "Radiographic Comparison of Three Methods for Nasal Saline Irrigation". The Laryngoscope 112 (8): 1394–1398. doi:10.1097/00005537-200208000-00013. PMID 12172251.  edit
16. ^ ENT Products Inc. - Nasaline Irrigator, http://www.entpro.com/products.php?productID=1
17. ^ ENT Products Inc., Nasaline Irrigator
18. ^ Davidson, Terence M. (M.D.), Handbook of Nasal Disease, Part III, Nasal Irrigation http://drdavidson.ucsd.edu/portals/0/nasal.htm#NASAL_IRRIGATION
19. ^ Davidson, Terence M. (M.D.), Handbook of Nasal Disease, Part III, Nasal Irrigation
20. ^ ^{a b c} Tomooka LT, Murphy C, Davidson TM (2000). "Clinical study and literature review of nasal irrigation". Laryngoscope 110 (7): 1189–93. doi:10.1097/00005537-200007000-00023. PMID 10892694. 
21. ^ "Error: no |title= specified when using {{Cite web}}". mayoclinic.com. http://www.mayoclinic.com/health/neti-pot-solution/AN01879. Retrieved 2011-11-09. 
22. ^ "| Neti Pot Nasal Irrigation". Netipotsecrets.com. 2010-06-20. http://www.netipotsecrets.com/nasal-irrigation/. Retrieved 2011-03-01. 
23. ^ Sajjan, U.; Moreira, J.; Liu, M.; Humar, A.; Chaparro, C.; Forstner, J.; Keshavjee, S. (2004). "A novel model to study bacterial adherence to the transplanted airway: Inhibition of adherence to human airway by dextran and xylitol". The Journal of Heart and Lung Transplantation 23 (12): 1382–1391. doi:10.1016/j.healun.2003.09.023. PMID 15607668.  edit
24. ^ Danhauer, J.; Johnson, C.; Rotan, S.; Snelson, T.; Stockwell, J. (2010). "National survey of pediatricians' opinions about and practices for acute otitis media and xylitol use". Journal of the American Academy of Audiology 21 (5): 329–346. doi:10.3766/jaaa.21.5.5. PMID 20569667.  edit

External links

• University of Wisconsin instructions, study and video
• Inter-Neti, information website, covers clinical evidence and explains proposed mechanisms of action
• Nasal irrigation with a plastic syringe