Nasal/Sinus Irrigation

Benjamin S. Bleier, MD

Irrigation of the nasal cavity is an ancient technique based on early homeopathic and yogic practices. Doctors have recognized the benefits of nasal irrigation and have begun to study them to see how well they work and when they should be used. While many questions remain, these studies have concluded that irrigations are beneficial, safe, and well tolerated by patients.

Preparing and applying the salt water rinses requires a significant amount of time and energy so many researchers have asked whether there is a real benefit. A recent review1 examined eight high quality studies and concluded that salt water irrigations are helpful to patients.

While irrigations help to clear the nose of mucus, they may also help to reduce inflammation. This may result from helping to nose to remove small particles, bacteria, and viruses which can cause allergy and inflammation.

Delivery Devices and Head Position
The goal of irrigations is to cleanse the entire nose however not all irrigation techniques can achieve this. Doctors have been studying how best to irrigate the nose using several different methods. Dr. Wormald and his colleagues2 looked at three common delivery devices including a nasal spray, a nebulizer, and a positive pressure flush. In all cases the fluid was able to enter the nose but had a difficult time getting into the sinus cavities themselves. While the positive pressure method had the best delivery to the forehead and cheek sinuses, these findings show that in the unoperated nose getting the rinse into the sinuses is quite limited. Other studies have shown that regardless of the specific device, higher delivery volumes seem to lead to the best coverage of the nasal lining4. When looking at patient symptoms, high volume irrigations have also been shown to be better than nasal sprays5. Sinus surgery has also been found to lead to better delivery of rinses into the sinus cavities6 however even following surgery high volume devices work better than nebulizers7,8,9 with respect to getting the fluid into the sinuses.

Head position during nasal irrigation may also have an impact on degree of delivery. Placing the head down during irrigation can help rinses get to the top of the nose and the forehead sinus3,4,10.

Saline Concentration
Most practitioners suggest using concentrations of saline which are the same as the salt concentration in the body(this is called isotonic) but the benefits of higher saline concentrations have also been studied. While some patients prefer higher concentrations, these may lead to increased nasal congestion and swelling resulting from irritation related to the high salt content11,12. High concentrations of salt have even resulted in damage to the small hairs that beat in the nose to keep it clean called “cilia”13. Other studies have shown that the addition of “buffering agents” to the saline such as baking soda results in more improvement in symptoms than salt water alone14. While multiple companies offer premixed salt packets which are convenient and relatively inexpensive, patients may elect to make their own saline at home. A common recipe involves the addition of 2-3 teaspoons of iodine free salt and 1/4-1/2 teaspoons of baking soda to 1 liter of sterile water.

Bottle Contamination
Because nasal irrigations are commonly used in the setting of nasal infection, delivery device cleanliness and sterility is very important. Dr. Welch and colleagues15 found that almost a third of the irrigation bottles used by patients in their study were contaminated with bacteria. Dr. Keen and colleagues16 took cultures of both the patient and the irrigation bottle and found that half the time the bottle and the nose grew the same bacteria. This indicates that the bottles can contaminate the nose if not cleaned properly. This study also explored several common sterilization methods including cold water irrigation, boiling water rinse, detergent cleaning, Milton’s antibacterial solution(a dilute bleach), and microwaving for 2 minutes with cold water. The authors reported that both the microwave and Milton’s solution techniques resulted in sterilization for up to 48 hours. Given that microwave safe irrigation bottles are now available, microwave sterilization and frequent bottle exchange is currently recommended to prevent bottle contamination.

Water Source
In the past 5 years, there have been news reports of 2 patients dying from encephalitis(a brain infection) resulting from exposure to Naegleria fowleri, an amoeba that is common in rivers and lakes. These patients had used neti pots with tap water which subsequently tested positive for this amoeba species. It should be noted that these cases are extremely rare and resulted from contamination of local tap water which is not common in a municipally treated water supply. However, appropriate caution should be used when selecting a water source for irrigation and boiled, distilled, or appropriately filtered water are recommended.

Medicated Irrigations
The benefits of saline irrigations have also been combined with active medications such as topical antibiotics17,18 and steroids19,20 to improve delivery into the nose. One study showed that high volume rinses improved the quality of life in patients with allergy who were already using nasal steroid sprays21. Irrigations which actually contain dilute steroids also have an important role in controlling symptoms, particularly in patients with chronic rhinosinusitis19. While medicated irrigations have been shown to be safe and effective, their role in the treatment of chronic sinusitis is being actively studied.

Recent research has confirmed that sinus and nasal irrigations with salt water are helpful. Multiple devices are available for delivery however the high volume and positive pressure methods seem to work the best. Both the irrigation device and the water source have the potential for contamination and thus proper sterilization of both is critical to the safe and effective use of irrigations. Medicated irrigations are being used more commonly and may improve our ability to treat chronic sinusitis.

1. Harvey R, Hannan SA, Badia L, Scadding G. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD006394.
2. Wormald PJ, Cain T, Oates L, Hawke L, Wong I. A comparative study of three methods of nasal irrigation. Laryngoscope. 2004 Dec;114(12):2224-7.
3. Harvey RJ, Goddard JC, Wise SK, Schlosser RJ. Effects of endoscopic sinus surgery and delivery device on cadaver sinus irrigation. Otolaryngol Head Neck Surg. 2008 Jul;139(1):137-42.
4. Beule A, Athanasiadis T, Athanasiadis E, Field J, Wormald PJ. Efficacy of different techniques of sinonasal irrigation after modified Lothrop procedure. Am J Rhinol Allergy. 2009 Jan-Feb;23(1):85-90.
5. Pynnonen MA, Mukerji SS, Kim HM, Adams ME, Terrell JE. Nasal saline for chronic sinonasal symptoms: a randomized controlled trial. Arch Otolaryngol Head Neck Surg. 2007 Nov;133(11):1115-20.
6. Singhal D, Weitzel EK, Lin E, Feldt B, Kriete B, McMains KC, Thwin M, Wormald PJ. Effect of head position and surgical dissection on sinus irrigant penetration in cadavers. Laryngoscope. 2010 Dec;120(12):2528-31.
7. Grobler A, Weitzel EK, Buele A, Jardeleza C, Cheong YC, Field J, Wormald PJ. Pre- and postoperative sinus penetration of nasal irrigation. Laryngoscope. 2008 Nov;118(11):2078-81.
8. Miller TR, Muntz HR, Gilbert ME, Orlandi RR. Comparison of topical medication delivery systems after sinus surgery. Laryngoscope. 2004 Feb;114(2):201-4.
9. Valentine R, Athanasiadis T, Thwin M, Singhal D, Weitzel EK, Wormald PJ. A prospective controlled trial of pulsed nasal nebulizer in maximally dissected cadavers. Am J Rhinol. 2008 Jul-Aug;22(4):390-4.
10. Karagama YG, Lancaster JL, Karkanevatos A, O'Sullivan G. Delivery of nasal drops to the middle meatus: which is the best head position? Rhinology. 2001 Dec;39(4):226-9.
11. Hauptman G, Ryan MW. The effect of saline solutions on nasal patency and mucociliary clearance in rhinosinusitis patients. Otolaryngol Head Neck Surg. 2007 Nov;137(5):815-21.
12. Mohammadian P, Schaefer D, Hummel T, Kobal G. Experimentally induced nasal irritation. Rhinology. 1999 Dec;37(4):175-8.
13. Harvey RJ, Psaltis A, Schlosser RJ, Witterick IJ. Current concepts in topical therapy for chronic sinonasal disease. J Otolaryngol Head Neck Surg. 2010 Jun;39(3):217-31.
14. Welch KC, Cohen MB, Doghramji LL, Cohen NA, Chandra RK, Palmer JN, Chiu AG. Clinical correlation between irrigation bottle contamination and clinical outcomes in post-functional endoscopic sinus surgery patients. Am J Rhinol Allergy. 2009 Jul-Aug;23(4):401-4.
15. Keen M, Foreman A, Wormald PJ. The clinical significance of nasal irrigation bottle contamination. Laryngoscope. 2010 Oct;120(10):2110-4.
16. Lim M, Citardi MJ, Leong JL. Topical antimicrobials in the management of chronic rhinosinusitis: a systematic review. Am J Rhinol. 2008 Jul-Aug;22(4):381-9.
17. Kingdom TT, Swain RE Jr. The microbiology and antimicrobial resistance patterns in chronic rhinosinusitis. Am J Otolaryngol. 2004 Sep-Oct;25(5):323-8.
18. Sachanandani NS, Piccirillo JF, Kramper MA, Thawley SE, Vlahiotis A. The effect of nasally administered budesonide respules on adrenal cortex function in patients with chronic rhinosinusitis. Arch Otolaryngol Head Neck Surg. 2009 Mar;135(3):303-7.
19. Welch KC, Thaler ER, Doghramji LL, Palmer JN, Chiu AG. The effects of serum and urinary cortisol levels of topical intranasal irrigations with budesonide added to saline in patients with recurrent polyposis after endoscopic sinus surgery. Am J Rhinol Allergy. 2010 Jan-Feb;24(1):26-8.

Revised 02/17/2015
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