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Nasal irrigation: From empiricism to evidence-based medicine. A review.

European Annals of Otorhinolaryngology · added Jan 2023

Publication
European Annals of Otorhinolaryngology
Date
2015-11-05
Type
review, evidence-based medicine, nasal irrigation
Keywords
1. Nasal irrigation 2. Seawater 3. Saline solution 4. Sinonasal pathologies 5. Mucociliary clearance
Practices
Nasal irrigation
Read the source

Summary

Nasal irrigation, especially with undiluted seawater, is highly effective for treating various nasal conditions and improving overall nasal health.

Key points

  • Nasal irrigation is effective for treating sinonasal issues.
  • Large-volume low-pressure irrigation with undiluted seawater is the most effective method.
  • Seawater has beneficial components like bicarbonates, potassium, calcium, and magnesium.
  • Slightly alkaline pH enhances mucociliary function.
  • No single irrigation solution is proven superior; further studies are needed.

Notes

“Large-volume low-pressure nasal irrigation using undiluted seawater seems, in the present state of knowledge, to be the most effective protocol.”

Outline

  1. Abstract
  2. Keywords
  3. References

Referred to by

Abstract

Nasal irrigation plays a non-negligible role in the treatment of numerous sinonasal pathologies and postoperative care. There is, however, a wide variety of protocols. The present review of the evidence-based literature sought objective arguments for optimization and efficacy. It emerged that large-volume low-pressure nasal douche optimizes the distribution and cleansing power of the irrigation solution in the nasal cavity. Ionic composition and pH also influence mucociliary clearance and epithelium trophicity. Seawater is less rich in sodium ions and richer in bicarbonates, potassium, calcium and magnesium than is isotonic normal saline, while alkaline pH and elevated calcium concentration optimized ciliary motility in vitro. Bicarbonates reduce secretion viscosity. Potassium and magnesium promote healing and limit local inflammation. These results show that the efficacy of nasal irrigation is multifactorial. Large-volume low-pressure nasal irrigation using undiluted seawater seems, in the present state of knowledge, to be the most effective protocol.

Keywords

Nasal irrigation

Seawater

Saline solution

1. Introduction

Several national and international consensus conferences now recommend nasal irrigation as adjuvant treatment in numerous sinonasal pathologies [1], [2], [3], [4], [5], [6]. It provides mechanical cleansing of mucus, crust, cell debris and various air contaminants (pathogens, allergens, airborne particles, etc.). It enhances mucociliary clearance [7], [8] and reduces the mucus contact time of airborne elements. It reduces local concentrations of pro-inflammatory mediators [9], [10], [11] and humidifies the nasal mucosa, notably postoperatively and in many chronic sinonasal pathologies.

A recent meta-analysis of 10 controlled trials taken from a review of 11,500 studies included more than 400 allergic rhinitis patients [7]. Regular saline irrigation in adults and children improved nasal symptomatology in 35% of cases and quality of life in 30%. Mucociliary clearance on saccharine test was increased by about 30%. The impact on medical drug consumption was harder to quantify; moreover, the included population was small for such a common treatment, and methods and administration times varied greatly, limiting the scientific value of the study [7].

The heterogeneity of the literature makes it difficult to get any clear idea concerning the various solutions and means of administration. Irrigation solution composition would seem to be an important issue: chronic patients sometimes report improvement with sea bathing, and some studies suggest that irrigation solutions taken from certain seas provide better functional improvement [12], [13].

The present article comprises a literature review and update on the various solutions and means of administration available.

1.1. Means of irrigation

To the best of our knowledge, there is no consensus regarding means of irrigation. A study of the cavity distribution of 40 mL of radio-opaque substance in healthy subjects reported benefit with positive pressure irrigation versus negative pressure administration (by sniffing) or nebulization: nasal cavity and sinus distribution was more exhaustive [14]. Wormald et al., using 5 mL Tc99m-labeled irrigation solution, found better nasal cavity and sinus distribution with douche administration than nebulization or sprays [15].

We found no studies, comparative or not, in the literature focusing on syringe administration, despite this being the most widespread method. Several studies reported greater efficacy with large-volume irrigation [16], [17]. A recent study compared 26 nasal irrigation devices available on the German market [18], testing them on a resin nasal cavity model based on normal non-congested cadaver nostrils. Irrigation volumes ranged from 30 to 500 mL, for a mean 200–250 mL. The greater the irrigation volume, the larger the cavity area covered by the irrigation: large-volume irrigation reaches a larger proportion of the nasal cavities. Depending on volume and device, application time ranged between 6 and 54 s, and output between 3.9 and 27.2 mL/s. Only compression systems delivering ≥120 mbar pressure reached the entire nasal cavity. The authors added that tight fit between nozzle and nostril and the possibility of inserting the nozzle into the vestibule and orienting it 45° upward optimized cavity coverage and minimized loss of irrigation solution [18]. It also appeared that good ergonomics, irrigation quality and microbial safety were associated with devices that were transparent, equipped with an anti-reflux nozzle, in high-quality supple and compressible plastic, with ≥5 mL/s output or ≥120 mbar administration pressure, that could be taken apart and washed by hand or in a dishwasher, and were adapted for microwave ovens.

Clinically, a prospective single-blind randomized study compared postoperative efficacy between two commercially available nasal irrigation devices; in 31 endonasal surgery patients, large-volume low-pressure irrigation was associated with better postoperative nasal cavity cleansing on the Lund-Mackay postoperative endoscopy score than low-volume high-pressure irrigation [19].

1.2. In vitro data

1.2.1. Composition of commercially available solutions

It is important to be aware of the fact that the exact composition of the various products and recipes could not be found in the literature, except for Physiomer®1 and Ringer's lactate. Table 1 and Fig. 1 show the chemical compositions of the various nasal irrigation solutions. There are several “recipes” for “home-made” saline, with or without buffer, that patients can make up themselves at home, using water, salt and, in some cases, sodium bicarbonate. Unlike normal saline (NaCl 0.9%), composition and sterility are neither controllable, reproducible or reliable. Home-made solutions using “sea” salt contain only chloride ions and sodium.

Fig. 1. Physical and chemical characteristics of various isotonic saline solutions versus seawater (biochemical analyses provided by Laboratoire de la Mer®).

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There are also commercially available products consisting of seawater diluted to one-third in distilled water (e.g., Stérimar®2, Marimer®3, Vicks®4) to obtain an isotonic solution. Although these are marketed as “seawater”, the one-third dilution conserves only part of the naturally present minerals, which are themselves proportionally diluted (http://www.sterimar.com/en/nasal-family-solutions.php). Another product consists of electrodialyzed seawater (Physiomer®), providing an isotonic solution with reliable osmolarity, while conserving high concentrations of the main seawater ions (https://register.epo.org/application?lng=en&number=EP98460042). Its composition is known and can be compared to physiological saline and Ringer's lactate (Table 1). Products obtained by this procedure are, like Ringer's lactate, rich in calcium, potassium and magnesium ions and buffering (bicarbonates), with low sodium ion content (Table 1). Like seawater, they have slightly alkaline pH (controlled pH close to 8), while normal saline is acidic, with pH varying from 4.5 to 7.

1.2.2. Role of the various components

It is now agreed that, in vitro, these ions show non-negligible action on epithelial cells. Sodium ions can inhibit hair-cell calcium flow, thus reducing ciliary beat frequency [20]. Magnesium ions reduce local inflammation by reducing mediator secretion [21] and degranulation [22] in cells implicated in allergy. Paradoxically, they increase IL-8 secretion by nasal epithelial cells [23]. Finally, magnesium and zinc can reduce respiratory mucosa cell apoptosis during inflammatory processes [24]. Calcium is involved in regulating ciliary beat frequency and synchronization, via various ciliated cell surface receptors [25], in all of which acetylcholine and serotonin act as messengers by increasing cell calcium intake [25]. Airflow also stimulates cell calcium intake and ciliary beat via shear-stress-induced mechanotransduction [25]. Potassium promotes respiratory epithelium repair via the EGF/EGFR pathway [26], [27]. Bicarbonate ions, as well as acting as buffer, efficiently reduce mucus viscosity, thus facilitating elimination by ciliated cell movement [28].

1.2.3. Role of pH and tonicity

In vitro, solutions with pH <7 or >10 reduced tracheal mucosa ciliary beat frequency in rats and chicken embryos [29]. In humans, solutions with acidic pH likewise reduced ciliary beat frequency, while slightly alkaline solutions enhanced it [30], [31]. In vivo, on the other hand, in humans, pH impact on mucociliary clearance is more difficult to ascertain. England et al. found no statistical correlation between pH and mucociliary clearance in 56 healthy non-smokers [32]. More recently, Chusakul et al. reported clear improvement in symptoms with alkaline isotonic solutions in allergic rhinitis; mucociliary clearance, on the other hand, was unaffected whatever the pH, in a range from 6.2 to 8.4 [33]. However, change in mucociliary clearance seems not to depend exclusively on pH: in vitro, in chicken embryo tracheal explants, hypertonic (1.5%) and hypotonic (0.45%) irrigation both reduced ciliary beat frequency as compared to physiological (0.9%) saline [29]. Beat arrest was irreversible with a 14% solution, and hypertonicity triggered mucus hypersecretion and increased the permeability of tight junctions [34], [35], [36]. These data correlated in vivo with increased secretion and exudation in response to hypertonic solutions [37]. Paradoxically, other authors reported improved in vivo mucociliary clearance on saccharine test in healthy subjects with hypertonic solutions between 3% and 5% [38], [39].

1.2.4. Advantages of seawater

Since 1995, it has been shown that seawater promotes cell growth, with a significantly stronger eutrophic effect than normal saline or seawater at one-third dilution [40]. In a more recent in vitro study, 2 to 4 hours’ exposure to electrodialyzed seawater enhanced viability in deprived bronchial epithelial cells as compared to isotonic normal saline [11]. In other studies, seawater significantly protected pig nasal mucosa against the effects of twice-daily 0.1% oxymetazoline (inflammation, fibrosis, metaplasia) [41].

In vitro, electrodialyzed seawater reduced production of pro-inflammatory molecules such as IL-8 or RANTES [10], [11], involved in the recruitment and activation of polynuclear neutrophils and eosinophils.

Thus, in vitro at least, it would seem that limited sodium chloride content is important for nasal irrigation solutions. Conversely, calcium provides an advantage in terms of restoring epithelial trophicity and mucociliary efficacy. Potassium should provide benefit in postoperative situations and/or certain chronic rhinosinusitis via its action on anti-inflammatory response; slightly alkaline pH with isotonic composition should have a similar effect.

1.3. Clinical advantages of undiluted seawater over other irrigation solutions

Certain studies reported clinical superiority for mineral-rich solutions compared to classic saline, but data are sparse (Table 2).

  • Statistical significative difference; nk: not known. In allergic rhinitis, iso- and hypertonic saline improved all symptoms in children, reducing recourse to antihistamines and corticosteroids [42], [43], with excellent tolerance [44], [45]. In 2007, a multicenter randomized study assessed the efficacy of electrodialyzed 2.2% hypertonic Saint-Malo seawater in 238 allergic or non-allergic chronic rhinosinusitis patients, and found strongly significantly superiority for nasal irrigation (with or without local corticosteroids) versus controls (antihistamines with local corticosteroids, without irrigation) in terms of symptoms and of recourse to corticosteroids [46]. Cordray et al. likewise reported that nasal irrigation with water from the Dead Sea, without antihistamines, was as effective as local corticosteroids in controlling nasal and ocular symptoms in mild-to-moderate seasonal allergic rhinitis [12]. Friedman et al., in a prospective randomized double-blind study, found greater improvement in symptom scores in 42 allergic or non-allergic chronic rhinosinusitis patients with Dead Sea water versus hypertonic saline [13]. The same author, using the same methodology, more recently reported a similar improvement in symptoms in 114 patients with irrigation with hypertonic Dead Sea water without corticotherapy versus hypertonic saline with local corticosteroids [47].

In acute infection, two prospective randomized studies showed better treatment with nasal irrigation. The first, a controlled multicenter study of 390 children with rhinitis, found faster improvement in nasal permeability and the quality and quantity of secretion with electrodialyzed seawater irrigation than in a control group without irrigation [48]. It also demonstrated that irrigation reduced number of episodes, ENT complications and medication (antipyretics, antibiotics, mucolytics and decongestants) in children suffering from frequent rhinitis [48]. The second, single-center, study of 69 children with acute sinusitis, found that standard treatment (antibiotics, mucolytics and local nasal decongestants) reduced symptoms more effectively when associated to nasal irrigation with an isotonic solution [49]. Both studies showed the efficacy of irrigation in these respective pathologies, but did not demonstrate the superiority of either solution, as there was no comparative arm.

In postoperative use, nasal irrigation is essential for cleansing the crusts and secretions inherent to any sinonasal surgery. It significantly reduces nasal secretion and shows a tendency to reduce postsurgical edema. Ringer's lactate, which is rich in calcium and potassium and less rich in sodium and chloride ions than isotonic saline, provided a stronger increase in mucociliary transport than isotonic saline after endonasal surgery [50].

Few studies have focused on postoperative seawater irrigation [51], [52], [53], and they lacked control groups without postoperative care to remove clots, crusts and secretion. Pigret and Jankowski found no significant difference between the effects of pressurized seawater and saline with antiseptics and mucolytics, in a small series (10 patients per group) [51]. Keerl et al., in an observational study of 121 patients, found nasal irrigation to be well tolerated, and that some patients continued in the long-term, including irrigation in their daily life routine [52]. Pinto et al. found no symptomatic benefit of irrigation, whether iso- or hypertonic [53], and recommended not implementing postoperative irrigation; their study, however involved certain defects: no inclusion criteria, and no details of surgical technique, numerous revision surgeries and application of an endonasal hemostasis substance. Moreover, the symptoms scores used were not validated, and final nasal cavity status was not noted [53].

Finally, certain preservatives, antiseptics and mucolytics have sometimes been associated to irrigation solutions. They slowed or arrested ciliary beat, and showed no clinical benefit [51], [54], [55]. A recent meta-analysis confirmed the non-superiority of adding an antibiotic and an antifungal agent to the irrigation solution in chronic rhinosinusitis [6].

2. Conclusion

Founded on empirical practice and common sense, nasal irrigation now plays an essential and self-evident role for the large majority of practitioners. The heterogeneity of protocols and studies make for confusion. It would, however, appear that: large-volume irrigation provides good distribution over the sinonasal cavities as a whole; and a stable, reproducible isotonic solution with slightly alkaline pH and a composition close to that of seawater optimizes trophic and functional recovery of the respiratory epithelium. Clinically, the literature fails to prove any clear superiority of one product over the others; however, the in vitro properties of undiluted seawater seem to provide definite advantage in many clinical situations, as compared with physiological saline. Further studies will be needed to confirm the present findings.

Disclosure of interest

L. de Gabory: occasional expert reports, consultancy and guest speaker for Laboratoire de la Mer®.

The other authors declare that they have no conflicts of interest concerning this article.

Acknowledgments

The authors thank Laboratoire de la Mer® for the data for the composition of the irrigation solutions shown in Fig. 1.

References

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