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Research

Saline Nasal Irrigation for Upper Respiratory Conditions

aafp.org · added Jan 2023

Type
medical study, journal article, literature review
Keywords
Top five keywords: saline nasal irrigation, upper respiratory conditions, chronic rhinosinusitis, allergic rhinitis, viral upper respiratory tract infection.
Practices
Nasal irrigationNasal spraying
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Summary

Saline nasal irrigation can be an effective treatment for chronic rhinosinusitis, and may also be helpful for managing symptoms of mild to moderate allergic rhinitis and acute upper respiratory tract infections, according to consensus guidelines, although more research is needed to confirm its effectiveness for these conditions. Saline nasal irrigation is generally considered safe and can be easily performed at home with a neti pot or nasal spray bottle.

Key points

  • Saline nasal irrigation bathes the nasal cavity with spray or liquid saline; it is an adjunct to other treatment.
  • Evidence is consistent and good for chronic rhinosinusitis, and limited or inconsistent for allergic rhinitis and viral upper respiratory infections.
  • Other uses (acute rhinosinusitis, pregnancy rhinitis, after sinus surgery) rest on consensus with little trial data.
  • Done by instilling solution in one nostril and letting it drain from the other, with a spray bottle or a neti pot; salinity of 0.9% to 3% is used.
  • No serious adverse events reported; minor effects are ear fullness, nasal stinging and rare nosebleeds.
  • The authors list incompletely healed facial trauma and conditions that raise the risk of aspiration as reasons not to use it.

Saline nasal irrigation is an adjunctive therapy for upper respiratory conditions that bathes the nasal cavity with spray or liquid saline. Nasal irrigation with liquid saline is used to manage symptoms associated with chronic rhino-sinusitis. Less conclusive evidence supports the use of spray and liquid saline nasal irrigation to manage symptoms of mild to moderate allergic rhinitis and acute upper respiratory tract infections. Consensus guidelines recommend saline nasal irrigation as a treatment for a variety of other conditions, including rhinitis of pregnancy and acute rhinosinusitis. Saline nasal irrigation appears safe, with no reported serious adverse events. Minor adverse effects can be avoided with technique modification and salinity adjustment.

Upper respiratory conditions, such as acute and chronic rhinosinusitis, viral upper respiratory tract infection (URTI), and allergic rhinitis, are common disorders that negatively affect patients' quality of life. Saline nasal irrigation is an adjunctive therapy for upper respiratory conditions, likely originating in the ayurvedic medical tradition.1 Its use, including indications, solutions, and administration devices, was first described in medical literature in the early 20th century.2 Saline nasal irrigation is an effective management strategy for many sinonasal conditions.3 In a survey of 330 family physicians, 87 percent reported recommending it to their patients for one or more conditions.4

Nasal irrigation is performed by instilling saline into one nostril and allowing it to drain out of the other nostril, bathing the nasal cavity. Saline nasal irrigation can be performed with low positive pressure from a spray or squirt bottle, or with gravity-based pressure using a vessel with a nasal spout, such as a neti pot. Both are available over the counter.

*A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to *https://www.aafp.org/afpsort.xml.

The exact mechanism of action of saline nasal irrigation is unknown. One possibility is that the breakdown of the protective function of the nasal mucosa plays a role in upper respiratory conditions. Saline nasal irrigation may improve nasal mucosa function through several physiologic effects, including direct cleansing5,6; removal of inflammatory mediators7,8; and improved mucociliary function, as suggested by increased ciliary beat frequency.9,10

Chronic rhinosinusitis (i.e., persisting for longer than 12 weeks) is the most common indication for saline nasal irrigation.4 Based on positive clinical and functional outcomes, a Cochrane review concluded that saline nasal irrigation is an appropriate adjunctive therapy for the symptoms of chronic rhinosinusitis.11 The strongest study in the review reported that patients with chronic sinus symptoms who used 2 percent liquid saline daily in addition to routine care had a 64 percent improvement in overall symptom severity compared with patients who used routine care alone.12 Patients also showed significant improvement in disease-specific quality of life at six months12 and at 18 months.13 These results were not reported for spray saline.14 Patients who used liquid saline also reported significantly decreased use of antibiotics and medication-based, non-saline nasal sprays.12

Two studies evaluated the effect of liquid saline on chronic rhinosinusitis in the context of workplace airborne irritants.15,16 After performing daily nasal irrigation with liquid saline, woodworkers (n = 45) exposed to varying levels of wood dust demonstrated significantly improved sinus symptoms, mucociliary clearance, and expiratory nasal flow.15 A similar study of volunteer woodworkers also reported positive findings.16

Liquid and spray saline nasal irrigation have been evaluated for the treatment and prevention of viral URTI. A Cochrane review is in progress.17 Two studies assessing treatment reported conflicting results.18,19 The studies used different outcome measures, which limits comparability. In a three-arm randomized controlled trial (RCT), 143 adults with viral URTI received hypertonic spray saline, normal saline, or no treatment.18 The treatments did not have a measurable effect on the duration or severity of nasal symptoms compared with the control group. However, in an RCT of 200 adults with viral URTI, patients treated with micronized saline spray had improved rhinometric resistance, nasal volume, mucociliary transit time, and symptom severity scores compared with patients using liquid saline.19 Compliance rates were not reported, making it difficult to compare micronized saline with liquid saline nasal irrigation.

An RCT of 60 adults evaluated the effectiveness of daily spray saline irrigation as preventive therapy for viral URTI.20 Patients performing preventive saline nasal irrigation reported significantly fewer infections, shorter symptom duration, and fewer days with nasal symptoms compared with those who did not perform preventive nasal irrigation.

Effects of daily saline irrigation were evaluated in a two-phase RCT of 390 children with URTI.21 The children were randomized into two groups. The first group received routine care and performed isotonic saline nasal irrigation with liquid or fine spray. The second group received routine care, but did not perform nasal irrigation. The trial consisted of a three-week treatment phase, followed by a nine-week prevention phase. In both phases, the patients performing nasal irrigation reported significantly better outcomes on nasal secretion, obstruction, and medication use assessments.

Saline nasal irrigation has been reported to benefit patients with allergic rhinitis. One study assessed the effects of small molecule spray (mist), large molecule spray, and liquid saline nasal irrigation on the concentration of inflammatory mediators in nasal secretions in patients with seasonal allergic rhinitis.8 The liquid and large molecule spray forms of saline significantly reduced the levels of histamine and leukotrienes. A small RCT evaluated children with laboratory-confirmed, pollen-triggered rhinitis and found that antihistamine medication plus liquid saline nasal irrigation significantly reduced allergy symptom severity and antihistamine medication use, compared with antihistamines alone.22 In another study, patients with a history of allergic rhinitis reported improvement of allergy symptoms when using liquid saline nasal irrigation.23

In consensus guidelines, saline nasal irrigation is considered safe and possibly effective for mild to moderate rhinitis of pregnancy and acute rhinosinusitis,24 although no clinical trials have assessed the treatment for these indications. A recent survey of family physicians who prescribe saline nasal irrigation showed that 17 percent have recommended it for rhinitis of pregnancy and 67 percent have recommended it for acute rhinosinusitis.4 Saline nasal irrigation has also been recommended for postoperative care of patients undergoing endoscopic sinus surgery,25 for sinonasal sarcoidosis,26 and for Wegener granulomatosis,27 although there is little evidence to support these uses.

Saline nasal irrigation appears safe, with no studies reporting serious adverse events. Minor adverse effects are common, including a sense of discomfort and nervousness during the first use.23 Fewer than 10 percent of patients using saline nasal irrigation reported adverse effects, such as self-limited ear fullness, stinging of the nasal mucosa, and epistaxis (rare).12,14,28 Adverse effects were ameliorated with technique modification and salinity adjustment,23 and did not cause patients to discontinue nasal irrigation.12,14 Similar adverse effects occurred with spray and liquid saline.14

Contraindications for saline nasal irrigation include incompletely healed facial trauma, because of the potential to leak saline into unwanted tissue planes or spaces; and neurologic or musculoskeletal problems, such as significant intention tremor, that increase the risk of aspiration.

Patients with an appropriate indication should be considered for a trial of saline nasal irrigation. Optimal salinity is unknown, although 0.9 to 3 percent saline solutions have been used most often. Optimal pH and temperature are also unknown, but are likely patient-specific.23 In the United States, lukewarm tap water appears safe for saline preparation; sterile water or premixed solution is recommended if potability is in doubt.

Saline nasal irrigation techniques are easily taught in primary care settings. Patients have identified effective education methods (e.g., coached practice, patient handouts) as key to successful initiation and maintenance.23 Free evidence-based bilingual resources (e.g., a recipe for saline solution, instructions for irrigation, troubleshooting tips, links to audio and video teaching media) are available from the University of Wisconsin School of Medicine and Public Health at http://www.fammed.wisc.edu/research/past-projects/nasal-irrigation.

This therapy rinses your nasal cavity, the area behind your nose, with salt water (saline). You can do it at home to help with your sinus problems, such as a stuffy or runny nose.

You can use a nasal cup, also known as a neti pot, and nasal saline salt packs. You can get these at many pharmacies. To use a nasal cup, follow three steps:

  1. Mix the solution. Follow the directions on the salt package to make salt water using lukewarm water. Put 4 fl oz (100 mL) of the solution in the nasal cup.
  2. Position the nasal cup. Lean over the sink so you are looking down into the basin. Turn your head slightly to one side, and gently put the spout of the nasal cup into your upper nostril so that it forms a comfortable seal. Do not press the spout against the middle part (septum) of your nose.
  3. Pour the solution. Tip the nasal cup so that the solution pours into your upper nostril. Make sure to breathe through your mouth. The solution will soon drain out of your other nostril (see drawings). When the cup is empty, breathe out through both nostrils to clear out extra salt water and mucus. Gently blow your nose into a tissue. Then, repeat the process in the other nostril. A variety of squirt and spray bottles are also available for nasal irrigation.

Start with one irrigation per day while you have symptoms. If you feel better, you may want to do it twice a day as part of your regular routine. Some patients use it to prevent sinus problems even when they don't have symptoms.

It is normal for drops of water to occasionally drain from your nose for up to 30 minutes after irrigation. You may want to carry tissues with you. If your nose stings or burns, try using half as much salt next time. You may also want to try a different water temperature. Do not use very hot or very cold water. You can also try nasal irrigation while you are in the shower.

Always rinse out the extra salt water and wash the nasal cup with soap and water after using it. Most nasal cups are dishwasher safe. When you want to use the cup again, mix a fresh salt water solution.