Use of Saline Nasal Irrigation Reviewed

November 30, 2009 — A review article published in the November 15 issue of American Family Physician offers guidance on use in the family practice setting of saline nasal irrigation as an adjunctive therapy for upper respiratory tract conditions.

"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," write David Rabago, MD, and Aleksandra Zgierska, MD, PhD, from the University of Wisconsin School of Medicine and Public Health in Madison. "Saline nasal irrigation is an adjunctive therapy for upper respiratory conditions, likely originating in the ayurvedic medical tradition. Its use, including indications, solutions, and administration devices, was first described in medical literature in the early 20th century."

Saline nasal irrigation bathes the nasal cavity with spray or liquid saline by instilling saline into 1 nostril and allowing it to drain out of the other nostril. Techniques using administration devices available over the counter include low positive pressure from a spray or squirt bottle, or gravity-based pressure using a neti pot or other vessel with a nasal spout.

Typically, 0.9% to 3% saline solutions are used, but optimal salinity, pH, and temperature are unknown, and these may vary based on patient preference.

Nasal irrigation using liquid saline may be helpful to manage symptoms of chronic rhinosinusitis that persist for 12 weeks or longer, and this is the most common indication for saline nasal irrigation. In 1 study included in a Cochrane review, daily use of 2% liquid saline, but not spray saline, in addition to routine care was associated with a 64% reduction in overall symptom severity vs routine care alone. These patients also had significant improvement in disease-specific quality of life at 6 months and at 18 months.

For management of symptoms associated with mild to moderate allergic rhinitis and acute upper respiratory tract infections, evidence supporting the use of spray and liquid saline nasal irrigation is less conclusive.

A range of other conditions, such as rhinitis of pregnancy and acute rhinosinusitis, may respond to saline nasal irrigation, according to consensus guidelines recommending their use in these conditions.

"The exact mechanism of action of saline nasal irrigation is unknown," Drs. Rabago and Zgierska write. "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 cleansing; removal of inflammatory mediators, and improved mucociliary function, as suggested by increased ciliary beat frequency."

Technique modification and salinity adjustment can help avoid minor adverse effects of saline nasal irrigation, such as a sense of discomfort and nervousness the first time nasal irrigation is used. Spray and liquid saline are associated with similar adverse effects.

Among patients using saline nasal irrigation, fewer than 10% reported adverse effects. These may include a self-limited sensation of ear fullness, stinging of the nasal mucosa, and rarely epistaxis. No serious adverse events have been reported.

Contraindications for saline nasal irrigation include incompletely healed facial trauma, because saline could potentially leak saline into other tissue planes or spaces; and conditions associated with increased risk for aspiration, such as significant intention tremor or other neurologic or musculoskeletal problems.

Clinical Recommendations

Key clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:

For symptoms of chronic rhinosinusitis, nasal irrigation is an effective adjunctive therapy (level of evidence, A).
Limited evidence suggests that nasal irrigation may be an effective adjunctive treatment of symptoms of irritant or allergic rhinitis, symptoms of viral upper respiratory tract infection, and postoperative care after endoscopic sinus surgery (level of evidence, B).
Other conditions for which nasal irrigation has been recommended are mild to moderate rhinitis of pregnancy, acute rhinosinusitis, sinonasal sarcoidosis, and Wegener's granulomatosis (level of evidence, C).

"Patients with an appropriate indication should be considered for a trial of saline nasal irrigation," Drs. Rabago and Zgierska conclude. "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."

The review authors have disclosed no relevant financial relationships.

Am Fam Physician. 2009;80:1117-1119. Abstract