Nasal Irrigation Doesn't Have to Be Torture

Matthew F. Watto, MD; Paul N. Williams, MD; Stuart K. Brigham, MD


December 11, 2020

This transcript has been edited for clarity.

Matthew F. Watto, MD: Welcome back to the Curbsiders. My co-hosts are Dr Stuart Kent Brigham and Dr Paul Nelson Williams. Paul, can you tell our audience what we are discussing today?

Paul N. Williams, MD: On this video, we're going to highlight one of our recent podcasts, when we talked with Dr Dink Jardine about how to deal with chronic rhinosinusitis. We're going to recap some of our favorite tips from that episode.

Watto: My understanding is that we make 500 mL of snot each day — to quote our guest — and that's a lot of snot. A half-liter. Why is it a problem? What can we do about it?

Williams: Often in internal medicine, and in medicine in general, we recommend things without adequate counseling. We'll give a patient a handful of condoms or a bagful of nicotine patches and say "Good luck and Godspeed" without actually explaining how to use them. I've been just as guilty of not telling patients how to do sinus irrigation. I will often say, "Here's a prescription for a neti pot" without telling them how to use it, because I wasn't sure myself. But Dr Jardine explained very practically how to do proper sinus irrigation, and how to troubleshoot.

Nasal irrigation basics. Designed by Beth Garbitelli

For instance, if it burns the patient's sinuses, they probably don't have enough salt in the irrigant, and they should use warm water (sort of baby-bottle temperature). He explained how to bend over the sink to avoid gagging, and say "kah kah kah" to keep the irrigant from running down the back of your throat. A lot of really practical considerations. I feel much better armed now in terms of guiding and counseling patients for sinus irrigation than I was before this episode. There was a lot of good stuff in this podcast.

Watto: She said that we make 500 mL of snot a day, but we swallow it or blow our noses and it doesn't bother us if we're not infected or inflamed because it's thin. And what the saline rinses do is thin out and help wash out that mucus, so you don't have that congested feeling, which I think is a great way to explain to patients why they need to do this.

Stuart K. Brigham, MD: Have you ever tried to use a sinus rinse? It's like water torture. I feel like I'm drowning.

Watto: I have done them before. I've used one of the neti pots, and I've tried the regular saline nasal spray. I actually like the pot better because I feel I get better results. But my sinuses don't bother me enough to be pouring a half-liter of water in in my nose every day.

Williams: I omit the water torture comment from my instructions.

Watto: And if someone really has sinus problems, that's the fundamental basis of therapy. You have to get them on irrigation.

Brigham: If patient can't stand irrigation, one of the first things that I use is intranasal steroids. They should be the first line of therapy, in my understanding, although I find time and time again that many junior physicians tend to overuse oral antihistamines. Have you seen that before?

Watto: I think it's just the ease of taking a pill. But you're not talking about acute sinusitis. You're talking about chronic sinusitis lasting 8-12 weeks or more, correct?

Brigham: Yes, because it takes upward of 2 weeks for the steroids to start working. That's one of our failures when counseling our patients — that they may not get relief immediately with intranasal corticosteroids. It may take a couple of weeks to start to see a benefit from them.

Watto: Right. And it works for chronic sinusitis, whether it's allergic or not. It seems to help with the congestion.

Another thing that Dr Jardine talked about was just a revelation to me. It was one of my favorite tips. She doesn't like to see a CT of the sinuses until the patient is optimized. So don't get the CT when the patient is feeling miserable, because she wants to know whether she needs to do surgery. When they're miserable and their sinuses are acting up, they're going to look terrible on a CT scan. So you want to get them as good as you can before you get the CT scan. And if the ear-nose-throat specialist or otolaryngologist will see the patient without a CT scan, then refer them and let the surgeon decide when to get the CT scan. That way, you don't expose the patient to more radiation and an additional copay by ordering an unnecessary CT scan.

Brigham: If you want to hear more, that's not all, because we have the full episode of our conversation with Dr Dink Jardine, #239: Sinusitis: It's Not That Tricky on our website or wherever you consume your podcasts. Take it from there, Matt.

Watto: And you can also join our mailing list and get a PDF copy of our show notes every week. Thank you for watching.

The Curbsiders are a national network of students, residents, and clinician educators from across the country, representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge, and bad puns. Learn more about their contributors and follow them on Twitter.

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