Cochrane review: Nasal saline irrigations for the symptoms of chronic rhinosinusitis

Abstract

BackgroundThe use of nasal irrigation for the treatment of nose and sinus complaints has its foundations in yogic and homeopathic traditions. There has been increasing use of saline irrigation, douches, sprays and rinsing as an adjunct to the medical management of chronic rhinosinusitis. Treatment strategies often include the use of topical saline from once to more than four times a day. Considerable patient effort is often involved. Any additional benefit has been difficult to discern from other treatments.ObjectivesTo evaluate the effectiveness and safety of topical saline in the management of chronic rhinosinusitis.Search strategyOur search included the Cochrane Ear, Nose and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4 2006), MEDLINE (1950 to 2006) and EMBASE (1974 to 2006). The date of the last search was November 2006.Selection criteriaRandomised controlled trials in which saline was evaluated in comparison with either no treatment, a placebo, as an adjunct to other treatments or against treatments. The comparison of hypertonic versus isotonic solutions was also compared.Data collection and analysisTrials were graded for methodological quality using the Cochrane approach (modification of Chalmers 1990). Only symptom scores from saline versus no treatment and symptom and radiological scores from the hypertonic versus isotonic group could be pooled for statistical analysis. A narrative overview of the remaining results is presented.Main resultsEight trials were identified that satisfied the inclusion criteria. Three studies compared topical saline against no treatment, one against placebo, one as an adjunct to and one against an intranasal steroid spray. Two studies compared different hypertonic solutions against isotonic saline.There is evidence that saline is beneficial in the treatment of the symptoms of chronic rhinosinusitis when used as the sole modality of treatment. Evidence also exists in favour of saline as a treatment adjunct. No superiority was seen when saline was compared against a reflexology ‘placebo’. Saline is not as effective as an intranasal steroid. Some evidence suggests that hypertonic solutions improve objective measures but the impact on symptoms is less clear.Authors' conclusionsSaline irrigations are well tolerated. Although minor side effects are common, the beneficial effect of saline appears to outweigh these drawbacks for the majority of patients. The use of topical saline could be included as a treatment adjunct for the symptoms of chronic rhinosinusitis.Plain language summaryNasal irrigation with saline (salt water) for the symptoms of chronic rhinosinusitis.The use of nasal irrigation for the treatment of nose and sinus complaints has its foundations in yogic and homeopathic traditions. It is often prescribed as an adjunct to other treatments such as intranasal steroids or antibiotics. However, there is significant effort involved in preparing and delivering the solutions. This review summarises the evidence for the effect of saline irrigations in the management of the symptoms of chronic rhinosinusitis. There is evidence that they relieve symptoms, help as an adjunct to treatment and are well tolerated by the majority of patients. While there is no evidence that saline is a replacement for standard therapies, the addition of topical nasal saline is likely to improve symptom control in patients with persistent sino‐nasal disease. No recommendations can be made regarding specific solutions, dosage or delivery. There are no significant side‐effects reported in trials.

Irrigation penetration of nasal delivery systems: A cadaver study

“…There are no trials that suggest that irrigant must penetrate sinuses in order to improve outcomes in CRS, yet there is clear evidence that nasal irrigation results in symptomatic improvement for these same patients. 2 One of the strengths of this study lies in the classification of irrigation devices as heavy volume irrigators or atomizers. In theory, atomizers have the advantage of delivering highly concentrated medicines directly to sinus mucosa whereas the heavy irrigators deliver a diluted drug with significant force that can accomplish debridement of sinus debris.…”

“…umerous studies have demonstrated the value of saline irrigations for patients with chronic rhinosinusitis (CRS), [1][2][3] but only limited research addresses the best means of delivering irrigation to sinonasal mucosa. Compelling evidence exists that nasal douching is more effective at providing gross topical coverage of sinus mucosa than spray or nebulizers.…”

Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years

“…98 There are 2 Cochrane reviews published on the use of saline nasal irrigation in acute sinusitis in adults that showed variable results. One review published in 2007 99 concluded that it is a beneficial adjunct, but the other, published in 2010, 100 concluded that most trials were too small or contained too high a risk of bias to be confident about benefits.…”

Funktionen und Funktionsstörungen der respiratorischen Schleimhaut der Nase und der Nasennebenhöhlen

“…Die Verwendung von Kochsalz-haltiger L ö sung zum Nasenduschen f ü hrt zu einer verbesserten Zilienschlagfrequenz [47] und somit zur Verbesserung der mukozili ä ren Clearance. Die Salzkonzentration in der Sp ü lfl ü ssigkeit ist nach einem Cochrane Review von untergeordneter Bedeutung [48] . Andererseits scheinen -abh ä ngig von der zugrunde liegenden Pathophysiologie -hypertone L ö sungen bei chronischer Rhinosinusitis und isotone L ö sungen bei akuter Sinusitis vorteilhaft zu sein [49] .…”