Safe & Effective Relief

Scientific evidence for efficacy

• Nasal irrigation with saline solutions is recommended by GPs and ENT specialists in the UK
• Nasal rinses may be used as an alternative to antihistamines, steroids, nasal sprays and antibiotics
• Alternatively they may be used in conjunction with other treatments to accelerate recovery and provide relief

Nasal irrigation as a therapeutic treatment for chronic rhinosinusitis

The use of saline solutions has been used for centuries in Ayurvedic medicine for the treatment of sinusitis, a condition that affects around 9.6 million people in the UK each year (1). Recent trials reveal that nasal irrigation is an effective means of reducing the symptoms and consequently, the practice is now widely supported by General Practitioners and Ear, Nose & Throat Specialists(2).

The symptoms & the causes

The symptoms of sinusitis are well-known:

• Blocked nasal passages
• Facial pain
• Headaches
• Perpetual discharge
• Difficulty in breathing

The most common causes are the residual effects of the common cold, flu or an allergic reaction to pollen, pets, dust mites and moulds. However, the symptoms can be associated with more serious conditions so anyone who suffers from this type of illness at frequent intervals should seek medical advice before resorting to self-treatment.

The causes of chronic repeated sinusitis are many and varied:

INFECTIONS

• Viral, bacterial and fungal
• Biofilms

LOCAL FACTORS

• Nasal obstruction
• Allergic reactions
• Foreign bodies
• Adenoid infection
• Tumour
• Trauma or anatomical aberration
• Dental infection
• Prior surgery

SYSTEMIC FACTORS

• Asthma
• Cystic fibrosis
• Granulomatous diseases

IMMUNE DEFICIENCIES
ENVIRONMENTAL

• Air pollution
• Smoke
• Exhaust fumes & swimming

The Efficacy of Nasal Rinses in Adults

According to MEDLINE, Nasal rinses based on Sodium chloride and Sodium bicarbonate rinses have been the subject of 2155 studies over the last 20 years. Needless to say, a review of this entire body of work is not to be recommended in a short article for busy professionals. Eight of these trials provide sufficient evidence of the efficacy of this treatment using different solutions and for the range of conditions associated with chronic sinusitis. The results also suggest that they are a good alternative to decongestants, mucolytics, antihistamines, steroids and antibiotics with fewer side effects.

Allergic Rhinitis

In a controlled randomised trial in 2014, Nguyen et al (3) treated 40 patients with an isotonic nasal solution applied twice daily over a period of 8 weeks. Sinus pressure was monitored along with the level of daily discomfort. The trial revealed significant improvement in nasal congestion and associated symptoms in 36 of the 40 patients treated. (P<0.001).

Chusakal et al (4) further investigated the remedial effects of three types of isotonic solutions – non-buffered, moderate alkaline (pH 7.2 TO 7.4) and alkaline (pH 8.3 to 8.4). Each patient rinsed twice daily with each of the treatments with 5 day interval gaps. The moderate pH treatment was significantly more effective and universally preferred 35 out of the patients.

Sinusitis

Pynnonen et al (5) in 2007 compared the efficacy of a saline nasal rinse with the best selling nasal spray. Of the 64 patients using the rinse, 58 reported significant relief over an 8 week period compared to only 25 out of the 63 in the case of the nasal spray.

Pre & Post Endoscopic Surgery

Freeman et al (6) investigated the effects of an isotonic saline applied 3 daily on patients following nasal surgery. The trials revealed that 17 out of the 22 patients using sinus rinse significant were able to breathe more easily compared to the control group because of a reduction in congestion and crusting. A trial carried out by Salib et al revealed similar results. Furthermore patient recovery was enhanced because of the reduction in discomfort.

Efficacy in the Treatment of Infants

In one of the more recent trials involving 60 children suffering from acute sinusitis, Yun-Ha Wang et al (7) measured nasal peak flow rate (NPEFR) and used nasal smears and radiography along with daily diary reports to measure the symptoms of the participants. The test showed significant improvement of all measures in 27 of the 29 treated group compared to only 8 of the 31 control group.

None of the trials in this large body of work revealed any side effects of sinus rinse treatments suggesting that they are both effective and safe.

How do nasal rinses work?

Nasal rinses function by flushing out the mucus and effectively removing other nasal congestants present in the nasal passages. The Sodium ions cleanse and the bicarbonate reduce the viscosity of the mucus so that it can be cleared from the nasal passages with minimal damage to the blood vessels and nasal membranes.

Correct Formulations & Methods of Application

Although this type of treatment may appear to be simplistic, it can in fact be potentially painful if the formulation is incorrect. The typical nasal rinse should contain 50% sodium chloride and 50% sodium bicarbonate. It is essential that the ingredients are pharmaceutical grade and the salt must be iodine free. The water used to mix should be boiled and then cooled in order to ensure that it is sterile. The typical application rate is around 1.9 gm per 240 ml of water.

In some rinses, antibiotics and other additives may be used in addition to the salt and bicarbonate but these should only be used if they are recommended by your physician and under the supervision of a pharmacist.

According to the FD&A, bottles should be replaced every 3 months to prevent infection. Improper use of neti-pots and bottles can lead to infection including the deadly naegleria fowleri commonly known as the “brain-eating amoeba”.

Pediatric versions of the applicators should be used for children under 12 and the procedure should be carefully supervised.

New Developments

Xylitol is a well-tolerated agent for sinonasal irrigation which has been demonstrated to achieve even better results than saline-only solutions. Experiments at the University of Iowa (8) compared the results of treating 25 patients on each of the 2 treatments and the inclusion of the Xylitol resulted in more rapid and more complete recovery. Of the 30, 2 patients did complain that the sweet taste of the Xylitol mix was not to their liking but the majority declared the treatment pleasant. Only 1 reported any stinging in the nasal passages.

Lin et al (9) carried out similar trials with 30 patients and the VAS and SNOT scores of the Xylitol solution were all consistently lower than the control group on the saline-only treatment.

One of the most interesting trials carried out in recent years was on Gulf war veterans who exhibited severe sinusitis symptoms that did not respond to antibiotics and other conventional treatments. In this trial (10), not only did the Xylitol reduce the symptoms to negligible proportions, the symptoms did not recur in the subsequent 6 months.

According to the Xylitol.org website, this ingredient acts in the following ways:

• Most of our human pathogens eat and attach to animal-based sugars with 6-carbon atoms and many of them cannot metabolize plant-based sugars with 5-carbon
• Lectins are the binding sites on bacteria and they attach to the animal host and its sugar complexes. This action decreases bacterial binding on plant sugars.
• Bacteria have a genetic inability to digest Xylitol.
• Xylitol works osmotically to increase airway surface which in turn optimizes mucociliary clearance

The Xylitol nasal rinse is highly recommended as an alternative to nasal sprays, antibiotics, antihistamines and steroids. It can also be use as an adjunct to the above prescriptive medications to enhance efficacy and the rate of recovery.

REFERENCES

1. Hamilos D. L.: “Chronic rhinosinusitis: epidemiology and medical management”. J. Allergy & Clinical Immunology. 128 (4):693-707
2. Visit website www.nhs.uk
3. Nguyen et al. Isotonic saline nasal irrigation is an effective adjunctive therapy to intranasal corticosteroid spray in allergic rhinitis. Am. J. Rhinol. Allergy 2014; 28(4): 308-11
4. Chusakal et al. Comparison of buffered and non-buffered nasal saline irrigations in treating allergic rhinitis. Laryngoscope 2013; 123(1) 53-56
5. Pynnonen et al. Nasal saline for chronic sinonasal symptoms: a randomisd controlled trial. Arch. Otolaryngol Head Neck Surgery: 2007; 133(11);1115-120
6. Freeman et al. A preliminary randomised controlled trial evaluating the efficacy of saline douching following endoscopic sinus surgery. Clin Otolaryngol 2008; 33(5): 462-465
7. Wang et al. Efficacy of nasal irrigation in the treatment of acute sinusitis in children. Int. J. Paediatric Otorhinolaryngology 2009. Vol. 73, 1696-1701
8. Lakshmi Durairaj: National Library of Medicine. NCT No.: 00924404
9. Lin et al. “Xylitol Nasal Irrigation in the treatment of chronic rhinosinusitis. Jornal Otolaryngol 2017, July-Aug 38(4): 383-389
10. Hayer S.D. et al; “Effectiveness of nasal irrigation for chronic rhinosinusitis and fatigue in patients with Gulf War Illness” Protocol- randomised control trial. Contemp. Clinical Trials 2015 March; 41: 219-226