to the editor: In the two-part article on acute bacterial rhinosinusitis (ABRS),^1,2 the authors correctly identified the challenges in diagnosing acute bacterial rhinosinusitis. They noted that although up to 98 percent of physicians prescribe antibiotics for patients with rhinosinusitis, most cases are viral or allergic rather than bacterial, and that most patients really want recommendations for symptom relief.¹

Nasal irrigation is an adjunctive therapy for ABRS and is noted to be “possibly effective” for the relief of sinus symptoms.² We believe the potential benefits of nasal irrigation outweigh the negligible risks, and that it should be considered for more patients with rhinosinusitis, especially those with recurrent symptoms for whom effective medical treatment often is difficult. Nasal irrigation has been associated with decreased sinus symptom severity and recently was identified as “an important component in the management of most sinonasal conditions” that is “effective and underutilized.”³

Nasal irrigation is an inexpensive, patient-controlled therapy that flushes the nasal cavity with saline solution, facilitating a wash of the structures within. Benefits from nasal irrigation may accrue from removal of nasal discharge and crusts, mucus thinning,³ and enhanced mucociliary clearance of nasal secretions. Nasal irrigation also may decrease mucosal inflammation osmotically.

Randomized controlled trials (RCTs) have assessed hypertonic saline nasal irrigation for several sinus-related conditions, including acute sinusitis (three studies), chronic sinus symptoms (two studies), and chronic sinusitis (three studies). Each reported improvement in sinus symptoms and on surrogate measures such as quality-of-life scales. None reported significant adverse events.

Our group recently reviewed the literature and assessed nasal irrigation for recurrent and chronic sinus symptoms in a RCT.⁴ We found significant improvement in quality-of-life scores and sinus symptoms, and decreased antibiotic and nasal spray use. Side effects were few, and patient satisfaction was high; reported adherence to daily nasal irrigation was 87 percent. Patients continued to note symptomatic improvement over 18 months.⁵ In a qualitative study,⁶ subjects reported that their use of nasal irrigation, especially at the onset of sinus symptoms, accounted for decreased medication use and physician visits, and may have prevented future episodes of rhinosinusitis.

Instructing patients is easy and brief. We present the rationale for hypertonic saline nasal irrigation as part of the treatment plan; if the patient is interested, we explain the technique with an illustrated patient handout (http://www.fammed.wisc.edu/research/projects/nasalirrigation.html).We recommend using nasal irrigation once daily from the onset of sinus symptoms until resolution. Nasal irrigation pots are available at most pharmacies.

The literature shows that even with the best clinical evaluation, we are likely to misdiagnose ABRS. Nasal irrigation can help reduce symptoms while the illness declares itself or resolves. Questions about exact salinity, pH, and frequency of nasal irrigation require further study. However, the data show that nasal irrigation is effective, safe, and tolerable for patients with sinonasal symptoms. Nasal irrigation should be considered for more patients with rhinosinusitis (including ABRS), especially those patients with recurrent and chronic symptoms who often have few effective treatment options.

IN REPLY: We thank Dr. Rabago and colleagues for their comments and agree that nasal irrigation is an adjunctive therapy that should be considered for patients with recurrent or chronic sinus symptoms. However, the focus of our review was acute bacterial rhinosinusitis. We reviewed the literature, which includes the articles cited by Dr. Rabago and colleagues, and found evidence that nasal irrigation was effective for relief of sinonasal symptoms in patients with chronic, frequent, recurrent sinusitis; recent intranasal or sinus surgery; allergic rhinitis; and age-related rhinitis. We found only two randomized controlled trials (RCTs) of nasal irrigation in adults.^1,2 Contrary to the claim of Dr. Rabago and associates that all studies of nasal irrigation have shown a benefit, one RCT¹ that included patients with colds and rhinosinusitis found no advantage of hypertonic saline nasal irrigation or normal saline nasal irrigation over observation. In another RCT,² six groups of 50 patients with acute sinusitis received one of three antibiotics and either a nasal decongestant or nasal irrigation. The study² found no differences among groups except for delayed radiologic healing in patients receiving cephradine (Velosef) plus a nasal decongestant. Although the findings of Dr. Rabago’s research, as presented in his letter, are interesting, the relevance of the findings to acute bacterial rhinosinusitis are unclear.

Dr. Rabago states that no study has reported significant adverse events. However, in one study,¹ 32 percent of patients who used hypertonic saline nasal irrigation complained of burning, and only 44 percent stated they would use it again. Other potential adverse side effects include local irritation, itching, otalgia, otitis media, exacerbation of asthma or chronic obstructive pulmonary disease, and sinus pooling with subsequent draining.³

Furthermore, there is no consensus regarding a uniform protocol for nasal irrigation. Various reports are inconsistent about the superiority of hypertonic saline nasal irrigation, normal saline nasal irrigation, or Ringer’s lactate solution irrigation.³ Different authors advocate buffered or nonbuffered solutions, and antimicrobial or xylitol additives.³ The importance of sterility is unknown. Multiple delivery methods and devices have been studied but not compared, including bottles or pots, bulb syringes, inhalers, and nebulizers.³

For these reasons, we rated nasal irrigation as “possibly effective.” In 2000, the investigators of an evidence report prepared for the Agency for Health Care Policy and Research found insufficient evidence to assess the benefits.⁴ In 2005, the Academy of Allergology and Clinical Immunology and the European Rhinological Society did not recommend the use of nasal saline douche for acute rhinosinusitis, again because of a lack of evidence.⁵ Though this review was concerned with the treatment of adults with acute bacterial rhinosinusitis, it also should be noted that the American Academy of Pediatrics found insufficient evidence to recommend saline nasal irrigation in children in 2001.⁶