| Nasal irrigation | |
|---|---|
| Intervention | |
A woman flushing her nose with a neti pot |
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| ICD-9-CM | 22.0 |
| MeSH | D055556 |
Nasal irrigation or nasal lavage or nasal douche is the personal hygiene practice in which the nasal cavity is washed to flush out excess mucus and debris from the nose and sinuses. Nasal cleansing began as an ayurvedic medicine technique in ancient India. The practice is generally well-tolerated and beneficial with only minor side effects.[1] Nasal irrigation in a wider sense can also refer to the use of saline nasal spray or nebulizers to moisten the mucus membranes.
According to its advocates, nasal irrigation promotes good nasal health. Patients with chronic sinusitis including symptoms of facial pain, headache, halitosis, cough, anterior rhinorrhea (watery discharge) and nasal congestion often find nasal irrigation to provide effective relief. In published studies, "daily hypertonic saline nasal irrigation improves sinus-related quality of life, decreases symptoms, and decreases medication use in patients with frequent sinusitis",[2] and irrigation is recommended as an adjunctive treatment for chronic sinonasal symptoms.[3][4]
Contents |
Nasal irrigation is used to treat a wide range of chronic sinus and nasal symptoms; for chronic rhinosinusitis it is an effective adjunctive therapy. It is also an effective measure against chronic sinus symptoms induced by work-place exposure to sawdust.[5] Further evidence suggests that nasal irrigation causes relief for both hay-fever and the common cold. The neti pot used with a saline solution has been shown to be an effective treatment for hay fever,[6] sinusitis, and other nasal conditions.
SNI could also be an effective treatment for allergic rhinitis[6] and chronic sinusitis.[7] A conference abstract presented in November 2009 indicated that frequent nasal irrigation led to higher rates of sinus infections. Short term use, however, seemed to be effective.[8]
Daily nasal irrigation with salt water solution (a mixture of 0.9% non-iodized sodium chloride and either purified or filtered water (do not use tap water, click here to find out why) warmed to around 98 degrees F/ 37 degrees C, with or without inclusion of a buffering agent such as sodium bicarbonate) is recommended as both an adjunctive[9] and primary treatment[10] in such cases and is preferable to the use of corticosteroids except in the most serious cases of acute bacterial sinusitis which should be immediately referred to an otolaryngologist.[11] Irrigation should be used with caution in infants, as nasal drops are not widely tolerated. [12]
Flushing the nasal cavity with salt water has been claimed to promote mucociliary clearance by moisturizing the nasal cavity and by removing encrusted material, although there is no clear evidence to support this.[10] In proper proportion, nasal salt water solution with slight acidic pH functions as an anti-bacterial irrigant. The flow of salt water through the nasal passage flushes the dirt, airborne allergens (dust and pollen), pollutants and bacteria-filled mucus.
Salt water flushing also loosens and thins the mucus, making it easier to expel. Without this build up of mucus, the tiny cilia, or hairs in the nasal passage are able to function more efficiently, pushing excess mucus either to the back of the throat or to the nose to be expelled.
Potential allergens (such as iodine) or contaminants (algae, etc.) are to be avoided in the sodium chloride, water, or buffering ingredients.[13] Premanufactured dosages of salt water flushing solutions can be purchased, or the user can mix non-iodized 'kosher' salt, with or without a buffering agent such as sodium bicarbonate or baking soda (table salt frequently is iodized, while sea salt may contain algae or other contaminants). Treatment guidelines in both Canada and the United States now advocate use of nasal irrigation for all causes of rhinosinusitis and for postoperative cleaning of the nasal cavity.[14]
A conference abstract presented in 2009 indicated that long-term nasal irrigation led to higher rates of sinus infections, which the principal researcher theorized was due to alterations in nasal immunological chemistry brought on by flushing out the protective elements of the mucous membrane of the nose.[15] Note that this study has not been published in any peer-reviewed journal, and that the results may have been affected by the method of selection of test subjects and by the neti pot methods followed by the subjects. No such results were observed for short term use. However, it is of note that efficacy studies in general have not been conducted on groups utilizing this specific treatment, and that claims regarding the efficacy of the technique rely largely on anecdotal evidence.[16]
While nasal irrigation is generally well-tolerated, at least two deaths from Naegleria fowleri have been reported from use of a neti pot. Naegleria fowleri present in unboiled or otherwise unsterilized water causes the fatal brain infection primary amoebic meningoencephalitis (PAM).[17] [18] [19] [20]
The probability of death from this Naegleria infection is as high as 98%, but the parasite can be killed by boiling water before use. According to Louisiana State Epidemiologist Raoult Ratard, "if you are irrigating, flushing, or rinsing your sinuses, for example, by using a neti pot, use distilled, sterile or previously boiled water to make up the irrigation solution."[21]
Currently, the best nasal irrigation system offers the following features and benefits: The irrigator has the anti-backwash valves, so the dirty solution will not flow back to the nasal cavity. This is particularly important for those people with bacterial or viral infections, such as the common cold or flu. The irrigator should be held up-right, like brushing your teeth. The head should not be tilted sideways. If the head is tilted sideways, the ear on the lower side could have the liquid entering it to cause an ear infection.
The simplest method, which requires no specialized equipment, is to snort water from cupped hands. The application of commercially available saline nasal spray is another simple alternative, but it is relatively inefficient for washing away debris although it may suffice for simple rehydration of mucous and tissues.[26][27]
A simple yet effective technique is to pour salt water solution into one nostril and let it run out through the other while the mouth is kept open to breathe, using gravity as an aid. Jala-neti, which means to cleanse the nose with water,[28] is an old yogic technique. The container used to administer the saline is called a "neti pot". Neti is Sanskrit for "nasal cleansing". A second neti technique known as sutra neti uses a piece of string instead of water.
Neti pots are typically made of metal, glass, ceramic or plastic. They rely on gravity, along with head positioning and repeated practice in order to rinse the outer sinus cavities. Typically it has a spout attached near the bottom, sometimes with a handle on the opposite side.[29] Some users are able to use neti pots without problems, while the sideways positioning of the head can induce vertigo in others. A more advanced variation of the technique (known in yoga as Vyutkrama Kapalaneti) involves pouring the same salt water solution into one nostril while the other is held closed, so that the solution runs out of the mouth. It is more challenging than the basic version (care must be taken to keep the saline solution out of the throat and to suppress possible vomiting reflex), but it can allow more thorough irrigation of the nasal cavity and the sinuses. Yet another technique (known in yoga as Seethkrama Kapalaneti) is to take the saline into the mouth and - leaning forward - force it out of the nostrils.
The second method of nasal irrigation is to introduce some form of positive pressure to the water introduced into the sinuses and nasal cavities in order to provide a more complete rinsing without resort to special techniques, such as holding the head to one side. Some products available from pharmacist supply retailers are essentially bottles made of flexible plastic with special tips to fit the nostril. These bottles, when filled with warm salt water solution, can be squeezed to exert positive pressure of the water flowing through the sinuses while the mouth is kept open at all times in order to breathe and prevent snorting the liquid down the throat. Even ordinary plastic water bottles can and have been used, as long as the nozzle will adequately fit a person's nostril. However, neither squeeze bottles nor bulb syringes provide the user with any genuine control over the pressure/volume of solution introduced. You need to make sure the pressure cannot be too high to prevent ear pressure or ear infection. The diameter of the hole in the center of the nostril fitting cannot be larger than 3 mm. If too large, a big wave of liquid can be forced to enter any where, such as middle ear, to cause ear pain or even ear infection.
Yet another type of product, the Nasaline irrigator, utilizes an oversized syringe with an injector-type plunger in place of the bulb.[30] Invented by a group of Swedish ENT specialists, the Nasaline contains a specially designed tip intended to better atomize the salt water through a swirling action at a predetermined, nonadjustable velocity as it is forced through the sinuses by the injector's plunger.[31]
Irrigation machines that utilize electric motor-driven pumps are also available. These irrigation devices pump salt water solution through a tube, in connection with a nasal adapter tip designed to seal against the nostril. Some of these machines allow adjustment of water volume/speed by use of an adjustment dial which regulates pump speed and volume per minute. Most of these motorized machines use a pulsatile or pulsating water pumping action at a relatively low, predetermined fixed pulse cyclic rate, designed to match the normal wave rate of healthy, unobstructed nasal cilia.[32] This matched pulse rate is claimed to stimulate the nasal cilia hairs and promote better sinus health, while reducing the severity of allergic reactions.[33] More sophisticated motorized irrigators have two or more pulse cycle settings that adjust the actual pulse cycle (as opposed to a simple volume/speed control, which does not alter the pulse cyclic rate). This design affords the user the option of using a higher pulse cyclic rate when suffering from partially closed sinuses, as in a typical case of acute sinusitis. The efficacy of all motorized pump irrigators has not yet been tested compared to simpler non-motorized mechanical pressure nasal irrigation methods.[34]
While nasal irrigation can be carried out using ordinary tap water, this is NOT safe (See Warning) and additionally can be uncomfortable because it irritates the mucous membranes. Therefore an isotonic or hypertonic salt water solution is normally used, i.e. water with enough salt to match the tonicity of the body cells and blood. For the same reason, lukewarm water is preferred over cold water, which in addition to irritating nasal membranes can also exaggerate the gag reflex during irrigation. Use of distilled, sterile or previously boiled and cooled water over ordinary tap water is advised. Tap water safe for drinking is not necessarily safe for nasal irrigation due to risk of rare but fatal brain infection. A small amount of baking soda is sometimes employed as a buffering agent to adjust the pH of the irrigating solution to that of the body.
Many pharmacies stock pre-manufactured sachets of pharmaceutical grade salt and baking soda designed to be used with the volume of water their corresponding device uses. Sometimes manufactured solutions such as lactated Ringer's solution and Alkalol[35] are used.
Optional additives include xylitol which is claimed to draw water into the sinus regions and helps displace bacteria.[36] Xylitol is commonly used to prevent acute otitis media in Europe and dental caries in the United States,[37] but research into xylitol use in the sinus cavities is lacking. Another nasal irrigation additive is aloe extract, which helps to prevent nasal dryness. Sodium citrate and citric acid help not only to balance the pH, also helps to improve the sense of smell. As noted above, in December 2011, the Louisiana state health department reported 2 deaths from Naegleria Fowleri in which the use of contaminated tap water for nasal irrigation was strongly implicated. [38]
The precise reasons for the efficacy of nasal irrigation are not well understood, although it is clear that the removal of mucus plays an important role.[10] Damage to the mucociliary transport system is an important factor in the development of sinonasal diseases, leading to a stasis of mucus.[34] The numerous proteins found in nasal mucus include inflammatory mediators, defensins and many whose function is not understood.[10] Thus hypotheses include that nasal irrigation may decrease inflammation through the removal of mucus, that it may improve mucociliary clearance, and that it may remove thickened mucus that cannot be handled by the cilia.[10][34]
In a study with eight healthy volunteers, solution was transported reliably to ethmoid and maxillary sinuses when it was snorted or applied with a squeeze bottle; a nebulizer was significantly less effective. Sphenoid and frontal sinuses were rarely reached, and not at all with the nebulizer.[27]
The earliest record of nasal irrigation is found in the ancient Hindu practice of Ayurveda whose roots are traced to the Vedas. The simplest method of nasal irrigation, that is to sniff water from cupped hands and then blowing it out, is also a step in the hygienic practices (Wudu) of Muslims.
Jefferson, Warren (2005). The Neti Pot for Better Health. Summertown: Healthy Living Publications. ISBN 9781570671869.