#155 “I got water up my nose.” From swimming accident to rhinosinusitis cure?
CLINICAL QUESTION
Is nasal saline irrigation (NSI) helpful for rhinosinusitis?
BOTTOM LINE
Nasal saline irrigation does not improve acute rhinosinusitis (example “colds”). It can improve allergic and chronic rhinosinusitis, improving symptoms ~30% and improving quality of life with rhinosinusitis at least 10% for one in two patients. Isotonic is as good as hypertonic and rinses are better than sprays (but with more adverse events).
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EVIDENCE
- We identified nine systematic reviews of NSI. Differences noted are statistically significant.
- Acute rhinosinusitis:
- Acute upper respiratory tract infection: Two systematic reviews1,2 (five Randomized Controlled Trials (RCTs), 749 patients, 27% adult).
- Days to wellness or antibiotic use: No difference.1
- One trial showed a potentially clinically non-meaningful ~0.3 on 4-point scale improvements in nasal symptoms.1
- Acute sinusitis in children: One systematic review but no RCTs.3
- Acute upper respiratory tract infection: Two systematic reviews1,2 (five Randomized Controlled Trials (RCTs), 749 patients, 27% adult).
- Allergic rhinosinusitis: One systematic review (nine RCTs, 295 patients, ~71% adult).4 Relative improvement of NSI versus no treatment.
- Mean total symptom score 32.5% better.
- Chronic rhinosinusitis: Six systematic reviews (1-8 RCTs, 127-389 patients).4-9
- Symptom score, NSI versus nothing: Standard Mean Difference 1.42 but clinical meaning is uncertain.5 Longest RCT at six months found:
- NSI improved symptom score from 4 to 2.4 versus no change without treatment.10
- Attaining a 10% improvement in nasal symptoms quality of life, Number Needed to Treat (NNT)=2.10
- Rinse versus spray:6 Rinse reduces symptoms more than spray, NNT=5.
- Compliance at eight weeks worse with rinse: 79% versus 93% spray (Number Needed to Harm (NNH)=8).
- Any adverse event: 43% rinse and 25% spray (NNH=6).
- Most common: Persistent nasal drainage.
- Isotonic versus hypertonic: Similar clinical endpoints.5,8,11
- Adverse events: Poorly reported; Nasal burning, ear plugging, and nausea most frequent.7
- Symptom score, NSI versus nothing: Standard Mean Difference 1.42 but clinical meaning is uncertain.5 Longest RCT at six months found:
- Acute rhinosinusitis:
- Systematic review quality varied from good1,5 to poor.2,8 Deficiencies include: No quality assessment,2,4,7-9 poor methods description,2,8 inadequate description of studies,2,4,6-8 large heterogeneity,2,4,5 and poor adverse event reporting.1-5,8,9 RCT quality frequently poor with inconsistent outcomes.
- Guidelines recommend NSI:
- As an option in chronic rhinosinusitis.12,13
- No recommendation14 or second-line option in allergic rhinitis.15
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