#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 reviews^1,2 (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
- 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

Context:

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

February 1, 2016

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Author(s):

Emma Huang BScPharm
G. Michael Allan MD CCFP

1. Hermelingmeier KE, Weber RK, Hellmich M, et al. Am J Rhinol Allergy. 2012; 26:e119-e125.

2. Shaikh N, Wald ER. Cochrane Database Syst Rev. 2014; 10:CD007909.

3. King D, Mitchell B, Williams CP, et al. Cochrane Database Syst Rev. 2015; 4:CD006821.

4. Achille N, Mosges R. Curr Allergy Asthma Rep. 2013; 13:229-35.

5. Harvey R, Hannan SA, Badia L, et al. Cochrane Database Syst Rev. 2007; 3:CD006394.

6. van den Berg JW, de Nier LM, Kaper NM, et al. Otolaryngol Head Neck Surg. 2014; 150(1):16-21.

7. Rudmik L, Hoy M, Schlosser RJ, et al. Int Forum Allergy Rhinol. 2013; 3(4):281-98.

8. Adappa ND, Wei CC, Palmer JN. Curr Opin Otolaryngol Head Neck Surg. 2012; 20(1):53-7.

9. Rudmik L, Soler ZM. JAMA. 2015; 314(9):926-39.

10. Rabago D, Zgierska A, Mundt M, et al. J Fam Pract. 2002; 51(12):1049-55.

11. Hauptman G, Ryan MW. Otolaryngol Head Neck Surg. 2007; 137(5):815-21.

12. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Otolaryngol Head Neck Surg. 2015; 152:S1-S39.

13. Kaplan A. Can Fam Physician. 2013; 59:1275-81.

14. Seidman MD, Gurgel RK, Lin SY, et al. Otolaryngol Head Neck Surg. 2015; 152(1 Suppl):S1-43.

15. Angier E, Willington J, Scadding G. Prim Care Respir J. 2010; 19:217-22.

Authors do not have any conflicts of interest to declare.