BrazJOtorhinolaryngol.2015;81(5):457---458
www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
EDITORIAL
Nasal
saline
irrigation:
therapeutic
or
homeopathic
夽
Irrigac
¸ão
nasal
com
soluc
¸ão
salina:
terapêutica
ou
homeopática
Inchronicrhinosinusitis(CRS),andmanychronicairway con-ditions, theunderlyinggoalis torestore mucosalfunction withtreatmentsfocusedonreducinginflammation, remov-ingbacterialinfection(orbiofilm)and,critically,replacing lost mucociliaryfunction.1 Nasal irrigations have come to
playalargeroleinthemanagementofchronicrhinosinusitis andtoalesserdegreeinallergicrhinitis(AR).Whilesaline nasal treatments are offered in different forms, such as spraysandnebulizers,itishigh-volumenasalirrigationthat hasfoundan integralpartincurrenttreatment guidelines forCRS.
Nasalirrigationsmayappearnovel,butthispracticeof sinus care has its originswithin theHatha Yoga Pradipika fromthe 15th century. Jala neti is the practice of water (Jala)irrigationandthustheoriginsofthenetipot.There areseveralShuddikriyas,orbodycleansingpractices,within yogic traditions and neti refers tonasal cleansing. Other cleansingtechniquesincludetheuseofstring(Sutra),ghee (Ghrita),andevenone’sownurine(Swamootra).However it isJala neti,or saline irrigation,that hasdemonstrated effectiveness(thankfully).
Western medicine has not been ignorant of its bene-fits; the first description of nasal irrigation appeared in the British Medical Journal in 1895. In 2007, a Cochrane review onnasalsalinetherapy demonstrateda large shift in symptom improvementonmeta-analysisof randomized controlled trials, with a 1.41 standardized mean differ-ence (SMD) in favor of saline therapy.2 This represents
an improvementof1.41 standarddeviations onthe symp-tom scale compared to placebo and compares favorably tothetreatment effectobserved inother sinonasal inter-ventionswithintranasalcorticosteroidsforCRS(SMD0.49) and immunotherapy for AR (SMD 0.71). This large symp-tomeffectunderscoresitsgrowingpopularity.Whilemany alternative therapies lie ona spectrum fromplausible to preposterous,nasalirrigationrestsontheformerendofthe
夽
Pleasecitethisarticleas:BarhamHP,HarveyRJ.Nasalsaline
irrigation: therapeutic or homeopathic.Braz J Otorhinolaryngol.
2015;81:457---8.
spectrum,not only for its effectiveness, but also for the substantiveresearchunderlyingitseffect.
Nasalirrigationisprimarilyamechanicalintervention.It doesnotdirectlyenhancemucosalimmunity(andmay tem-porarilyremove innate factors), nor is it a decongestive. Veryhypertonicsalineonlyactsasaprovocationtothe air-wayandisusedbyrespiratoryphysiciansforthatpurpose. Additionally,it does notdirectly enhance ciliaryfunction. Formany hypersecretory conditions, such as CRS, it may helpto temporarily improve mucus rheologybut it is the mechanical removalof inflammatorymucin that improves mucociliaryfunction.
InCRS, mucostasisisamajorcomponentof the patho-physiology. Although mucociliary dysfunction may be a primaryfactorinconditionssuchascysticfibrosis,itis usu-allya secondaryeventcaused byinflammation, appearing in chronic airway conditions such as eosinophilic CRS or bronchiectasis.Lossofciliatedmucosaandsquamous meta-plasiaarepartof thechronic remodelingchangesseen in CRS.3 As inthe lowerairway, some ofthese changesmay
notbeimmediatelyreversible,andtheroleofnasalsaline irrigationistoovercometheacquiredmucostasis.The abil-itytotemporarily(orpermanently)substituteforimpaired mucociliaryclearanceisessentialtosuccessfulsinus man-agement.
The role of the surgeon is critical for effective nasal saline irrigation therapy. Endoscopic sinus surgery (ESS) improves the access of topical therapies for both the mechanicallavageofmucinousproductsanddrugdelivery.4
Delivery of nasal saline and additional topical therapies is bestachieved with large volume devices.5 Low-volume
devicesdonotreliablypenetratethesinuses,andalthough nasalcavitydelivery occurs,thisisnottruesinustherapy. High-volumedevices(>60mL,butgenerally>100mL)have beenfoundtoimprovedeliveryintothesinuses.5,6The
def-initionof‘‘high-volume’’isarbitrary,butclinicalevidence suggests it is important for mechanical lavage and drug delivery.7 Unfortunately,high-volumedevicescanproduce
Eustachian tube symptoms and local irritation in 10---20% ofusers.However,theseareoftenmildandcomplianceis high.2
http://dx.doi.org/10.1016/j.bjorl.2015.07.002
1808-8694/©2015Associac¸ãoBrasileirade OtorrinolaringologiaeCirurgiaCérvico-Facial.Published byElsevierEditoraLtda.Allrights
458 EDITORIAL
Low-volumedevicessuchasdrops,sprays,andnebulizers are nasal cavity therapies, and are used in the manage-mentofAR,buthavealimitedaroleinmanagingCRS,as theyhave limitedreachwithinthesinusesandprovide no mechanismforcorrectingmucostasisvialavage.
Conclusion
Nasal saline solutions are helpful in reducing mucosal inflammation,removing bacterialproducts, andimproving sinonasal function in CRS. Nasal irrigation enables effec-tive local pharmacologic management when true sinus distributionoftopicaltherapiesis required,primarily cor-ticosteroids, antibiotics, and mucolytics. The mechanical shear force that is provided by high volumeirrigations in thepost-operativestateislikelyamajorfactortomanage mucostasis. Current evidence suggests that optimal topi-calsinusdeliveryoccursaftersurgeryandwithhigh-volume irrigationdevices.Mostimportantly,theyarealow-costand welltoleratedtherapyforpatientswithCRS.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.TimperleyD,SchlosserRJ,HarveyRJ.Chronicrhinosinusitis:an educationand treatmentmodel. OtolaryngolHead NeckSurg. 2010;143Suppl.3:S3---8.
2.HarveyRJ,HannanS,BadiaL,ScaddingG.Nasalsalineirrigations forthesymptomsofchronic rhinosinusitis.CochraneDatabase SystRev.2007:CD006394.
3.BarhamHP,OsbornJL,SnidvongsK,MradN,SacksR,HarveyRJ. Remodellingchangesoftheupperairwaywithchronic rhinosi-nusitis.IntForumAllergyRhinol.2015;5:565---72.
4.RudmikL,HoyM,SchlosserRJ,HarveyRJ,WelchKC,LundV,etal. Topicaltherapiesinthemanagementofchronicrhinosinusitis:an evidence-basedreviewwithrecommendations.IntForumAllergy Rhinol.2013;3:281---98.
5.Thomas WW 3rd, Harvey RJ, Rudmik L, Hwang PH, Schlosser RJ.Distributionoftopicalagentstotheparanasal sinuses:an evidence-basedreviewwithrecommendations.IntForumAllergy Rhinol.2013;3:691---703.
6.OrlandiRR,SmithTL,MarpleBF,HarveyRJ,HwangPH,KernRC, etal.Updateonevidence-basedreviewswithrecommendations inadultchronicrhinosinusitis.IntForumAllergyRhinol.2014;4 Suppl.1:S1---15.
7.PynnonenMA,MukerjiSS,KimHM,AdamsME,TerrellJE.Nasal salineforchronicsinonasalsymptoms:arandomizedcontrolled trial.ArchOtolaryngolHeadNeckSurg.2007;133:1115---20.
HenryP.Barham, RichardJ.Harvey∗ RhinologyandSkullBaseResearchGroup,AppliedMedical ResearchCentre,UniversityofNewSouthWalesand MacquarieUniversity,Australia
∗Correspondingauthor.
