ILLUSTRATIVE CASE
A 45-year-old woman presents to your office with an 8-month history of nasal congestion and thick nasal discharge. Her symptoms have waxed and waned, the patient reports. She’s tried decongestants, antibiotics, and nasal steroids, with limited success. The patient has not had a recent respiratory infection, has never had sinus surgery, and does not want to be on long-term medication. You wonder if there’s an alternative treatment you can offer.
Rhinosinusitis is one of the most common conditions seen by primary care physicians in the United States, and its incidence and prevalence are increasing.2,3 While acute rhinosinusitis is usually self-limiting and resolves within a month, some patients develop chronic—and hard to treat—sinonasal symptoms.
No single cause, no definitive treatment
We’ve moved away from the notion that chronic rhinosinusitis is always a manifestation of persistent bacterial infection, and now recognize that there’s an inflammatory, nonbacterial component.4 In any given patient, several mechanisms—acting either simultaneously or independently—may contribute to sinonasal symptoms.3
Chronic sinusitis is treated in a variety of ways, including medications, immunotherapy, and surgery. Despite their limited efficacy, antibiotics and nasal steroids have been the mainstays of treatment.5 Treating underlying allergies, when they exist, may be helpful. But regardless of which treatment patients receive for chronic rhinosinusitis, many remain symptomatic.6
Benefits of saline irrigation extend beyond postop care
Otolaryngologists recommend saline irrigation after sinus surgery to clear secretions, debris, and crusts; reduce the risk of postoperative mucosal adhesions; and expedite mucosal healing.7,8 Saline irrigation is also gaining popularity as an alternative approach to chronic sinusitis symptom relief, and several randomized controlled trials (RCTs) have demonstrated both objective and subjective efficacy of this treatment for sinonasal disease.8-11
In 2007, the Cochrane Collaboration reviewed evidence for the effectiveness of nasal saline irrigation for symptoms of chronic rhinosinusitis. The reviewers concluded that it is well tolerated and beneficial, whether used alone or as an adjunctive treatment.12
Nasal saline sprays are often recommended because they’re thought to be better tolerated than other delivery modes.13 There have, however, been no comparisons of the relative efficacy of different means of saline delivery, until now.
STUDY SUMMARY: Nasal irrigation and spray go head-to-head
This study was a high-quality, prospective RCT comparing nasal spray and nasal irrigation.1 Subjects were recruited from the general population. To be eligible, participants had to be 18 years of age or older and have reported at least one of the following chronic rhinosinusitis symptoms on 4 or more days each week in the preceding 2 weeks:
- nasal stuffiness
- nasal dryness or crusting
- nasal congestion
- thick or discolored nasal discharge.
In addition, the symptoms must have been present on at least 15 of the preceding 30 days. Exclusion criteria included recent sinus surgery, a respiratory infection within the past 2 weeks, and the use of nasal saline within the past month.
Researchers enrolled 127 patients in the study; 63 were randomized to the nasal spray group and 64 to the large-volume, low-pressure irrigation group. Demographic and baseline characteristics of the groups were similar. The average ages of those in the irrigation and spray groups were 45 and 48 years, respectively. Most patients were nonsmokers and had been symptomatic for 7 to 12 months.
Twice-daily treatment. Researchers asked the patients to perform the assigned treatment twice daily for 8 weeks, but the patients were also permitted to continue using their usual medications. Symptom severity and disease-specific quality of life were assessed with the Sino-Nasal Outcome Test (SNOT-20), a 20-item survey that measures physical problems, emotional consequences, and functional limitations of sinusitis.14
The SNOT-20 is a validated, self-administered survey that asks patients to score items such as runny nose, postnasal discharge, need to blow the nose, reduced productivity, and embarrassment, on a 0- to 5-point scale (0=never, 5=always). A SNOT-20 score of 100 indicates the worst possible symptoms.
As a measure of chronicity of symptoms, patients were also asked to estimate how many months they’d had these symptoms during the last year. In addition, they were instructed to keep a diary to document treatment compliance and the use of other medications for sinonasal symptoms.
To measure outcomes, the researchers provided patients with mail-in packets so they could send in their completed SNOT-20 questionnaire and the medication diary completed at 2, 4, and 8 weeks after randomization.
Biggest improvements seen in irrigation group
Severity of symptoms. In each outcome measurement period, the saline irrigation group had lower SNOT-20 scores than the nasal spray group. At 2 weeks, the irrigation group scores were 4.4 points lower than the spray group (P=.02); at 4 weeks, the scores were 8.2 points lower (P<.001), and at 8 weeks the scores were 6.4 points lower (P=.002). Those in the irrigation group also had a significantly greater change from baseline than the patients in the spray group at 4 weeks (16.2 vs 7.4, P=.002) and at 8 weeks (15.0 vs 8.5, P=.04). The difference was marginally significant at 2 weeks (12.2 vs 6.7, P=.05).