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Hopkins C, Surda P, Walker A, Wolf A, Speth M, Jacques T, et al. EPOS 4 patients. Rhinology. 2021 Suppl. 30: 1-57.

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Saline Irrigation
(Salt water rinses)

Why have you been prescribed this medication?

The goal of saline nasal irrigations is to improve symptoms and quality of life in chronic rhinosinusitis (CRS) patients with a low risk of side effects. Thus, saline irrigations represent one of the pillars of the treatment of CRS; however, their benefit in the treatment of post-viral or bacterial acute rhinosinusitis is less clear. Their proven benefit and their unlikely adverse effects make the saline irrigations a part of the first-line treatment for CRS patients, both in patients with CRS with nasal polyps and with CRS without nasal polyps. In addition, they have also shown their benefit in the case of children with CRS.


How it works

Saline nasal irrigation may improve nasal function and therefore improve the symptoms. These irrigations help with the removal of crusts, mucus, and substances that stimulates inflammation of the nasal mucosa (allergens, biofilm ...) and improve the hydration of the nasal mucosa. Furthermore, they are also useful in the distribution of medications, such as intranasal corticosteroids, through the nasal cavity and paranasal sinuses.


How, when and for how long you should use it

CRS as a chronic disorder usually requires chronic treatment. Thus, saline nasal irrigations should be performed as the symptoms persist, or forever. There are many different methods for irrigations: nasal sprays, nasal squeeze bottles, nebulization, netipots, bulb syringes ... None has proven to be clearly better than another in improving symptoms. Thus, it is recommended to use the one with which the patient feels more comfortable. There are also high and low flow volume irrigations or hyper- tonic serum, though their benefit is not clear.

There is also no standard treatment protocol, but it is usually recommended to irrigate 1 or 2 times a day, before the application of the rest of the medication, such as intranasal corticosteroids.

Steroids are often added to salt-water solutions so that they can be rinsed into the sinus cavities, especially after surgery. There are many other substances that can be added to irrigations, however, the ones that have the best-shown benefit to the patient are xylitol, sodium hyaluronate, and xyloglucan.

In summary, saline nasal irrigations are recommended as the initial long-term treatment of CRS. You can perform it with various devices, using isotonic saline, once or twice a day, and prior to the application of the rest of your medication. In some cases, the addition of other substances may be useful.


Please see the linked video on the ERS website for a demonstration of saline irrigation.


Side effects (and what to do if they occur)

One of the greatest advantages of saline nasal irrigations is that adverse effects are rare. Adverse effects such as local irritation, ear pain, nosebleeds, headache, nasal burning, and nasal drainage have been reported. The addition of substances to saline irrigations can favour the appearance of the mentioned adverse effects or others, as in the case of the use of baby shampoo and reversible smell loss.

If these side effects appear, changing the application device and reviewing the irrigation technique usually improves or solves them. In cases of persistence and worsening of symptoms, it may be necessary to stop.


Patient reports on using the medication – tips, tricks, what to expect, etc.

Guillermo is a 38-year-old male who was diagnosed a year ago with chronic rhinosinusitis with nasal polyps. He reported regular rhinorrhea and nasal congestion. At diagnosis, topical corticosteroids and nasal saline irrigations twice per day were prescribed. He declares that the symptoms improve a lot with the treatment and that even at times when some of the symptoms worsen, he performs irrigations more than twice a day. That helps him feel better. He performs high-flow irrigations (figure) with an isotonic solution on both sides. First, he flexes and turns his head and starts the irrigations through the upper nostril, making the irrigation come out through the other nostril. To irrigate the other side, change the position of the head to always wash from the upper side (video). This helps to clean the nasal cavity and improve his symptoms of rhinorrhea and nasal congestion.


Patricia is a 45-year-old female with chronic rhinosinusitis with nasal polyps, asthma, and intolerance to non-steroidal anti-inflammatory drugs (N-ERD: NSAID-exacerbated respiratory disease). She was diagnosed many years ago and has had two operations. She performs regular treatment with saline nasal irrigations 3-4 times a day and topical corticosteroids twice a day. She tells us that due to work reasons and lack of time, she stopped doing irrigations so regularly and she notices a significant worsening in her symptoms. She performs the irrigations with a nasal spray with isotonic serum, two sprays on each side each time.


Frequently Asked Questions

Is it safe to use tap water?

Tap water isn’t safe in many countries for use as nasal irrigation because it’s not adequately filtered or treated. Tap water may contain microorganisms that could cause potentially serious infections. The best option is to use sterile saline, or when using tap water, it must be boiled and then cooled or passed through a filter.


How often do I need to clean or replace my saline irrigation bottle?

The irrigation bottle should be disinfected and cleaned to avoid infections. It is recommended to rinse the irrigation device with hot water and antibacterial soap and leave the device open to dry completely after each use. Besides, this device has to be periodically replaced. It is usually recommended to change it every three months according to the manufacturers' indications


I found an article about the risk of infections with sinus rinse bottles – should I be worried?

There are some extremely rare, reported cases of severe infection after the use of nasal irrigations. However, these cases were associated with the use of non-sterile or non-boiled water, typically using well water, which is known to have a higher risk of amoebic contamination. Therefore, it is advisable to avoid the use of tap water and to carry out a correct and daily cleaning of the irrigation device.


Do I have to buy the salt sachets or can I make my own?

You can use salt sachets or you can buy a saline solution. If you prefer to do it yourself, it is recommended to use 2 teaspoons of both non-iodized salt and baking soda (sodium bicarbonate) for each litre of water. Remember that if the water used is not sterile it must be filtered or boiled to avoid infection. As a general guide, you should add ½ teaspoon of each for every cup (240ml, or one typical rinse bottle full of saline) of water. Some people prefer to mix an equal volume of salt and baking soda in an airtight container and add a teaspoon of the ready-made mixture to the rinse bottle.

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