Nasal Irrigation


    I have been irrigating my nose since my first sinus surgery. I was instructed to do so post-surgical to remove the blood and other gunk produced by the surgery. Having found irrigation to be helpful in removing nasal gunk, and having a problem with an excess of such gunk most of the time, I have made it a habit to irrigate once or twice every day

    The solution I use follows the recipe given me by my surgeon:

    If I am going to irrigate with my Water-Pik (and special attachment), I use all two cups of the solution, once it has cooled down.  If I am going to use a rubber bulb syringe, I pour half a cup of the solution into a tea cup for use soon (after it cools) and store the rest for use later (at which time I warm it up in the microwave).

    The rubber bulb syringe I use was sold for the purpose of irrigating the ear, but works just fine for the nose. The instructions given by my surgeon are to lean over the sink and shoot the fluid up one and then the other nostril with enough force to loosen the crud, aiming towards the back of the head and the top of the back of the head. I have found a different procedure more helpful for removing the gunk from my nose. I lean my head back and then squeeze as much solution into one nostril as I can. I keep my head back for a while, allowing the solution to dissolve the crud, and then I lean forward and expel the cruddy solution.

 

Ear syringe used to irrigate the nose.

Water pick tip cut off to reduce the pressure.  It you use the tip that is designed for teeth without modifying it the pressure will be too great.  The modified tip worked OK, but lacked a way to keep the fluid from draining down out of the same nostril

Here is the tip sold by WaterPik for nasal irrigation.  It not only reduces the pressure but also seals the nose.  In this way the fluid is forced up one nostril and then comes out the other nostril.

Find one of these on the Internet.

 

    The recipe I gave above produces a buffered isotonic saline solution -- one with salinity approximately equal to that of body fluids (0.9%). Picking salt or sea salt is specified to avoid the other ingredients that are added to table salt. For details on the composition of sea water, see Relative Composition of Major Components of Seawater. In addition to sodium and chloride, sea water contains a fair amount of magnesium, calcium, potassium, and sulfate ions.

    I buy my sea salt at a local grocery store. I use only refined sea salt (white, like table salt). One can find unrefined sea salt, but I recommend against it -- it may contain things like clay particles and who knows what else, things I don't want to be putting up my nose.  Unrefined sea salt might, however, also contain some minerals that you would want to include in your nasal rinse.

    There is some recent evidence that irrigation with a simple isotonic saline solution (NaCl 0.9%) can slow mucociliary clearance [Boek W. M., Keles N., Graamans K., & Huizing E. H. (1999). Physiologic and hypertonic saline solutions impair ciliary activity in vitro. Laryngoscope 109, 396-399]. The cilia, tiny hair-like structures, normally beat gunk out of the sinuses. Isotonic saline can reduce this action, and hypertonic saline (saltier than isotonic -- for example, sea water, which is usually about 3.5%) is reputed to be able to produce permanent damage to the cilia, but a Ringer's solution does not have this potentially undesirable effect.

So, what is Ringer's solution? Ringer strived to find an isotonic solution that would keep the heart beating outside of the body. He used chlorides of sodium, magnesium, calcium, and potassium. The basic recipe for the solution is:

    Ringer's solution can be bought, but it can be expensive. One should be able to prepare, at home, a simple Ringer's solution, by adding to the recipe I gave above (for two cups of buffered isotonic saline) a pinch (1/30th of a teaspoon) of potassium chloride and of calcium chloride - see Irrigation.

    It is not difficult for patients to mix, at home, a solution that closely approximates a Ringer's solution,  One may get some of the other salts (KCl and CaCl2 ) found in Ringer's by using sea salt, but probably not in the same proportions as in Ringer's.  I have not been able to find very good information on the composition of sea salt, but it does appear that many of the salts in sea water are precipitated out in the process of preparing the sea salt that you can buy at the grocer.  See "Making sea salt" In the document The Chemical Composition of Seawater.  I also suspect that the mineral composition of sea salt differs across different brands, depending on the specifics of the process used to refine the product.

    A helpful correspondent pointed me to the page at Oasis Nasal Spray. This product, manufactured from salts from the Dead Sea, has proportionately more calcium, magnesium, bromine, and potassium, but less sodium, sulfate, and carbonate than does ocean water. The manufacturer cites several sources in reaching the conclusion that the higher concentration of magnesium ions makes their product superior to regular sea salt for nasal irrigation. It is suggested that dead sea salt solutions are less likely to cause damage to cilia and that it has an anti-inflammatory effect. I am not qualified to evaluate these claims, so please take them with a grain of salt. 


References on Nasal Irrigation

These references were kindly provided by Dr. David Rabago (see the link below).

  1. Ray NF, Baraniuk JN, Thamer M, et al.: Healthcare expenditures for sinusitis in 1996: contributions of asthma, rhinitis and other airway disorders. J Allergy Clin Immunol 1999; 103:408-14.
  2. McCaig LF, Hughes JM; Trends in antimicrobial drug prescribing among office-based physicians in the United States JAMA 1995; 273:214-9.
  3. CDC, Vital and Health Statistics, Current Estimates from the National Health Interview Survey, 1994 (U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics): DHHS Pub. No. PHS 96-1521, December 1995.
  4. Glicklich RE, Metson R; The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg 1995; 113: 104-9.
  5. Kaliner MA, Osuguthorpe JD, Fireman P, et al. Sinusitis bench to bedside: current findings, future directions. J Allergy Clin Immunol 1997; 99:S829-47.
  6. Druce HM, Adjuncts to medical management of sinusitis; Otolaryngol Head Neck Surg 1990; 103:880-3.
  7. Zieger RS. Prospects for ancillary treatment of sinusitis in the 1990's. J Allergy Clin Immunol 1992; 90:478-93.
  8. Talbot AR, Herr TM, Parsons DS. Mucocilliary clearance and buffered hypertonic saline solution. Laryngoscope 1997; 107:500-3.
  9. Robinson M, Hemming AL, Regnis JA et al. Effect of increasing doses of hypertonic saline on muccociliary clearance in patients with cystic fibrosis. Thorax 1997; 52:900-3.
  10. Homer JJ, Dowley AC, Condon L, El-Jassar P, Sood S. The effect of hypertonicity on nasal mucociliary clearance. Clin. Otolaryngol 2000; 25:558-60.
  11. Homer JJ, England RJ, Wilde AD, Harwood GRJ, Stafford ND. The effect of pH of douching solution on mucociliary clearance. Clin Otolaryngol 1999; 24:312-5.
  12. Heatley DG, McConnell KE, Kille TL, Leverson GE Nasal irrigation for the alleviation of sinonasal symptoms. Otolaryngol Head Neck Surg 200l; 125:44-8.
  13. Tamooka LT, Murphy C, Davidson TM. Clinical study and literature review of nasal irrigation. Laryngoscope 2000; 110:1189-93.
  14. Taccariello M, Parikh A, Darby Y, Scadding G. Nasal douching as a valuable adjunct in the management of chronic rhinosinusitis. Rhinology 1999. 37:29-32.
  15. Bachmann G, Hommel G, Michel O. Effect of irrigation of the nose with isotonic salt solution on patients with chronic paranasal sinus disease. Eur Arch Otorhinolaryngol 2000; 257:537-41.
  16. Shoseyov D, Bibi H, Shai P, Shoseyov N, Shazberg G, Hurvitz H. Treatment with hypertonic saline versus normal saline wash of pediatric chronic sinusitis. J Allergy Clin Immunol 1998; 101:602-5.
  17. Rabone SJ, Saraswati SB. Acceptance and effects of nasal lavage in volunteer woodworkers. Occup Med 1999; 49:365-9.
  18. Holmstrom M, Rosen G, Walander L. Effect of nasal lavage on nasal symptoms and physiology in wood industry workers. Rhinology 1997; 35:108-12.
  19. Sincleanse, Med Systems, Inc. 2002. http://www.sinucleanse.com/sinu2.html.
  20. .
  21. Ware JE, Kosinski M, Keller SD. A 12-item short-form health survey: construction of scales and preliminary test of reliability and validity. Med Care 1996;34:220-6.
  22. Benninger MS, Senior BA; The Development of the rhinosinusitis disability index. Arch Otolyryngol Head Neck Surg 1997; 123:1175-9.
  23. Guyatt GH, Bombardier C, Tugwell P. Measuring disease-specific quality of life in clinical trials. CMAJ 1986;134:889-95.
  24. Senior BA, Glaze C, Benninger MS. Use of the Rhinosinusitis Disability Score (RSDI) in rhinologic disease. American Journal of Rhinology 2001;15:15-20.
  25. Deyo RA,.Patrick DL. The significance of treatment effects: The clinical perspective. Medical Care 1995;33:AS286-AS291.
  26. Redelmeier DA, Guyatt GH, Goldstein RS. Assessing the minimal important difference in symptoms: A comparison of two techniques. J Clin Epidemiol 1996;49:1215-9.
  27. Samsa G. How should the minimum important difference for a health-related quality-of-life instrument be estimated? Medical Care 2001;39:1037-8.
  28. Jaeschke R, Singer J, Guyatt GH. Measurement of health status: Ascertaining the minimal clinically important difference. Controlled Clinical Trials 1989;10:407-15.
  29. Bellamy N, Carr A, Dougados M, Shea B, Wells G. Towards a definition of "difference" in osteoarthritis. J Rheumatology 2001;28:427-30.
  30. Powell CV,.Kelly A-M. Determining the minimum clinically significant difference in visual analog pain score for children. Annals of Emergency Medicine 2001;37:28-31.
  31. Todd KH,.Funk JP. The minimum clinically important difference in physician-assigned visual analog pain scores. Academic Emergency Medicine 1996;3:142-6.
  32. Wells GA, Tugwell P, Kraag GR, Baker PR, Groh J, Redelmeier DA. Minimum important difference between patients with rheumatoid arthritis: the patient's perspective. Journal of Rheumatology 1993;20:557-60.
  33. Wendeler HM, Muller J, Dieler R, Helms J. Nasenspuling mit isotoner Emser-Salz-Losung bei chronischer rhinosinusitis. Otorhinolaryngol Nova 1997; 7:254-8.

Links to Abstracts of Articles on Nasal Solutions and Mucociliary Function

Boek (1999) -- Physiologic and hypertonic saline solutions impair ciliary activity in vitro: Boek WM, Keles N, Graamans K, Huizing EH, Laryngoscope 109, 396-399.

Ünal et al. (2001) -- Ringer-Lactate solution versus isotonic saline solution on mucociliary function after nasal septal surgery: Murat Ünal, Kemal Görür, Cengiz Özcan. Journal of Laryngology & Otology, 115, 796-797.

Xylitol -- Will putting sugar alcohols up your nose help?  I have not tried this.

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This page most recently revised on 23-March-2106.