Not sure I want to rinse my nose everyday for sinus problems, but here goes. I advise rinsing the nose for chronic sinusitis every day, but patients initially turn their nose up at this suggestion (pun intended). I find myself intrigued at the interest in nasal irrigation, flushing, or whatever else you want to call it. So who did I turn to but #Reddit Allergy. So what to my wondering eyes did appear, but questions abound for the right sinus rinse! Google search for sinus rinse yields > 7,000,000 hits and searching PubMed 750–you think there might be a problem there? Misinformation abounds and of course every advertiser/company has the best product! Who do you believe? I’m about to give you some guidelines that you can rest assured have at least been studied in one published article. And by the way, to answer your question below, if the water doesn’t come out the other side, you’ve got nasal congestion that needs further evaluation by your allergist or ENT. My comments are highlighted in RED in the lists after each article. There is no test at the end, but maybe next time….

• Budesonide is a steroid that can always be added to ANY device you use to flush the nose
• When you hear “double-blind, placebo-controlled, randomized clinical trial” you’re on the right track to some real (and reliable) research. In this study participants didn’t know if they were getting budesonide or placebo; now remember, in any study the placebo effect can be as high as 30-40% and this is why you can’t make recommendations only based on your treatment “experience”.
• SNOT-22 score–really? Let me know if you want more information on this one. No takers yet!
• The results? Budesonide was better than saline for the sinuses, but it’s difficult to measure clinically meaningful benefits to sinus treatment. And who’s going to admit to a better SNOT score?
• The good news: no side effects noted with the irrigation; so it may look bad, but won’t hurt you!

Here’s the abstract from the above study–>

IMPORTANCE: Recent studies suggest that budesonide added to saline nasal lavage can be an effective treatment for patients with chronic rhinosinusitis (CRS). PARTICIPANTS: This double-blind, placebo-controlled, randomized clinical trial was conducted at a quaternary care academic medical center between January 1, 2016, and February 16, 2017. A total of 80 adult patients with CRS were enrolled; 74 completed baseline assessments; and 61 remained in the trial to complete all analyses. Data analysis was conducted from March 2017 to August 2017. INTERVENTIONS: All study participants were provided with a sinus rinse kit including saline and identical-appearing capsules that contained either budesonide (treatment group) or lactose (control group). MAIN OUTCOMES AND MEASURES: The primary outcome measure was the change in Sino-Nasal Outcome Test (SNOT-22) scores, pretreatment to posttreatment, in the budesonide group compared with the control group. Secondary outcome measures included patient-reported response to treatment, as measured with a modification of the Clinical Global Impressions scale, and endoscopic examination scored by the Lund-Kennedy grading system. RESULTS: Of the 74 participants who completed baseline assessments (37 in each study arm), mean (SD) age, 51 (14.7) years, 50 (68%) were women. Of the 61 who remained in the trial to complete all analyses, 29 were randomized to budesonide treatment, and 32 to saline alone. The average change in SNOT-22 scores was 20.7 points for those in the budesonide group and 13.6 points for those in the control group, for a mean difference of 7 points in favor of the budesonide group (95% CI, -2 to 16). A total of 23 participants (79%) in the budesonide group experienced a clinically meaningful reduction in their SNOT-22 scores compared with 19 (59%) in the control group, for a difference of 20% (95% CI, -2.5% to 42.5%). The average change in endoscopic scores was 3.4 points for the budesonide group and 2.7 points for the control group. There were no related adverse events. CONCLUSIONS AND RELEVANCE: This study shows that budesonide in saline nasal lavage results in clinically meaningful benefits beyond the benefits of saline alone for patients with CRS. Given the imprecision in the treatment effect, further research is warranted to define the true effect of budesonide in saline nasal lavage.

• Inflammation is once again the key to sinus problems even in the adult population.
• 1-2% of total physician visits, not just allergists or ENTs. Very impressive.
• Evidence-based approach to assist in optimizing patient care is the “Holy Grail” of being a doctor. If only we had this for COVID-19. Truth of the matter is, it takes years to analyze and accumulate enough data to make statements about evidence-based medicine, so for some issues, you’ll just have to wait.
• I won’t bore you with the details, but these results come from HUUGE databases such as MEDLINE and Cochrane. It’s nice to be able to “mine the database” and combine multiple studies in the analysis of your final conclusion.
• Compared with no treatment, saline irrigation was good, “add-in” topical steroids were better; leukotriene antagonists (Singulair) and oral antibiotics also showed improvement in not just sinusitis, but also resolution of nasal polyps.
• And now let me introduce DUPIXENT! Approved for use in treatment of nasal polyps even without steroids. That is the problem with research–shelf life isn’t the greatest.

I’ve included the abstract below for easier reading–>

IMPORTANCE: Chronic sinusitis is a common inflammatory condition defined by persistent symptomatic inflammation of the Sino nasal cavities lasting longer than 3 months. It accounts for 1% to 2% of total physician encounters and is associated with large health care expenditures. OBJECTIVE: To summarize the highest-quality evidence on medical therapies for adult chronic sinusitis and provide an evidence-based approach to assist in optimizing patient care. EVIDENCE REVIEW: A systematic review searched Ovid MEDLINE (1947-January 30, 2015), EMBASE, and Cochrane Databases. FINDINGS: Twenty-nine studies met inclusion criteria: 12 meta-analyses (>60 RCTs), 13 systematic reviews, and 4 RCTs that were not included in any of the meta-analyses. Saline irrigation improved symptom scores compared with no treatment (standardized mean difference [SMD], 1.42 [95% CI, 1.01 to 1.84]; a positive SMD indicates improvement). Topical corticosteroid therapy improved overall symptom scores (SMD, -0.46 [95% CI, -0.65 to -0.27]; a negative SMD indicates improvement), improved polyp scores (SMD, -0.73 [95% CI, -1.0 to -0.46]; a negative SMD indicates improvement), and reduced polyp recurrence after surgery (relative risk, 0.59 [95% CI, 0.45 to 0.79]). Systemic corticosteroids and oral doxycycline (both for 3 weeks) reduced polyp size compared with placebo for 3 months after treatment (P < .001). Leukotriene antagonists improved nasal symptoms compared with placebo in patients with nasal polyps (P < .01). Macrolide antibiotic for 3 months was associated with improved QOL at a single time point (24 weeks after therapy) compared with placebo for patients without polyps (SMD, -0.43 [95% CI, -0.82 to -0.05]). CONCLUSIONS AND RELEVANCE: Evidence supports daily high-volume saline irrigation with topical corticosteroid therapy as a first-line therapy for chronic sinusitis. A short course of systemic corticosteroids (1-3 weeks), short course of doxycycline (3 weeks), or a leukotriene antagonist may be considered in patients with nasal polyps. A prolonged course (3 months) of macrolide antibiotic may be considered for patients without polyps.

• Fungus among us–we don’t think very often about fungal sinus infections, but in this study, symptoms improved with antifungal treatment. Fortunately, this is topical amphotericin B as the IV route was called “amphoterrible” for good reason.
• IgE is an antibody used for diagnosis and treatment of allergic rhinitis (one of the biological measurement of IgE is skin testing), but can also be used to measure inflammation due to infection.
• In this study, almost 25% of ALL participants had recurrence of chronic sinusitis, but it was improved in the amphotericin B rinse group. IgE went down as well. It’s nice to know that something works for sinus problems, but now that we have DUPIXENT, the results are probably even more of a game changer!

OBJECTIVE: To determine the effect of topical antifungal irrigation fluid containing amphotericin B on nasal polyp and their recurrence pattern, and to study the association of serum IgE in predicting the presence of fungus along with the nasal polyps. METHODOLOGY: All adult patients having nasal polyps, who had not undergone any previous nasal surgery, were included in the study. Patients aged under 18 years, history of granulomatous diseases, immunosuppression, invasive fungal sinusitis, and pregnant ladies were excluded from the study. The ratio was kept as 1:2; one receiving irrigation with amphotericin B and the other only saline nasal irrigation without the medicine. Serum IgE level of more than 250 ng/ml was taken as a high value. RESULTS: A total of 87 patients were inducted. Overall 22 (25.3%) patients had recurrence of symptoms at six-month followup visit. Twelve (13.7%) of these were in the placebo group and 10 (11.5%) were in the amphotericin B nasal irrigation group. Serum IgE level preoperatively ranged between 52 – 9344 ng/dl; postoperatively it ranged from 13-1050 ng/dl. CONCLUSION: Amphotericin B improved the CT scan score of the patients. The nasal irrigation of amphotericin B did not show significant change in the recurrence pattern of chronic sinuses with polyps. Serum IgE can be used as marker for the presence and response to treatment for non-invasive fungal sinusitis.

• Bacteria have evolved sneaky ways to protect themselves from death by antibiotics. Thus, bacterial infections in the form of adherent biofilms are frequently implicated in the pathogenesis and recalcitrance of chronic rhinosinusitis. You dirty rat! That’s for you Jimmie Cagney from “Taxi” (actually a misquote, but that’s for another time!)
• Lots of methods to suck out your boogers from battery powered to suction from your own mouth into a separate “trap”. Oh parents will do anything to suck out moist mucous!
• Who would be recruited for this study? Yuck
• We are left with that SNOT score again to measure any benefit from our treatment with the Snot Sucker.
• Battery powered nasal irrigation (snot suckers) came up with 2.5 million hits on Google–it’s popular.

I copied parts of the above abstract for details–>

The Hydrodebrider, a disposable powered irrigation and suction device, has been developed specifically to remove biofilm from the paranasal sinuses. We conducted a prospective study to evaluate the tolerability and efficacy of the Hydrodebrider in the office setting with the use of local anesthesia. Of the original 13 adults we recruited, 10 completed the entire study protocol. All enrolled patients had previously undergone sinus surgery that involved the creation of a maxillary antrostomy large enough to allow placement of a Hydrodebrider device, and the endoscopic findings in all patients were consistent with chronic sinusitis. In conclusion, powered irrigation with suction is a well-tolerated procedure in the office setting and might be a useful short-term adjunct in the management of recalcitrant chronic sinusitis.

Surely, there has to be some conclusions from all this?

• Don’t get overwhelmed with all of the choices for cleaning out your nose.
• Using nasal irrigation can include antibiotics, topical steroids, anti-fungal medication, baby shampoo just to name a few. Every doctor who deals with this has their own cocktail.
• Although clinical research shows that nasal irrigation has a place in the treatment of chronic sinusitis & nasal polyps, you may just want to see your allergist for more aggressive measures such as allergy immunotherapy (AIT), Dupixent, Fasenra, Xolair or many of the other biologics available to treat nasal polyps and chronic sinusitis without using all of those steroids.

#chronic-sinusitis, #nasal-flush, #neil-med-irrigation, #netti-pot, #sinus-irrigation