Nasal shower after all rather harmful?

Question

Hello,
as I have again and again problems with the sinuses it would interest me, if nasal shower in CF is going on to be recommended? My general practitioner said to me that more actual studies have shown a rather negative effect, as via a nasal shower supposedly germs are flushed increasingly into the sinuses. How is the actual recommendation, now?
A furhter question: does isotonic sea salt nasal spray dry out indeed the mucosa? My general practitioner dehorted my also of that.
Many thanks for you answers.

Answer

Hello,

At the annual congress of the "American College of Allergy, Asthma & Immunology (ACAAI)" 2009, T.M. Nsouli from San Diego presented data from 69 patients, who performed nasal douches with saline solution daily due to chronic inflammation of the nose and the paranasal sinuses (rhinosinusitis). A subgroup of patients continued to perform the nasal douches 2 times a day for another 12 months, but did not apply these procedures in the following 12 months. 24 additional patients rinsed their upper airways once a day by nasal douche.
Interestingly, the frequency of rhinosinusitis decreased from altogether 544 during the period of 2 nasal douches a day to 204 at the time without nasal douche (equivalent to a decrease of 62.5%). In the control group with nasal douches once daily, about twice as many cases of rhinosinusitis occurred.
This result gives reason to overthink the usage of the nasal douches. However, for technical reasons data should be interpreted very carefully, as they are not based on a placebo-controlled study. Additionally, these data have not been published yet and did not run through the standard Peer-Review-process. The scientific quality of this study data is therefore unclear and until now we can not foresee whether this study has direct consequences for us.
The highest level on objectivity is provided by the so-called Cochrane Reviews. Following strict quality criteria, the authors search for publications and contributions to certain topics and derive a common conclusion.
In 2007 a Cochrance Review on the topic nasal douche has been published by R. Harvey et al. (Nasal saline irrigations for the symptoms of chronic rhinosinusitis, Cochrane Collaboration. JohnWiley & Sons, Ltd). The authors identified 64 clinical studies on this topic; out of these, only 8 fulfilled the qualitative inclusion criteria. They stated that saline-lavages in chronic rhinosinusitis have a positive effect, both as a stand-alone therapy as well as in combination with additional therapies like application of topic nasal steroids. The authors conclude that the benefit of a nasal lavage outweighs the risk for most of the patients and that the nasal lavage makes sense as a supporting therapy in case of chronic rhinosinusitis.

Additionally I can report about many patients from my clinical daily work, who state that nasal douches reduced their rhinosinusitis symptoms significantly.

Several aspects deserve additional attention:
Healthy upper airways and sinuses as well as the lower airways, are lined with a carpet of cilia, which permanently does a highly efficient self-rinsing procedure. Cilia move in a water-solution and reach into a sticky mucus layer, in which germs and other substances are caught and eliminated
A nasal douche in order to get rid of secretion and crusts does not appear necessary and helpful to me in case of a well functioning self-clearance, since the mucus layer is washed-out as the first immunological defence line. Risks could prevail.
Which special risks of the nasal douche exist in CF? From a "nasal can" warm watery salt solution is flushed into the nose (and partly into the sinuses). Pseudomonas aerugionsa, the opportunistic germ with highest impact on the on-going destruction of the CF-airways, multiplies especially in standing water and humid environment. In case the "nasal cans" turn out to be a germ reservoir themselves due to insufficient hygiene, the therapy by itself could become a special risk. We know about this problem from the inhalation therapy, so there are special hygiene recommendations for nebulizer care in CF. Otherwise germs could be transported in exactly the segment, we want to care for and treat by therapy itself. Therefore, inhalators have to be prepared for the next usage by cooking, sterilizing and consequent drying. The same precautions should be applied for nasal douches.
In conclusion, the former mentioned investigation which up-to now is not published as an article, does not speak against the usage of the nasal douche.
However, a consequent hygiene of the nasal can and sterility of the used solutions is absolutely necessary. Whether prophylactic nasal douches in CF make sense in order to avoid problems of rhinosinusitis cannot be answered concludingly at the moment.

Regarding your second question:
Does isotonic sea-salt nasal spray dry out the mucosa?
Decongestant nasal sprays and drops with drugs like Xylometazolin, Oxametazolin etc. (alpha-sympathomimetics), have their effect via the constriction of vessels of the nasal mucosa. In case the blood stream of the nasal mucosa is reduced for more than 5-7 days, this therapy impairs mucosal regeneration which therefore is called rhinitis medicamentosa.
On the contrary, saline-solutions and topic steriods help to regenerate the mucosa so they are considered as a long-term therapy without drying-out mucosa.

Jochen Mainz

23.04.2010