This letter concerns recommendations for adjunctive sinusitis care in the recent supplement, “Managing acute maxillary sinusitis in the family practice” (J Fam Pract 2003; 10:S4–S11). While Dr Brunton reviews the evidence for nonsteroidal anti-inflammatory drugs (NSAIDs), topical anti-inflammatories, antihistamines, and decongestants, he omits an important adjunctive therapy.
Hypertonic saline nasal irrigation (HSNI) was formally identified as adjunctive care for sinusitis in 1990.1 HSNI is an inexpensive, patient-controlled therapy that flushes the nasal cavity with saline solution, facilitating a wash of the structures within. Benefits from HSNI may accrue from removal of nasal discharge and crusts, mucus thinning,1 and enhanced mucocilliary clearance of nasal secretions.2 HSNI may also decrease mucosal inflammation osmotically.
To date, 8 randomized controlled trials have assessed HSNI for several different sinus-related conditions, including 3 for acute sinusitis, 2 for chronic sinus symptoms, and 3 for chronic sinusitis. All have reported significant positive outcomes on a variety of outcome measures. None report significant side effects or adverse events.
Our group recently reviewed these studies and conducted a 6-month randomized controlled trial of HSNI in subjects with histories of frequent acute or chronic sinusitis. Compared to control subjects using standard of care therapy, subjects using HSNI plus standard of care reported improved quality of life (P<.05), improved nasal symptoms (P<.01), reduced use of nasal sprays (P<.06), and reduced use of antibiotics (P<.05). Adherence to daily HSNI was high; side effects were insignificant and infrequent.3 A 12-month follow-up study found continued quality of life improvement, and consistent, frequent long-term use of HSNI in a standard clinical setting.4
Instructing patients in the office is easy and brief. We present the rationale for HSNI as part of the treatment plan; if the patient is interested, we explain the technique with an illustrated patient handout, which is available online at www.fammed.wisc.edu/research/sinusitis/sinusitis.html. We recommend using nasal irrigation once daily at the onset of sinus symptoms until resolution. Nasal irrigation pots are increasingly available at local pharmacies nationwide.
While questions about exact salinity, pH, and scheduling of therapy require further study, HSNI deserves consideration as adjunctive therapy by clinicians treating acute sinusitis.
David Rabago, MD; Bruce Barrett, MD, PhD;
Aleksandra Zgierska, MD, PhD,
Department of Family Medicine,
University of Wisconsin, Madison