Sinus Cleansing Could Cut Drug Overuse for Sinusitis, URIs

People who suffer from allergic rhinitis, sinusitis, and recurrent upper respiratory infections can benefit greatly from routine sinus cleansing, said Linda Dahl, MD, an Ear, Nose & Throat specialist based in New York City.

“I have been recommending this practice to my patients for years, and it really should be mandatory for anyone who is being referred for sinus surgery,” Dr. Dahl said. For many of her patients, daily sinus flushing has obviated the need for antibiotics, antihistamines, and other medications.

Practitioners of Ayurvedic medicine and yoga have advocated this simple self-care technique for centuries as a cornerstone of personal hygiene. Known as Jala Neti in India, it has been gradually catching on in the US, in part due to the popularity of yoga. It involves flushing the sinuses with warm, slightly salinated water, typically via a small hand-held teapot shaped vessel or “neti pot.”

By breaking up trapped mucus and flushing bacterial and fungal pathogens out of the deep recesses of the sinuses, irrigation helps to break the cycle of chronic inflammation that drives chronic sinus problems.

Nothing to Sneeze At

Dr. Dahl said that while many of her ENT colleagues have begun to recognize the benefits of sinus cleansing, the full benefit of this practice has yet to be realized, especially in terms of its ability to reduce the need for pharmaceutical and surgical interventions for recurrent sinus problems.

Approximately 90 million Americans suffer from sinusitis, rhinitis, chronic bronchitis, and asthma, all of which may be greatly improved with routine sinus washing. While these disorders are seldom life threatening, they can be highly burdensome to patients, and on a population basis they carry a significant cost.

According to the American Academy of Allergy, Asthma & Immunology (www.aaaai.org), allergic rhinitis affects roughly 60 million Americans. Roughly 8% of all adults and 9% of all children have the disorder, which results in 12 million visits to doctors’ offices each year. In 2005, this one condition caused $11.2 billion in direct medical costs, over half of which was for prescription drugs.

AAAAI believes sinusitis affects about 12% of the US population under age 45, with 55% of these people also suffering from allergic rhinitis. It accounts for roughly 30 million courses of antibiotics and 40,000 sinus surgeries per year.

Recurrent sinus problems are a major source of the antibiotic overuse that is driving many pathogens to develop resistance, rendering these drugs less effective. According to data from the Centers for Disease Control (CDC), antibiotics are prescribed in 68% of all physician office visits for acute respiratory tract problems. Of these, 80% are deemed unnecessary according to CDC guidelines.

The result? $1.1 billion is spent annually on unnecessary antibiotic prescriptions.

 Part of the Hygiene Routine

Only a small percentage of the population that could potentially benefit from sinus cleansing is currently practicing it. For many people, the prospect of a surge of water up the nose sounds quite unpleasant. Some shy away from trying it because they fear choking on the cleansing solution.

In reality, there’s very little danger of “drowning.” Done properly the procedure can be quite comfortable. “Many of the people that come to see me are so miserable that they’re willing to try almost anything,” said Dr. Dahl. “And once they try this, it rapidly becomes part of their daily routines, just like brushing their teeth.”

For someone who’s been congested and had difficulty breathing for years, sinus cleansing can often have immediate positive effects.

It is four times easier to absorb oxygen from air that has been moisturized and warmed by passing through the sinuses than from air drawn directly into the lungs via the pharynx. In other words, people who are chronic mouth-breathers due to constant sinus congestion have significantly compromised respiration. In many cases, this clears up fairly quickly with daily sinus cleansing.

Updating the Neti Pot

The WaterPik company, famous for its “water flossing” dental hygiene systems, is hoping to improve the acceptability of sinus cleansing with the recent launch of its SinuSense line. It includes “updates” on the classic neti pot design, which the company hopes will make the practice more comfortable.

“One of the main issues is control of the water flow,” said Michael Wakefield, product manager for SinuSense (www.waterpiksinusense.com). He noted that all the models in the line have a means of controlling the water flow rate. The neti pot and neti bottle designs, both of which are gravity-fed, include a one-touch flow control valve so the user can regulate the flow of fluid into the sinuses; the battery powered “Pulsator” has a flow control trigger, giving patients complete control over the water stream.

All devices are fitted with a soft plastic nozzle rather than the hard plastic, ceramic or metal fittings found on many other sinus irrigation devices.

Mr. Wakefield, who personally practices sinus cleansing daily after learning about it following his second sinus surgery, said WaterPik’s powered Pulsator was developed in part because the company found out some people were adapting their WaterPik dental devices for nasal use.

Salt water is by far the most widely used fluid for sinus irrigation. But some practitioners find it to be irritating. At high concentrations the salt can paralyze and disable the cilia on the mucosal lining of the sinuses. Some advocate for the use of xylitol instead. A naturally occurring 5-carbon sugar alcohol, xylitol has no effect on the cilia, but it does prevent the adherence of many bacterial pathogens (Read To Ameliorate Seasonal Allergies, Choose Xylitol Washes Over Saline from our Spring 2007 edition).

WaterPik’s Mr. Wakefield contends that the problem is not so much with saline itself as with the concentrations that people mix. Isotonic solutions are not irritating and have no ill effect on the mucosal lining. But many people “guess-timate” their own proportions, and end up making hypertonic solutions that can be irritating. SinuSense products come with a supply of pre-measured “Soothing Saline” powder sticks that patients mix with water. In addition to the salts, the pre-mixed powder contains aloe extract and eucalyptus.

The temperature of the water can make a big difference in the patient’s experience of sinus cleansing. Room temperature or slightly warm water is best.  Definitely do not use cold water. It is also a good idea to use distilled rather than tap water; the pH, chlorine content, and contaminant loads in municipal water supplies can vary very widely.

Generally, it’s a good idea to avoid sinus cleansing within an hour of bedtime, as delayed or secondary discharge of water from the sinuses can be unpleasant and messy.