Review

Efficacy of Nasal Saline Sprays to Relieve

Symptoms of Chronic Sinusitis
Darwin F. Yeung, BA, MD Candidate 2012, Faculty of Medicine, University of Toronto

Abstract
Background: Chronic sinusitis is a common condition that significantly reduces quality of life. Nasal
saline irrigation is a simple and effective way to reduce symptoms. However, few studies have investigated the efficacy of low-volume nasal saline sprays
in symptom relief.
Objective: To determine whether nasal saline sprays
are effective in reducing symptoms of chronic sinusitis.
Methodology: An Ovid MEDLINE search (1948 to
2010) was conducted using the MeSH headings
listed and limited to randomized controlled trials
in English. Studies were excluded if symptoms were
considered to be acute, if symptom relief was not
the primary outcome measure, or if sprays were not
the primary treatment being investigated.
Results: Of the 42 articles retrieved, 8 met inclusion
criteria. The majority of studies showed symptom
improvement with the use of a nasal saline spray.
Two studies showed greater symptom relief with
hypertonic rather than isotonic saline sprays. In a
third study, tonicity had little impact on nasal obstruction, but resulted in differences in mucociliary
clearance, airway patency, and nasal irritation. Intranasal saline of any tonicity remained inferior to
intranasal corticosteroids. Both saline and antibiotic
sprays improved symptoms and quality of life but saline was superior in reducing congestion while antibiotics were superior in reducing pain. Despite the
efficacy of the spray, saline irrigation offered greater
symptom relief.
Conclusion: Nasal saline sprays effectively reduce
symptoms of chronic sinusitis. However, saline irrigation and intranasal steroids may still be preferred
therapeutic options. Future studies should clarify
the relative merit of hypertonic over isotonic saline.

hronic sinusitis affects about 5% of all Canadians and

up to 14% of Americans.1,2 In the United States, it was
responsible for about 24 million patient visits in 1992
and approximately $5.8 billion of health spending in 1996.3
In addition, it was the ninth most common reason for absenteeism and short-term disability among six large US employers in 1999.4 Beyond its economic impact, chronic sinusitis
imposes a large burden on quality of life. Chronic sufferers
seeking otolaryngologic care report scores of physical pain
and functioning that are comparable to other chronic diseases like congestive heart failure, chronic obstructive pulmonary disease, angina, and back pain.5 Self-reported scores of
wellbeing among patients with chronic sinusitis fall into a category shared by those suffering from thyroid disease, asthma,
migraines, hypertension, arthritis, epilepsy, cancer, or inflammatory bowel disease.6
Sinusitis is often precipitated by viral infections or allergens that cause inflammation of the sinus mucosa leading
to obstruction of the nasal passage. Consequently, patients
develop characteristic symptoms of nasal congestion, mucopurulent nasal discharge, and facial pain with or without
fever, maxillary toothache, and facial swelling.7 Other common symptoms include headache, halitosis, and hyposmia or
anosmia.7 The condition is considered acute if symptoms
last for four weeks or less, recurrent when 4 or more acute
episodes occur per year with symptoms lasting at least 10 days,
and chronic if symptoms persist beyond 12 weeks.7 Current
guidelines support the use of a longer 21-day course of antibiotics like amoxicillin-clavulanate or clindamycin to treat the
condition and encourage adjunctive therapy such as topical
nasal steroids, nasal irrigation with saline, or antihistamines if
allergy is a contributing factor.
Nasal saline irrigation in particular offers a simple yet effective means to achieve symptom relief. A recent Cochrane
review found moderate-quality evidence that saline irrigations reduce symptoms and serve well as a form of adjunctive
therapy.8 Few studies, however, have investigated the efficacy
of low-volume nasal saline sprays in symptom relief. Since
the benefit from saline irrigation may come more from the
mechanical clearance of mucous and bacteria than from the
potential anti-inflammatory effect of saline, the use of lowvolume, high-velocity saline sprays may not provide the same
degree of benefit. This review summarizes evidence with regards to the efficacy of nasal saline sprays in reducing symptoms of chronic sinusitis.

Corresponding Author:
Darwin F. Yeung
e-mail: darwin.yeung@utoronto.ca

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Review
Efficacy of Nasal Saline Sprays to Relieve Symptoms of Chronic Sinusitis

Methods
An Ovid MEDLINE search of studies published from 1948
to 2010 was conducted using the following MeSH headings:
(1) sinusitis; (2) sodium chloride; (3) rhinitis; and (4) saline
solution, hypertonic. The search was limited to randomized
controlled trials published in English, which yielded a total of
40 studies. The retrieved studies were further excluded for the
following reasons: (1) symptoms were deemed acute; (2) symptom relief was not the primary outcome; or (3) sprays were not
the primary method of saline infusion. Patients recruited in
the studies need not have fit into the strict definition of chronic sinusitis, but must have displayed its characteristic sinonasal
symptoms over a protracted period of time. Therefore, studies of patients deemed to have conditions like allergic rhinitis
were also included. Eight studies fulfilled the aforementioned
criteria and were selected for this review. Only data published
in peer-reviewed journals were analyzed and reviewed.

Results
Details of each study such as the type of patients recruited,
the interventions compared, and the outcomes observed are
listed in Table 1. The studies involved six different comparisons of interventions.

Hypertonic saline spray vs. no therapy. Hypertonic saline sprays are more effective than no local therapy in reducing nasal symptoms of rhinoconjunctivitis and lowering rates
of antihistamine use.9 Garavello et al. (2005) studied a sample
of 40 children less than 16 years old who suffered from symptoms of rhinoconjunctivitis due to grass pollen for at least
1 year.9 Patients used either a hypertonic saline spray (three
sprays per nostril three times a day for seven weeks) or no local therapy and were compared based on self-reported symptom score and amount of antihistamine use.9 A statistically
significant reduction in symptoms and antihistamine use occurred by Week 6 and Week 5 respectively.9
Hypertonic saline spray and antihistamine vs. antihistamine alone. Hypertonic saline sprays in addition to an antihistamine provide better symptom relief than an antihistamine alone.10 Rogkakou et al. (2005) studied a small sample of
14 patients with a mean age of 32 years who suffered from
persistent allergic rhinitis treated with cetirizine.10 The group
of patients who used hypertonic saline spray for four weeks
in addition to cetirizine showed significant improvement in
upper airway and global symptom scores than those on cetirizine alone.10

Table 1. Randomized controlled trials investigating the efficacy of nasal saline sprays in reducing symptoms of chronic sinusitis
Study

Population

Intervention/Comparison

Outcomes

Cordray 2005

N = 21
Age >18
Seasonal allergic rhinitis
>2 of 6 sinonasal symptoms

Hypertonic Dead Sea saline

spray (2 sprays TID) vs.
aqueous triamcinolone spray
(110 g OD) vs. nasal saline
spray (2 sprays TID) 7 days

Dead Sea saline and triamcinolone: statistically

significant improvement in quality of life score
Triamcinolone more effective than Dead Sea saline
No significant improvement in the placebo saline group

Desrosiers 2001

N = 20
Mean age 49 years
Rhinosinusitis for
>8-12 weeks
Failed 21-day trial of
antibiotics

Saline and tobramycin: significant improvement in

4 mL (20 mg/mL) tobramycin
quality of life, symptoms, and parameters of sinonasal
vs. 4 mL (1 mg/mL) quinine
(control) in 0.9% NaCl both TID endoscopy at Week 4 and 8
Pain symptoms reduced more with tobramycin than
4 weeks
saline at Week 2 but not at Weeks 4 or 8
Saline better at reducing obstruction at Weeks 2, 4, 8

Garavello 2005

Intranasal rinsing with hyper N = 40

tonic saline (3.0%) TID
Mean age 9.1 years
7 weeks via atomizer vs. no
Grass pollen rhinoconjunctivitis
local therapy (control)
for >1 year

Hauptman 2007

N = 80
Mean age 36 years
Rhinosinusitis
Sinonasal test score >20

1 mL hypertonic saline vs.

1 mL physiological saline via
metered-dose nasal spray
bottle 1 dose

Both groups: improved mucociliary clearance times,

nasal stuffiness, obstruction
Hypertonic saline: larger decrease in clearance times,
increased burning/irritation
Normal saline: significantly increased airway patency

Pinto 2006

N = 60
Recurrent/chronic sinusitis
Within 5 days of sinus surgery

Normal saline vs. buffered

hypertonic saline vs. no spray

Hypertonic saline caused significantly more nasal

discharge and pain than nasal saline
No significant differences in nasal obstruction,
headache, or trouble sleeping

Pynnonen 2007

Isotonic saline nasal irrigation

N = 127
vs. isotonic saline nasal spray
Mean age 46.6 years
both BID 8 weeks
>1 of 5 sinonasal symptoms
for >4 days/week over 2 weeks
or >15 days over 30 days

Rogkakou 2005

N = 14
Mean age 32 years
Persistent allergic rhinitis

Cetirizine vs. cetirizine with

hypertonic saline spray
4 weeks

Significant additional improvement in upper airway and

global symptom score with adjuvant saline spray

Shoseyov 1998

N = 34
Mean age 9 years
Chronic maxillary sinusitis

Normal saline vs. hypertonic

(3.5%) saline both 10 drops
TID 4 weeks

Hypertonic saline group: significant improvement in

cough, postnasal drip, and radiology scores

UTMJ Volume 88, Number 2, March 2011

Statistically significant improvement in rhinitis score in

treatment group by Week 6 and 7 of treatment
Statistically significant reduction in antihistamine use in
treatment group from Week 5 to 7

Both groups: significant improvement in symptom

severity/frequency, medication use at Weeks 2, 4, 8
Irrigation group: consistently better outcomes
Postnasal drainage was the most common adverse
event with no significant difference between the groups

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Efficacy of Nasal Saline Sprays to Relieve Symptoms of Chronic Sinusitis

Hypertonic saline spray vs. corticosteroid spray. Hypertonic saline sprays and corticosteroid sprays both reduce
symptoms over time, but corticosteroids provide a greater
degree of symptom relief than hypertonic saline.11 Among
21 patients at least 18 years old with seasonal allergic rhinitis, Cordray et al. (2005) showed that patients who used the
aqueous triamcinolone spray (110 g once a day) reported
a greater improvement in the Rhinoconjunctivitis Quality of
Life Questionnaire score than those who used the intranasal
hypertonic Dead Sea saline spray (two sprays into each nostril three times a day) after seven days of treatment.11 Both
groups, however, showed a statistically significant improvement in symptom score after treatment.11
Normal saline spray vs. antibiotic spray. Normal saline
sprays are more effective in relieving nasal congestion while
antibiotic sprays are more effective in relieving pain.12 Both
normal saline sprays and antibiotic sprays offer comparable
improvement in quality of life, overall symptoms, and endoscopic appearance.12 Desrosiers et al. (2001) studied 20 patients with a mean age of 49 years suffering from symptoms of
rhinosinusitis unresponsive to maximal medical and surgical
therapies for more than 8 weeks.12 The study compared the
efficacy of a 20 mg/mL tobramycin solution to a 1 mg/mL
quinine control solution in normal saline, each delivered via
sprays three times a day for four weeks.12 The antibiotic spray
provided greater initial pain relief than the nasal saline spray
after two weeks of treatment, but not after four weeks of treatment.12 On the other hand, the saline spray was consistently
more effective in reducing nasal obstruction throughout the
eight-week period of follow-up.12
Normal saline spray vs. hypertonic saline spray. Whether one type of solution can be considered superior to the
other is still unclear at this point. However, hypertonic saline
sprays have been frequently found to cause increased nasal
drainage and have been associated with greater irritation and
pain. Four studies have investigated the relative merits of a hypertonic versus a normal saline nasal spray in reducing sinonasal symptoms.11,13,14,15 Cordray et al. (2005) observed a significant improvement in self-reported symptom score before
and after treatment with the hypertonic Dead Sea saline spray
but not with the normal saline.11 Shoseyov et al. (1998) similarly found hypertonic (3.5%) saline superior to nasal saline
in a study of 34 children ages 3 to 16 years with chronic maxillary sinusitis.13 The hypertonic saline group showed significant improvement in cough score, nasal secretion and postnasal drip score, and radiology score while the normal saline
group showed improvement in only postnasal drip score.13 In
another study, Pinto et al. (2006) explored the postoperative
impact of saline sprays on nasal symptoms of 60 patients who
underwent functional endoscopic sinus surgery.14 Hypertonic
saline was found to cause significantly more nasal discharge
and pain than nasal saline.14 Neither hypertonic saline nor
normal saline resulted in significant improvement in nasal
obstruction, headache, and sleep after surgery.14 Hauptman
et al. (2007) reconciled many of these findings in a study
of 80 patients with a mean age of 36 years whose severity of
rhinosinusitis achieved a minimum sinonasal test score of
20.15 Hypertonic saline was superior in terms of mucociliary

86

clearance rates while normal saline was superior in achieving

nasal airway patency.15 There was no significant difference between the two in nasal stuffiness and obstruction.15 Adverse
events, such as the sensation of burning and nasal irritation,
were more common among patients using hypertonic saline.15
Normal saline spray vs. normal saline irrigation. Normal
saline irrigation is more effective than normal saline sprays
in reducing symptoms and neither one caused more adverse
events than the other.16 Pynnonen et al. (2007) compared the
efficacy of nasal saline irrigation to nasal saline sprays in 127
patients with a mean age of 47 years who experienced at least
1 of 5 established sinonasal symptoms for at least four days per
week over two weeks or more than 15 days over 30 days. Although both interventions resulted in significant reductions in
symptom severity, symptom frequency, and number of patients
using additional medications during follow-up, the irrigation
group experienced consistently better outcomes. Postnasal discharge was the most common adverse event, but its prevalence
was not significantly different between the two groups.

Discussion
Chronic sinusitis is a commonly encountered condition
that places a substantial burden not only on the healthcare
system, but also on the quality of life of chronic sufferers.
Since recurrent antibiotic use, intranasal steroid administration, and surgery may not be the most desirable therapeutic
options for this condition, nasal saline sprays offer a simple
and convenient way to reduce symptoms.
This review is limited by the paucity of studies that have
investigated the efficacy of nasal saline sprays in reducing
chronic sinonasal symptoms. In addition, the few studies that
did explore the efficacy of nasal saline sprays used significantly different methodologies. For instance, the eight studies included in the review offered six different comparisons
of interventions. Consequently, conclusions drawn from five
of these six comparisons were based on only one study. The
demographic profile, duration of medication use, and outcomes measured also differed markedly across studies. Studies may have focused on specialized populations such as pediatric patients, patients whose symptoms were refractory to
other medical and surgical treatments, and patients who had
just undergone nasal surgery. Studies may have also looked at
outcomes in the short-term immediately after use of the spray
or within a week of its use, while others had a more longitudinal approach and assessed outcomes after up to eight weeks
of treatment. Outcome measures ranged from the validated
Rhinosinusitis Quality of Life Questionnaire to individually
developed symptom scores to attempts at more objective
physiological measurements of mucociliary clearance.
Despite these limitations, the findings from the current review generally support the use of nasal saline sprays to reduce
sinonasal symptoms. It would therefore be reasonable to recommend nasal saline sprays as an adjunct to other therapies
such as antibiotics or antihistamines. Use of the sprays immediately after sinus surgery, however, may cause irritation
and may not be advisable at this time. Furthermore, saline
irrigation has still been shown to be more effective than saline
sprays and therefore should be encouraged. A saline spray

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Efficacy of Nasal Saline Sprays to Relieve Symptoms of Chronic Sinusitis

would be the reasonable alternative if nasal irrigation was

not well tolerated. Antibiotic sprays may be considered for
patients primarily complaining of pain while corticosteroid
sprays may be considered initially for more severe sinonasal
symptoms.
The role of saline tonicity on symptom relief is one area
that remains poorly understood. Some studies suggest that
hypertonic saline offers better outcomes, but also leads to irritation and thus poorer compliance. Patients should be informed that both isotonic and hypertonic saline sprays have
shown benefit and carry similar adverse event profiles. Because of the scarcity and heterogeneity of studies on nasal
saline sprays, future studies are needed to clarify the current
findings.

References

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