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Keywords: Nasal irrigation plays a non-negligible role in the treatment of numerous sinonasal pathologies and
Nasal irrigation postoperative care. There is, however, a wide variety of protocols. The present review of the evidence-
Seawater based literature sought objective arguments for optimization and efficacy. It emerged that large-volume
Saline solution
low-pressure nasal douche optimizes the distribution and cleansing power of the irrigation solution in
the nasal cavity. Ionic composition and pH also influence mucociliary clearance and epithelium trophicity.
Seawater is less rich in sodium ions and richer in bicarbonates, potassium, calcium and magnesium than
is isotonic normal saline, while alkaline pH and elevated calcium concentration optimized ciliary motility
in vitro. Bicarbonates reduce secretion viscosity. Potassium and magnesium promote healing and limit
local inflammation. These results show that the efficacy of nasal irrigation is multifactorial. Large-volume
low-pressure nasal irrigation using undiluted seawater seems, in the present state of knowledge, to be
the most effective protocol.
© 2015 Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.anorl.2015.08.001
1879-7296/© 2015 Elsevier Masson SAS. All rights reserved.
282 P.-L. Bastier et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 281–285
Table 1 100% 2
6
Composition (mg/L) of physiological saline, electrodialyzed seawater and Ringer’s 12
8
26
lactate [40,48]. 80%
23 Main elements (calcium,
61 potassium, magnesium)
Physiological Seawater Ringer’s lactate
60% 56
saline (Physiomer® ) (source: Vidal® 40 Buffers (bicarbonate, nitrate,
[40,48] dictionary 2014) 46
sulfate)
40%
Author, year Study design Indication Population Series Treatment Groups Group size Assessment criterion P Level of
size time (weeks) evidence
Multicenter Type of
comparison
Slapak et al., 2008 Yes Open Acute rhinitis Children 401 12 A Standard treatment 101 Nasal secretion P < 0.05* (B > A) I
[48] or non- B Standard treatment 289 abundance and
complicated + electrodialyzed type
flu seawater
P.-L. Bastier et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 281–285
Strnad et al., 2007 Yes Open Allergic and Adults and 238 6 A Rhinocorticoids 78 Nasal index P < 0.05* (B > A I
[46] non-allergic children + antihistamines score and C > A)
rhinosinusitis B Electrodialyzed 80
seawater
+ rhinocorticoids
+ antihistamines
C Electrodialyzed 80
seawater
+ antihistamines
Friedman et al., No Double-blind Chronic Adults 114 4 A Hypertonic Dead Sea 59 SNOT P = 0.082 I
2012 [47] rhinosinusitis water 20
B Hypertonic saline 55
+ rhinocorticoids
Wang et al., 2009 No Open Acute sinusitis Children 69 3 A Isotonic saline 30 PRQLQ (Pediatric P < 0.05* II
[49] B No irrigation 39 Rhinoconjunctivitis (A > B)
Quality of Life
Questionnaire)
Friedman et al., No Double-blind Chronic Adults 42 4 A Hypertonic Dead Sea 22 Rhinosinusitis P = 0.003* (A > B) II
2006 [13] rhinosinusitis water symptoms
B Hypertonic saline 20
Chusakul et al., No Double-blind Allergic rhinitis Adults 36 1.5 A Isotonic saline 12 Rhinologic P > 0.05 II
2013 [33] B Buffered moderately 12 symptoms
alkaline isotonic saline
C Buffered strongly 12
alkaline isotonic saline
Ünal et al., 2001 No nk Post- Adults 32 3 A Ringer’s lactate nk Saccharine P < 0.05* (A > B) II
[50] septoplasty B Isotonic saline nk mucociliary
clearance test
Li et al., 2009 [43] No Open Moderate to Children 26 12 A Rhinocorticoids 6 Rhinologic P < 0.05* (C > A II
severe + antihistamines symptoms and C > B)
permanent B Isotonic saline 9
allergic rhinitis + antihistamines
C Isotonic saline 12
+ rhinocorticoids
+ antihistamines
Garavello et al., No Open Seasonal Children 20 6 A Hypertonic saline 10 Daily rhinitis P < 0.05* II
2003 [42] allergic rhinitis B No irrigation 10 score (A > B)
283
284 P.-L. Bastier et al. / European Annals of Otorhinolaryngology, Head and Neck diseases 132 (2015) 281–285
and increased the permeability of tight junctions [34–36]. These symptoms more effectively when associated to nasal irrigation
data correlated in vivo with increased secretion and exudation in with an isotonic solution [49]. Both studies showed the efficacy of
response to hypertonic solutions [37]. Paradoxically, other authors irrigation in these respective pathologies, but did not demonstrate
reported improved in vivo mucociliary clearance on saccharine test the superiority of either solution, as there was no comparative arm.
in healthy subjects with hypertonic solutions between 3% and 5% In postoperative use, nasal irrigation is essential for cleansing
[38,39]. the crusts and secretions inherent to any sinonasal surgery. It sig-
nificantly reduces nasal secretion and shows a tendency to reduce
1.2.4. Advantages of seawater postsurgical edema. Ringer’s lactate, which is rich in calcium and
Since 1995, it has been shown that seawater promotes cell potassium and less rich in sodium and chloride ions than isotonic
growth, with a significantly stronger eutrophic effect than nor- saline, provided a stronger increase in mucociliary transport than
mal saline or seawater at one-third dilution [40]. In a more recent isotonic saline after endonasal surgery [50].
in vitro study, 2 to 4 hours’ exposure to electrodialyzed seawa- Few studies have focused on postoperative seawater irrigation
ter enhanced viability in deprived bronchial epithelial cells as [51–53], and they lacked control groups without postoperative care
compared to isotonic normal saline [11]. In other studies, seawa- to remove clots, crusts and secretion. Pigret and Jankowski found
ter significantly protected pig nasal mucosa against the effects of no significant difference between the effects of pressurized seawa-
twice-daily 0.1% oxymetazoline (inflammation, fibrosis, metapla- ter and saline with antiseptics and mucolytics, in a small series (10
sia) [41]. patients per group) [51]. Keerl et al., in an observational study of 121
In vitro, electrodialyzed seawater reduced production of pro- patients, found nasal irrigation to be well tolerated, and that some
inflammatory molecules such as IL-8 or RANTES [10,11], involved patients continued in the long-term, including irrigation in their
in the recruitment and activation of polynuclear neutrophils and daily life routine [52]. Pinto et al. found no symptomatic benefit
eosinophils. of irrigation, whether iso- or hypertonic [53], and recommended
Thus, in vitro at least, it would seem that limited sodium chlo- not implementing postoperative irrigation; their study, however
ride content is important for nasal irrigation solutions. Conversely, involved certain defects: no inclusion criteria, and no details of sur-
calcium provides an advantage in terms of restoring epithelial gical technique, numerous revision surgeries and application of an
trophicity and mucociliary efficacy. Potassium should provide ben- endonasal hemostasis substance. Moreover, the symptoms scores
efit in postoperative situations and/or certain chronic rhinosinusitis used were not validated, and final nasal cavity status was not noted
via its action on anti-inflammatory response; slightly alkaline pH [53].
with isotonic composition should have a similar effect. Finally, certain preservatives, antiseptics and mucolytics have
sometimes been associated to irrigation solutions. They slowed
1.3. Clinical advantages of undiluted seawater over other or arrested ciliary beat, and showed no clinical benefit [51,54,55].
irrigation solutions A recent meta-analysis confirmed the non-superiority of adding
an antibiotic and an antifungal agent to the irrigation solution in
Certain studies reported clinical superiority for mineral-rich chronic rhinosinusitis [6].
solutions compared to classic saline, but data are sparse (Table 2).
In allergic rhinitis, iso- and hypertonic saline improved all 2. Conclusion
symptoms in children, reducing recourse to antihistamines and
corticosteroids [42,43], with excellent tolerance [44,45]. In 2007, Founded on empirical practice and common sense, nasal
a multicenter randomized study assessed the efficacy of electro- irrigation now plays an essential and self-evident role for the
dialyzed 2.2% hypertonic Saint-Malo seawater in 238 allergic or large majority of practitioners. The heterogeneity of protocols and
non-allergic chronic rhinosinusitis patients, and found strongly sig- studies make for confusion. It would, however, appear that: large-
nificantly superiority for nasal irrigation (with or without local volume irrigation provides good distribution over the sinonasal
corticosteroids) versus controls (antihistamines with local cortico- cavities as a whole; and a stable, reproducible isotonic solution
steroids, without irrigation) in terms of symptoms and of recourse with slightly alkaline pH and a composition close to that of sea-
to corticosteroids [46]. Cordray et al. likewise reported that nasal water optimizes trophic and functional recovery of the respiratory
irrigation with water from the Dead Sea, without antihistamines, epithelium. Clinically, the literature fails to prove any clear superi-
was as effective as local corticosteroids in controlling nasal and ocu- ority of one product over the others; however, the in vitro properties
lar symptoms in mild-to-moderate seasonal allergic rhinitis [12]. of undiluted seawater seem to provide definite advantage in many
Friedman et al., in a prospective randomized double-blind study, clinical situations, as compared with physiological saline. Further
found greater improvement in symptom scores in 42 allergic or studies will be needed to confirm the present findings.
non-allergic chronic rhinosinusitis patients with Dead Sea water
versus hypertonic saline [13]. The same author, using the same Disclosure of interest
methodology, more recently reported a similar improvement in
symptoms in 114 patients with irrigation with hypertonic Dead Sea L. de Gabory: occasional expert reports, consultancy and guest
water without corticotherapy versus hypertonic saline with local speaker for Laboratoire de la Mer® .
corticosteroids [47]. The other authors declare that they have no conflicts of interest
In acute infection, two prospective randomized studies showed concerning this article.
better treatment with nasal irrigation. The first, a controlled mul-
ticenter study of 390 children with rhinitis, found faster improve- Acknowledgments
ment in nasal permeability and the quality and quantity of secretion
with electrodialyzed seawater irrigation than in a control group The authors thank Laboratoire de la Mer® for the data for the
without irrigation [48]. It also demonstrated that irrigation reduced composition of the irrigation solutions shown in Fig. 1.
number of episodes, ENT complications and medication (antipyret-
ics, antibiotics, mucolytics and decongestants) in children suffering
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