NIHR Signal Flushing your nose with salt water may be moderately useful for symptoms of sinusitis

Published on 18 October 2016

Nasal irrigation seems moderately effective for symptoms of sinusitis. People using nasal irrigation showed greater improvement in their sinus-related quality of life compared to people who didn’t use irrigation. They were also less likely to use over-the-counter medicines, and to have spent fewer days unwell with symptoms by six months.

Steam inhalation, meanwhile, seems to have minimal effect on quality of life compared with no inhalation. Neither treatment caused side effects or affected the rate of respiratory infections.

Sinusitis is common and can be difficult to treat, having considerable impact on daily life. Inhaling steam is a simple popular therapy, but past evidence has suggested that it’s not very effective. Previous studies have shown that nasal irrigation is effective, but these were small, hospital-based studies. This UK-based trial treated over 600 people in general practice. However, the trial did not directly compare nasal irrigation with steam inhalation. As such it is not possible to say with complete certainty that one is better than the other.

People need to perform nasal irrigation effectively to get maximum benefit and this may be difficult to maintain.

Share your views on the research.

Why was this study needed?

Sinus problems are common affecting around 10% of UK adults. However, it can be difficult to find their exact cause leading to long-term symptoms that can negatively affect people’s quality of life.

People with sinus problems are often prescribed antibiotics, but past studies suggest they have only a modest effect and NICE recommend against their prescription. Previous systematic reviews also indicate that steam inhalation, despite its popularity, is not very effective. Whereas flushing out the nasal passage using a salt water solution showed promise as a potential treatment. This suggests some misalignment of what the evidence is saying and what people are doing in practice.

Past studies of nasal irrigation have been small and mainly from specialist settings, whereas most people with sinusitis are treated by their GP. Therefore, this randomised controlled trial aimed to compare GP advice to use steam inhalation or nasal irrigation with usual care.

What did this study do?

Adults (671) from 72 GP practices were randomly allocated to one of four advice strategies: usual care, advice on inhaling steam, advice on performing nasal saline irrigation, or advice on both steam inhalation and nasal irrigation.

Steam inhalation used a bowl of recently boiled water for five minutes. Nasal irrigation involved washing out the nose daily with 150ml of a home-prepared solution of one teaspoon of salt and half a teaspoon of baking soda in one pint of tap water.

Participants had experienced two episodes of acute sinusitis or one episode of chronic sinusitis in the past three years, and reported symptoms having moderate to severe impact on their quality of life. Outcomes were measured on the rhinosinusitis disability index (RSDI) – a self-assessment of the physical, functional and emotional impact on sinusitis. A ten point improvement (reduction in score) on this 100 point scale is thought to be clinically important.

The analysis of the four groups was by a 2x2 factorial design, where steam inhalation was compared with no steam inhalation, and nasal irrigation was compared with no nasal irrigation. As such this was not a direct comparison between the two interventions.

What did it find?

  • At three months average RSDI scores had reduced slightly by 2.51 points with nasal irrigation compared no irrigation (95% confidence interval [CI] ‑4.65 to ‑0.37). Comparatively with steam inhalation scores had reduced by an average 0.73 points compared to no inhalation (95% CI ‑2.85 to 1.39). Suggesting a small effect of nasal irrigation and no effect of steam.
  • At six months score reductions were still greater with nasal irrigation vs. no irrigation (‑2.41, 95% CI ‑4.66 to ‑0.16) than with steam inhalation vs. no inhalation (‑0.60, 95% CI ‑2.87 to 1.68).
  • At six months, a greater proportion of people using nasal irrigation achieved a clinically meaningful 10-point decrease in their RSDI score: 44.1% with irrigation vs. 36.6% without irrigation. Comparatively the proportion was 41.5% with steam inhalation vs. 39.4% without inhalation.
  • Both nasal irrigation and steam inhalation significantly reduced the likelihood of headaches compared with, respectively, no irrigation or no inhalation at three months, but not by six months. Nasal irrigation significantly reduced the use of over-the-counter treatments at six months but not three months. Neither treatment had a significant effect on the likelihood of adverse effects or respiratory infections compared with not receiving the treatment.
  • By six months people receiving irrigation had spent fewer days unwell with sinusitis symptoms – an average of four days compared to seven days without irrigation.

What does current guidance say on this issue?

NICE recommends against prescribing antibiotics to otherwise healthy people who present with acute rhinosinusitis.

For chronic sinusitis, the Royal College of Surgeons (RCS) commissioning guidance advises treatment with nasal corticosteroids or nasal irrigation. Again, antibiotic treatment is not recommended. If symptoms do not improve after three months, the RCS recommends referral to a specialist.

What are the implications?

Nasal irrigation seems to have a beneficial effect on sinusitis symptoms compared with when it is not given, though the study authors note that it was less effective than observed in previous studies. Meanwhile steam inhalation seems to give little benefit.

Both nasal irrigation and steam inhalation are low cost treatments that people can administer in the comfort of their own home. With no difference in the rate of adverse effects, the apparent benefit of irrigation on the person’s quality of life suggests this may be the preferable option for GPs to recommend.

There might be a need to increase the amount of coaching to ensure that people are performing irrigation correctly to get maximum benefit.

Citation and Funding

Little P, Stuart B, Mullee M, et al; SNIFS Study Team. Effectiveness of steam inhalation and nasal irrigation for chronic or recurrent sinus symptoms in primary care: a pragmatic randomized controlled trial. CMAJ. 2016;188(13):940-9.

The study was funded by a grant from the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research (grant no. RP-PG-0407-10098).

Bibliography

Chong LY, Head K, Hopkins C, et al. Saline irrigation for chronic rhinosinusitis. Cochrane Database Syst Rev. 2016;(4):CD011995.

NICE. Respiratory tract infections (self-limiting): prescribing antibiotics. CG69. London: National Institute for Health and Care Excellence; 2008.

RCS. Commissioning guide: rhinosinusitis. CG69. London: Royal College of Surgeons of England; 2013.

Why was this study needed?

Sinus problems are common affecting around 10% of UK adults. However, it can be difficult to find their exact cause leading to long-term symptoms that can negatively affect people’s quality of life.

People with sinus problems are often prescribed antibiotics, but past studies suggest they have only a modest effect and NICE recommend against their prescription. Previous systematic reviews also indicate that steam inhalation, despite its popularity, is not very effective. Whereas flushing out the nasal passage using a salt water solution showed promise as a potential treatment. This suggests some misalignment of what the evidence is saying and what people are doing in practice.

Past studies of nasal irrigation have been small and mainly from specialist settings, whereas most people with sinusitis are treated by their GP. Therefore, this randomised controlled trial aimed to compare GP advice to use steam inhalation or nasal irrigation with usual care.

What did this study do?

Adults (671) from 72 GP practices were randomly allocated to one of four advice strategies: usual care, advice on inhaling steam, advice on performing nasal saline irrigation, or advice on both steam inhalation and nasal irrigation.

Steam inhalation used a bowl of recently boiled water for five minutes. Nasal irrigation involved washing out the nose daily with 150ml of a home-prepared solution of one teaspoon of salt and half a teaspoon of baking soda in one pint of tap water.

Participants had experienced two episodes of acute sinusitis or one episode of chronic sinusitis in the past three years, and reported symptoms having moderate to severe impact on their quality of life. Outcomes were measured on the rhinosinusitis disability index (RSDI) – a self-assessment of the physical, functional and emotional impact on sinusitis. A ten point improvement (reduction in score) on this 100 point scale is thought to be clinically important.

The analysis of the four groups was by a 2x2 factorial design, where steam inhalation was compared with no steam inhalation, and nasal irrigation was compared with no nasal irrigation. As such this was not a direct comparison between the two interventions.

What did it find?

  • At three months average RSDI scores had reduced slightly by 2.51 points with nasal irrigation compared no irrigation (95% confidence interval [CI] ‑4.65 to ‑0.37). Comparatively with steam inhalation scores had reduced by an average 0.73 points compared to no inhalation (95% CI ‑2.85 to 1.39). Suggesting a small effect of nasal irrigation and no effect of steam.
  • At six months score reductions were still greater with nasal irrigation vs. no irrigation (‑2.41, 95% CI ‑4.66 to ‑0.16) than with steam inhalation vs. no inhalation (‑0.60, 95% CI ‑2.87 to 1.68).
  • At six months, a greater proportion of people using nasal irrigation achieved a clinically meaningful 10-point decrease in their RSDI score: 44.1% with irrigation vs. 36.6% without irrigation. Comparatively the proportion was 41.5% with steam inhalation vs. 39.4% without inhalation.
  • Both nasal irrigation and steam inhalation significantly reduced the likelihood of headaches compared with, respectively, no irrigation or no inhalation at three months, but not by six months. Nasal irrigation significantly reduced the use of over-the-counter treatments at six months but not three months. Neither treatment had a significant effect on the likelihood of adverse effects or respiratory infections compared with not receiving the treatment.
  • By six months people receiving irrigation had spent fewer days unwell with sinusitis symptoms – an average of four days compared to seven days without irrigation.

What does current guidance say on this issue?

NICE recommends against prescribing antibiotics to otherwise healthy people who present with acute rhinosinusitis.

For chronic sinusitis, the Royal College of Surgeons (RCS) commissioning guidance advises treatment with nasal corticosteroids or nasal irrigation. Again, antibiotic treatment is not recommended. If symptoms do not improve after three months, the RCS recommends referral to a specialist.

What are the implications?

Nasal irrigation seems to have a beneficial effect on sinusitis symptoms compared with when it is not given, though the study authors note that it was less effective than observed in previous studies. Meanwhile steam inhalation seems to give little benefit.

Both nasal irrigation and steam inhalation are low cost treatments that people can administer in the comfort of their own home. With no difference in the rate of adverse effects, the apparent benefit of irrigation on the person’s quality of life suggests this may be the preferable option for GPs to recommend.

There might be a need to increase the amount of coaching to ensure that people are performing irrigation correctly to get maximum benefit.

Citation and Funding

Little P, Stuart B, Mullee M, et al; SNIFS Study Team. Effectiveness of steam inhalation and nasal irrigation for chronic or recurrent sinus symptoms in primary care: a pragmatic randomized controlled trial. CMAJ. 2016;188(13):940-9.

The study was funded by a grant from the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research (grant no. RP-PG-0407-10098).

Bibliography

Chong LY, Head K, Hopkins C, et al. Saline irrigation for chronic rhinosinusitis. Cochrane Database Syst Rev. 2016;(4):CD011995.

NICE. Respiratory tract infections (self-limiting): prescribing antibiotics. CG69. London: National Institute for Health and Care Excellence; 2008.

RCS. Commissioning guide: rhinosinusitis. CG69. London: Royal College of Surgeons of England; 2013.

Effectiveness of steam inhalation and nasal irrigation for chronic or recurrent sinus symptoms in primary care: a pragmatic randomized controlled trial

Published on 20 July 2016

Little, P.,Stuart, B.,Mullee, M.,Thomas, T.,Johnson, S.,Leydon, G.,Rabago, D.,Richards-Hall, S.,Williamson, I.,Yao, G.,Raftery, J.,Zhu, S.,Moore, M.

Cmaj , 2016

BACKGROUND: Systematic reviews support nasal saline irrigation for chronic or recurrent sinus symptoms, but trials have been small and few in primary care settings. Steam inhalation has also been proposed, but supporting evidence is lacking. We investigated whether brief pragmatic interventions to encourage use of nasal irrigation or steam inhalation would be effective in relieving sinus symptoms. METHODS: We conducted a pragmatic randomized controlled trial involving adults (age 18-65 yr) from 72 primary care practices in the United Kingdom who had a history of chronic or recurrent sinusitis and reported a "moderate to severe" impact of sinus symptoms on their quality of life. Participants were recruited between Feb. 11, 2009, and June 30, 2014, and randomly assigned to 1 of 4 advice strategies: usual care, daily nasal saline irrigation supported by a demonstration video, daily steam inhalation, or combined treatment with both interventions. The primary outcome measure was the Rhinosinusitis Disability Index (RSDI). Patients were followed up at 3 and 6 months. We imputed missing data using multiple imputation methods. RESULTS: Of the 961 patients who consented, 871 returned baseline questionnaires (210 usual care, 219 nasal irrigation, 232 steam inhalation and 210 combined treatment). A total of 671 (77.0%) of the 871 participants reported RSDI scores at 3 months. Patients' RSDI scores improved more with nasal irrigation than without nasal irrigation by 3 months (crude change -7.42 v. -5.23; estimated adjusted mean difference between groups -2.51, 95% confidence interval -4.65 to -0.37). By 6 months, significantly more patients maintained a 10-point clinically important improvement in the RSDI score with nasal irrigation (44.1% v. 36.6%); fewer used over-the-counter medications (59.4% v. 68.0%) or intended to consult a doctor in future episodes. Steam inhalation reduced headache but had no significant effect on other outcomes. The proportion of participants who had adverse effects was the same in both intervention groups. INTERPRETATION: Advice to use steam inhalation for chronic or recurrent sinus symptoms in primary care was not effective. A similar strategy to use nasal irrigation was less effective than prior evidence suggested, but it provided some symptomatic benefit. TRIAL REGISTRATION: ISRCTN, no. 88204146.

Nasal irrigation in this trial involved a SinuCleanse Neti Pot (Ascent Consumer Products). This is a patented clear blue plastic teapot-like device where users can see the water level and check that the salt is completely dissolved in the solution before using. It is intended for use with SinuCleanse saline solution. These items can be purchased online.

Participants in this trial were given verbal instructions on using the device, as well as a link to a demonstration clip on YouTube.

Alternative devices are available, and may have different effectiveness to that used in this study.

Expert commentary

Chronic sinus symptoms are a common presentation in general practice and often result in recurrent antibiotics, prolonged corticosteroid use or ENT referral. This study sought to compare nasal irrigation and steam inhalation with placebo and in combination as conservative, free interventions. Results were gained through patient reported outcome measures at three and six months from baseline. The study was sufficiently powered. Nasal irrigation was found to be statistically significant, albeit with less effect than previously suggested. Steam inhalation was not found to be helpful. While not ground breaking this should empower GPs to provide accurate advice on self-management of long term sinus symptoms – with the encouragement that patients need to be committed.

Dr Peter Chamberlain, GP and Lead Clinician for Strategy and Innovation, South Sefton Clinical Commissioning Group