Nasal Saline for Chronic Sinonasal Symptoms: A Randomized Controlled Trial

I've been recommending nasal saline to patients with sinusitis for a while – and this article provides a compelling argument for the use of a neti pot rather than the traditional "saline spray."

Use of neti pots has increased quite a bit lately – largely due to a clinical event known as the "oprah effect."   Forget the RCT as a Gold Standard.  If Oprah advises a clinical intervention – we all should hop on board.

I usually intorduce the concept to patients by showing them the first 60 seconds of this video.  


It's quicker to just ask "have you heard of a neti pot" and if the answer is "no", I flip my x61 screen around and show the video. Why irrigation works. 

This just makes sense.  If there is poo in your toilet – does putting clorox make it go away?  Of course not – you need to flush.  If there are boogers clogging your sinuses – will antibiotics make the boogers go away?  Of course not – you need to flush.

I find that rather few of my patients request antibiotics now for the treatment of sinusitis symptoms.  This is a good thing – since it's rather clear that only a fraction of patients with sinusitis benefit from antibiotics.  Educating patients today will make things easier for everyone in the future.  As we know – physicians overestimate patients' expectations for antibiotics in the first place – Here's a nice summary of the most recent practice guideline on sinusitis treatment. Note a few things:

  • Most patients with sinusitis don't benefit from antibiotics.  Antibiotics benefit only one of 7 patients they are prescribe to for sinusitis.  6/7 of patients prescribed antibiotics for sinusitis gain no benefit from the intervention, and 1 of every 9 patients prescribed antibiotics is harmed in some way by this treatment. 
  • Nasal irrigation is not a component of this guideline.  We'll have to wait for the "post-Oprah" guideline in a few years. This cochrane reivew provides additional insight that saline irrigation is safe and effective.
  • If antibiotics are used, there is little difference between medications re: efficacy.  translation:  don't use expensive broad spectrum agents.  Amoxicillin is fine.  For penicillin allergic patients, use TMP/SMX or erythromycin (250 QID will  minimize GI side effects).

Tags: sinusitis saline neti pot