Ancient Remedy for Chronic Rhinosinusitis Comes with Fresh Warnings

As if newspaper headlines announcing a “brain-eating disease” caused by N. fowleri are not enough of a scare, nasal irrigation may be suffering from another decidedly modern problem despite its antiquarian roots. For years, Yoder noted, the climate-sensitive ameba was thought to be isolated to southern-tier states, with infectious outbreaks usually tied to swimming in untreated water in small ponds and lakes. In the last two years, however, such cases of N. fowleri infections—some fatal—have been reported for the first time in Minnesota and Kansas, he and his colleagues reported.

Does that mean that it is more likely that N. fowleri could be found in premise plumbing in northern states, placing patients who use tap water for nasal irrigation at an increased risk? “There’s no direct evidence for that,” said Yoder. “But this bug’s geographical range is definitely showing signs of expansion, which points to the need for increased vigilance by physicians.”

Benefits in Children

Julie L. Wei, MD, an associate professor of otolaryngology-head and neck surgery at the University of Kansas School of Medicine in Kansas City, said she is aware of the CDC report on N. fowleri and nasal irrigation. “I haven’t had a single case where I thought untreated tap water was a problem, but of course one fatality is one too many in any physician’s practice,” she said.

“Many of my parents and patients have asked me about this, and so I tell them if you want to be 100 percent safe, go ahead and boil tap water for nasal irrigation and then let it cool (a hassle), or buy distilled water from the local pharmacy.” Dr. Wei said that to avoid burns, the tap water should be allowed to cool until it reaches room temperature or slightly warm temperature. “I’ve also found that irrigation is most comfortable using water at those temperatures,” she said. Given the rare nature of these infections, however, “I have not yet taken the step of having everyone take these precautions.”

Dr. Wei is much less ambivalent when it comes to the benefits of nasal irrigation for treating children with symptoms of chronic rhinosinusitis. She is the lead author of a 34-patient study (Laryngoscope. 2011;121:1989-2000) showing that once-daily nasal irrigation alone, without use of other medications, yielded a nearly three-point gain in a quality-of-life (QOL) survey adapted to sinus disease, as well as significant or complete reversal of mucosal thickening on CT scans.