Ancient Remedy for Chronic Rhinosinusitis Comes with Fresh Warnings

Nasal irrigation also proved to be well tolerated: Only a few side effects were noted, such as ear pain and acute otitis media, none of which were deemed serious based on an accepted adverse event scale. “Perhaps surprising to physicians, more than 90 percent of the children (aged 4 and higher) were able to comply with the once-daily irrigation protocol during a six-week period,” said Dr. Wei. She attributed that outcome to the detailed training and education on proper nasal irrigation techniques that she and her staff provide to parents and their young children (see “Tips for Treating Chronic Rhinosinusitis with Nasal Irrigation”).

One other finding in Dr. Wei’s study underscored another trend she has been seeing in clinical practice—antibiotic overuse. In the study, 14 of 19 patients in the saline group and 17 of 21 in a gentamicin group—the topical antibiotic yielded no significant additive benefits—reported completing up to nine courses of systemic antibiotic therapy in a six-month period prior to enrollment. “This finding illustrates the chronicity of this disease and it being [resistant] to routine medical therapy, including antibiotics, antihistamines, OTC decongestants and even leukotriene-receptor antagonists,” Dr. Wei said.

At least half of the patients in her study, she noted, had been on some combination of those medications. “Yet nearly all of them were so refractory that many came for another opinion after a previous otolaryngologist had recommended sinus surgery, which we were able to avoid with regular use of nasal irrigation.”

“For me, that can only mean one thing,” Dr. Wei said. “What many of us have historically been doing for these patients simply isn’t working.”

On the rare occasions that Dr. Wei does perform sinus surgery in children—she does so only in patients who have failed at least a six-week course of once-daily saline irrigation and who have evidence of persistent disease clinically and on CT scan—she sees signs of why those medications aren’t working. Specifically, “I don’t see pus or any other signs of active infection,” she said. “Instead, I see inflammation and mucosal thickening, which leads to significantly reduced mucociliary activity, resulting in buildup of thickened secretions or “gunk” in the sinuses and all the symptoms that we traditionally associate—wrongly—with acute sinus infections.”

Thus it’s not surprising, she said, that antibiotics often don’t work in such patients. Nasal irrigation, in contrast, has been shown in studies to improve mucociliary clearance, thin mucus and potentially decrease inflammation (Clin Otolaryngol. 2000;25:558-560; Laryngoscope. 1997;107:500-503), which may partly account for the efficacy of nasal irrigation.