“I’m not saying chronic sinusitis isn’t a disease; you certainly won’t get better until we fix you,” Dr. Wei said. “But we should not try to fix this problem with antibiotics.” Instead, “sinus irrigation should be recommended as a first-line treatment for pediatric rhinosinusitis—certainly before even considering sinus surgery and even adenoidectomy.”
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November 2012More Evidence of Efficacy
Other physicians who treat children and adults with chronic sinusitis share Dr. Wei’s concerns about the overuse of antibiotics for the disease—as well as her view that nasal irrigation is a superior therapy in selected patients.
David Rabago, MD, an assistant professor of medicine in the department of family medicine at the University of Wisconsin in Madison, has published several studies on the modality, one of which, published in 2002, was given an “A” rating in a Cochrane review that concluded that nasal irrigation can be an effective adjunctive therapy for chronic rhinosinusitis (J Fam Pract. 2002;51:1049-1055; Cochrane Database Syst Rev. 2007;(3):CD006394).
In Dr. Rabago’s study, 76 patients with a history of frequent sinusitis and chronic sinus symptoms were randomized to treatment with nasal irrigation daily for six months with a commercially produced nasal irrigation system; 24 patients were included as controls.
The primary finding of the study was a statistically significant improvement in QOL scores related to chronic rhinosinusitis symptoms, Dr. Rabago reported. Specifically, scores for patients in the sinus irrigation group averaged 6.0 and 15.5 points higher than controls at three and six months, respectively (p<0.05).
Among the secondary outcomes in the study, “we were particularly struck by the reduction in antibiotic use we documented in the nasal irrigation group,” Dr. Rabago told ENT Today. Antibiotics were used for 10±0.02 weeks in the experimental group, compared with 19±0.04 weeks in the control arm (p<0.05).
“Given the small numbers in our study, we really didn’t expect to see such tight effectiveness data on medication use,” he said. “So even though this was not a primary outcome, it’s nevertheless an important finding, given the prevalence of antibiotic overuse and the problems with resistance that can cause.”
Dr. Rabago added an important caveat for any physician who wants to start recommending nasal irrigation for the control of sinus symptoms. “It’s very effective—provided you give patients adequate education and training.”
That observation, he noted, is not based solely on clinical experience: Dr. Rabago authored a study of patient attitudes regarding nasal irrigation, which found that certain training methods were favored by patients learning how to use proper technique (Ann Fam Med. 2006;4:295-301). “Videos, personal instruction, handouts—these were the tools that seem to work best at promoting adherence,” he said.
Potential Drawbacks
Benjamin F. Asher, MD, an otolaryngologist with an integrative medicine practice in New York City, isn’t ready to crown nasal irrigation as the front-line therapy for all patients with chronic sinusitis. In fact, “I only use it in patients with an active infection and who have had sinus surgery, with cavities and crusting,” Dr. Asher said. In other cases, he explained, “I’ve found there are treatments which are just as effective as nasal irrigation but are much less annoying to the patient and are easier to comply with.”
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