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According to a new study in the latest issue of the Archives of Otolaryngology — Head & Neck Surgery, saline irrigation treatments show greater efficacy versus saline spray for providing short-term relief of chronic nasal and sinus symptoms.

In the United States, 29.5 million people 18 years of age and older are affected by sinusitis [1]. Millions more are affected by other types of allergic and non-allergic rhinitis (meaning irritation and inflammation of the mucosal membrane of the nose). Some people can reduce symptom severity using medication, including antihistamines and anti-inflammatory drugs. Antibiotics are frequently prescribed for acute and chronic sinusitis. However, their use far outweighs the predicted incidence of bacterial infection, suggesting that antibiotics are overprescribed for sinus infections. Regardless of the medication used however, for many patients, symptoms persist.

Nasal irrigation - the flooding of the sinus cavity with warm saline solution - can help to reduce sinus congestion and is often recommended by otolaryngologists (ear, nose and throat physicians) for a variety of sinus conditions. The goal of nasal irrigation is to clear excess mucus and foreign debris out of the sinuses, and to moisturize the mucosal membrane. The practice has been subjected to clinical testing and has been found to be safe and beneficial with no apparent side effects (for reviews of clinical evidence, see [2-3]). The practice is simple and inexpensive, and has been shown to decrease the symptoms of a variety of nasal and sinus conditions. As an alternative to irrigation, saline spray is often used because it is thought to be similar to and better tolerated than irrigation. However, the effectiveness of nasal saline spray has not been proven in clinical trials.

A new study from researchers at the University of Michigan Health System concludes that nasal irrigation is more effective that commonly used saline sprays for treating chronic nasal and sinus symptoms. Participants in the study, 127 adults with chronic nasal and sinus symptoms, were randomly assigned to irrigation or spray for 8 weeks. Those using nasal irrigation showed a statistically significant change in symptom severity as early as 2 weeks into the study. After 8 weeks, only 40% of participants in the irrigation group reported frequent (defined as “often or always”) nasal and sinus symptoms compared with 61% in the spray group [4].

Both groups experienced adverse effects. More were reported in the irrigation group. However, most adverse effects were minor and none required that treatment be stopped. The most commonly reported adverse effect was post-irrigation drainage, which occurs when saline in the upper sinuses isn’t expelled and later drains.

The study is the first of it’s kind to show greater efficacy of saline irrigation treatments versus saline spray for providing short-term relief of chronic nasal symptoms. According to lead author Melissa A. Pynnonen, M.D., clinical assistant professor in the University of Michigan Department of Otolaryngology [5]:

The irrigation group achieved a clinically significant improvement in quality of life in terms of the severity of their symptoms, whereas the spray group did not. Strikingly, they also experienced 50 percent lower odds of frequent nasal symptoms compared with the spray group.

An interview-based study assessing the attitudes regarding use of nasal irrigation for frequent rhinosinusitis as well as chronic sinus and nasal symptoms published last year found that [6]:

• Nasal irrigation produced rapid and long-term improvement in the quality of life.
• Users felt empowered.
• Barriers to use included discomfort, time and mild side effects.
• Instruction and at-home use can overcome the fore-mentioned barriers.

The take-home message? If you’re using saline spray to treat chronic sinus symptoms, you will experience a much greater benefit in terms of both symptom severity and frequency with saline nasal irrigation.

Do you use nasal irrigation? Why or why not?

References

1. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2005. U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Health Statistics. 2006 Dec.
2. Papsin and McTavish. Saline nasal irrigation: Its role as an adjunct treatment. Can Fam Physician. 2003 Feb;49:168-73.
   View abstract
3. Harvey et al. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD006394.
   View abstract
4. Pynnonen et al. Nasal saline for chronic sinonasal symptoms: a randomized controlled trial. Arch Otolaryngol Head Neck Surg. 2007 Nov;133(11):1115-20.
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5. Sinus problems are treated well with safe, inexpensive treatment, UMHS study finds. Department of Public Relations and Marketing Communications Newsroom. University of Michigan Health System. 2007 Nov 19.
6. Rabago et al. Qualitative aspects of nasal irrigation use by patients with chronic sinus disease in a multimethod study. Ann Fam Med. 2006 Jul-Aug;4(4):295-301.
   View abstract

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Healthcare use of antibiotics far outweighs the predicted incidence of bacterial causes of acute and chronic sinusitis. That’s the conclusion of a new study published in the March 2007 issue of Archives of Otolaryngology - Head and Neck Surgery.

Antibiotics are only effective against bacterial infection. Many sinus infections are due to viral infection, allergies or hormonal changes. Physicians try to avoid antibiotic use to reduce the emergence of dangerous resistant bacterial strains, such as methicillin-resistant Staphylococcus aureus. However, most patients with sinus congestion want immediate relief and, because more effective drugs for chronic sinusitis are lacking, demand antibiotics.

The four-year prospective study found Americans made on average 4.25 million visits to healthcare facilities per year for sinus infection between 1999 and 2002. At least one antibiotic was prescribed in nearly 83% of cases of acute sinusitis and 70% of cases of chronic sinusitis. Antibiotics were prescribed more often than antihistamines, nasal decongestants, corticosteroids, and antitussive, expectorant, and mucolytic agents (order reflects the frequency of recommended medication).

The penicillins amoxicillin and amoxicillin-clavulanate potassium (brand name Augmentin) were the most commonly used antibiotics for both chronic and acute bacterial sinusitis. According to the Sinus and Allergy Health Partnership, the next most frequently used antibiotics should be erythromycins, lincosamides, and macrolides. However, the authors found cephalosporins, sulfonamides, trimethoprim, and tetracyclines were more commonly used.

Corticosteroids are used to reduce or prevent inflammation of the sinus mucous membranes. They do this by altering the actions of various cells of the immune system. Corticosteroids may be applied topically as a nasal spray or orally. Oral corticosteroids are rarely used to treat sinusitis. Prolonged use of oral corticosteroid treatments can cause serious side effects, including thinning of the bones, diabetes and increased risk of infection. Corticosteroid nasal sprays generally don’t cause these side effects. In addition, discontinuing use of corticosteroids does not lead to rebound congestion like topical nasal decongestants, frequently used to reduce sinus inflammation and congestion.

The use of corticosteroids was found in 15 to 16 percent of visits for acute and chronic cases of sinusitis. The authors maintain the rate of corticosteroid use is higher than published studies imply is necessary for acute sinusitis, while the rate may actually be lower than indicated for chronic sinusitis. Several studies suggest that intranasal corticosteroid use in conjunction with antibiotics are effective for improving the symptoms of acute sinusitis compared with antibiotic therapy alone [1-3]. Recent promising results from a study in patients with acute, uncomplicated sinusitis found that mometasone furoate (brand name Nasonex) nasal spray used twice daily produced significant symptom improvements versus amoxicillin and placebo, without predisposing the patient to disease recurrence or bacterial infection [4]. However, further studies may be needed to better clarify the role and proper dosage of corticosteroids when used alone or in combination with antibiotic therapy in the management of acute and chronic sinusitis.

The authors of the study express concern regarding the problems surrounding antibiotic overuse and conclude:

“When two-thirds of patients with sinus symptoms expect or receive an antibiotic and as many as one-fifth of antibiotic prescriptions for adults are written for a drug to treat rhinosinusitis, these disorders hold special pertinence on the topic.”

Increasing antibiotic resistance
Children average six to eight colds per year. Of those, only 0.5 to 5 percent will develop a sinus infection [6]. Nevertheless, sinusitis is the fifth most common diagnosis for which an antibiotic is prescribed [5]. There are a number of methods to determine whether a sinus infection is bacterial, including:

• Nasal cytology - examining a swab from the lining of the nose.
• Nasal endoscopy - running a tube into the nose to obtain a sample of mucus from the sinus cavity.
• X-ray, computer tomography, magnetic resonance imaging (MRI) or ultrasound
• Sinus puncture and bacterial culture - usually only performed if a reasonable diagnosis cannot be made using noninvasive techniques.

Unfortunately, all these methods are expensive and time-consuming.

A recent study found that 28% of Haemophilus influenzae strains cultured from patients with an acute exacerbation of chronic or acute sinusitis were resistant to ampicllin; 79% of Streptococcus pneumoniae strains were found to be penicillin-intermediate resistant [7]. An earlier study in 2001 in children with sinusitis found that 44% of Haemophilus influenzae cultures isolated were ampicillin resistant (41% having high-grade resistance) and 64% of Streptococcus pneumoniae isolates were resistant to penicillin (24% having high-grade resistance) [8].

Antibiotic resistance is an emerging public health crisis. Today, virtually all important bacterial infections in the United States and throughout the world are becoming resistant. The Centers for Disease Control and Prevention calls antibiotic resistance one of the world’s most pressing public health problems.

Remember
Taking antibiotics for viral infections will increase the risk of antibiotic resistance. Millions of antibiotics prescribed in doctors’ offices each year are for viral infections, which cannot effectively be treated with antibiotics. An alternative therapy for sinus infection is nasal irrigation, which can relieve symptoms, reduce inflammation and remove stagnant mucus in the nasal passages, making it difficult for infections to develop. The spread of viral infections can be reduced through frequent hand washing and by avoiding close contact with others.

References

• Meltzer et al. Intranasal flunisolide spray as an adjunct to oral antibiotic therapy for sinusitis. J Allergy Clin Immunol. 1993 Dec;92(6):812-23.
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• Barlan et al. Intranasal budesonide spray as an adjunct to oral antibiotic therapy for acute sinusitis in children. Ann Allergy Asthma Immunol. 1997 Jun;78(6):598-601.
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• Dolor et al. Comparison of cefuroxime with or without intranasal fluticasone for the treatment of rhinosinusitis. The CAFFS Trial: a randomized controlled trial. JAMA. 2001 Dec 26;286(24):3097-105.
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• Meltzer et al. Treating acute rhinosinusitis: comparing efficacy and safety of mometasone furoate nasal spray, amoxicillin, and placebo. J Allergy Clin Immunol. 2005 Dec;116(6):1289-95. Epub 2005 Oct 24.
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• Anon et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg. 2004 Jan;130(1 Suppl):1-45.
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• Ramadan, HH. Pediatric sinusitis: update. J Otolaryngol. 2005 Jun;34 Suppl 1:S14-7.
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• Tellez et al. Microbiology of acute sinusitis in Mexican patients. Arch Med Res. 2006 Apr;37(3):395-8.
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• Slack et al. Antibiotic-resistant bacteria in pediatric chronic sinusitis. Pediatr Infect Dis J. 2001 Mar;20(3):247-50.
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