Nasal irrigation

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Nasal irrigation
Woman flushing her nose with a neti pot
ICD-9-CM 22.0
MeSH D055556

Nasal irrigation, (also called nasal lavage or nasal douche) is a personal hygiene practice in which the nasal cavity is washed to flush out mucus and debris from the nose and sinuses. The practice is generally well-tolerated and reported to be beneficial with only minor side effects.[1] Nasal irrigation in a wider sense can also refer to the use of saline nasal spray or nebulizers to moisten the mucous membranes.

According to its advocates, nasal irrigation promotes good sinus and nasal health. Patients with chronic sinusitis including symptoms of facial pain, headache, halitosis, cough, anterior rhinorrhea (watery discharge) and nasal congestion are reported often to find nasal irrigation to provide relief. In published studies, "daily hypertonic saline nasal irrigation improves sinus-related quality of life, decreases symptoms, and decreases medication use in patients with frequent sinusitis",[2] and irrigation is recommended as an adjunctive treatment for chronic sinonasal symptoms.[3][4]

Medical uses[edit]

Nasal irrigation device commonly available at pharmacies

Nasal irrigation is used for a range of sinus and nasal symptoms.[5]

Chronic sinusitis[edit]

For chronic sinusitis it can be an effective add-on therapy. It is also reported to be an effective measure against chronic sinus symptoms induced by work-place exposure to sawdust.[5] Further evidence suggests that nasal irrigation causes relief for both hay-fever and the common cold. Nasal irrigation could also be an effective treatment for allergic rhinitis[6] and chronic sinusitis.[7]

A daily nasal and sinus rinse with a salt-water solution (a mixture of 0.9% non-iodized sodium chloride and either purified or filtered water warmed to around 37°C/98°F, with or without inclusion of a buffering agent such as sodium bicarbonate) has been recommended as both an add-on[8] and primary treatment[9] in such cases and is preferable to the use of corticosteroids except in the most serious cases of acute bacterial sinusitis.[10] Irrigation should be used with caution in infants; however, saline drops or saline as a mist is well tolerated for infants and children with upper respiratory tract symptoms leading to nasal congestion.[11] Filtered water may also be used with an absolute filtration down to 0.1 micron.[12]

Treatment guidelines in both Canada and the United States recommend use of nasal irrigation for all causes of rhinosinusitis and for postoperative cleaning of the nasal cavity.[13]


Utilizing a sinus rinse and nasal irrigation are well accepted for the temporary relief of the symptoms associated with allergic rhinitis. The mechanism of action is actual flushing of the allergens from the nasal and sinus passages with large volume saline irrigation.[14]

Acute upper respiratory infection[edit]

There is tentative evidence for benefit of saline irrigation in acute upper respiratory tract infections such as the common cold and acute sinusitis.[15]

Sinus surgery[edit]

Sinus surgery can improve the effectiveness of irrigation of the sinuses.[16] Large volume nasal saline irrigation as a sinus rinse is a preferred method.[16]


Ceramic neti pot

The simpliest method is to snort water from cupped hands, but that clears little more than the nostrils. The application of commercially available saline nasal spray is another alternative, but it is relatively inefficient for washing away debris, although it may suffice for simple re-hydration of mucous membrane and tissues.[17][18]

Another simple yet effective technique is to pour salt water solution into one nostril and let it run out through the other while the mouth is kept open to breathe, using gravity as an aid.

Neti pots rely on gravity, along with head positioning and repeated practice in order to rinse the outer sinus cavities. Typically they have a spout attached near the bottom, sometimes with a handle on the opposite side.[19]

Various squeeze bottles for nasal irrigation have also been used. The basic design is a plastic squeeze bottle with a straw-like tube. Application of gentle pressure forces the solution through the tube and out of the tip into the nostril. Newer designs utilize valves to prevent backwash contamination. The medical literature demonstrates that most nasal wash bottles become contaminated after use, even with proper instructions for cleaning.[20] The most advanced squeeze bottle utilizes valve technology and a removable top and bottom cap to maximize cleaning and drying to prevent bacterial and mold growth after use.

Bulb syringes are commonly for infants and children. Large syringe devices with a specially designed nasal tip may also be used. Irrigation machines that utilize electric motor-driven pumps are also available. These irrigation devices pump salt water solution through a tube in connection with a nasal adapter tip designed to seal against the nostril. Some of these machines allow adjustment of water volume or speed by use of an adjustment dial which regulates pump speed. Most of these motorized machines use a pulsating water pumping action at a relatively low, fixed rate, designed to match the normal wave rate of healthy, unobstructed nasal cilia.[21] This matched pulse rate is claimed to stimulate the nasal cilia hairs and promote better sinus health, while reducing the severity of allergic reactions.[22] More sophisticated motorized irrigators have two or more pulse cycle settings that adjust the actual pulse cycle (as opposed to a simple volume and speed control, which does not alter the pulse rate). This design affords the user the option of using a higher pulse rate when suffering from partially closed sinuses, as in a typical case of acute sinusitis. The efficiency of all motorized pump irrigators has not yet been compared to simpler non-motorized mechanical pressure nasal irrigation methods.[23]

Solutions used[edit]

While nasal irrigation can be carried out using ordinary tap water, this is potentially unsafe and can be uncomfortable as it irritates the mucous membranes. Therefore, an isotonic or hypertonic salt water solution is normally used, i.e. water with enough salt to match the tonicity of the body cells and blood. For the same reason, lukewarm water is preferred over cold water, which in addition to irritating nasal membranes can also exaggerate the gag reflex during irrigation. A small amount of baking soda is sometimes employed as a buffering agent to neutralize the pH of the irrigating solution.

Many pharmacies stock pre-manufactured sachets of pharmaceutical-grade salt and baking soda designed to be used with the volume of water in the corresponding device. It is also simple to make a salt-baking soda mixture.[24]

Potential allergens, such as iodine, and contaminants are to be avoided in the sodium chloride, water, and buffering ingredients.[1] Pre-manufactured dosages of salt water flushing solutions can be purchased, or the user can mix non-iodized 'kosher' salt, with or without a buffering agent such as sodium bicarbonate or baking soda. (Table salt frequently is iodized.)

Compounded medication[edit]

A number of other compounds may be included in irrigation fluids such as the steroid budesonide in an effort to treat chronic rhinosinusitis.[25]

Adverse effects[edit]

The solution used for irrigation should be distilled, sterile or previously boiled due to the risks involved with using potentially contaminated water.[26] If this is done, the procedure is generally safe.[26]

Deaths have been reported as a consequence of using Naegleria fowleri-contaminated water for sinus irrigation.[26] Naegleria fowleri in unsterilized water can cause the brain infection primary amoebic meningoencephalitis (naegleriasis),[27] which carries a 95% risk of fatality.[28] Very few cases of naegleriasis (in the low hundreds) have ever occurred globally; in the United States, despite two deaths in Louisiana in 2011 (both from the same treatment plant), no cases have ever been recorded that involve tap water from normal treated supplies where a water heater has raised the temperature above 50°C/120°F.


Saline solutions used in nasal irrigation reduce inflammation through osmosis. Swelling is a major factor in sinus dysfunction. Removal of mucus plays an important role in sinus health, and nasal irrigation facilitates this by flushing out thickened mucus that cannot be handled by the cilia,[9][23] improving mucociliary clearance and also removing infected material.[9] Damage to the mucociliary transport system is an important factor in the development of sinonasal diseases, leading to a stasis of mucus.[23] The numerous proteins found in nasal mucus include inflammatory mediators, defensins and many whose function is not understood.[9]

In a study with eight healthy volunteers, solution was transported reliably to ethmoid and maxillary sinuses when it was snorted or applied with a squeeze bottle; a nebulizer was significantly less effective. Sphenoid and frontal sinuses were rarely reached, and not at all with the nebulizer.[18]

Flushing the nasal cavity with salt water has been claimed to promote mucociliary clearance by moisturizing the nasal cavity and by removing encrusted material, although there is no clear evidence to support this.[9]


The earliest record of nasal irrigation is found in the ancient Hindu practice of Indian Ayurveda whose roots are traced to the Vedas. It was customary to perform jala-neti daily, as part of soucha (personal hygiene according to scriptures). Jala-neti, which means to cleanse the nose with water, is an old yogic technique from India. The container used to administer the saline is called a "neti pot". This process removes mucus, dirt and clears the nose. A second neti technique known as sutra neti uses a piece of string instead of water.

See also[edit]


  1. ^ a b Harvey R, Hannan SA, Badia L, Scadding G (2007). Harvey, Richard, ed. "Nasal saline irrigations for the symptoms of chronic rhinosinusitis". Cochrane Database of Systematic Reviews (3): CD006394. doi:10.1002/14651858.CD006394.pub2. PMID 17636843. 
  2. ^ Rabago D, Zgierska A, Mundt M, Barrett B, Bobula J, Maberry R (2002). "Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: A randomized controlled trial". The Journal of family practice. 51 (12): 1049–1055. PMID 12540331. 
  3. ^ Rabago D, Pasic T, Zgierska A, Mundt M, Barrett B, Maberry R (2005). "The Efficacy of Hypertonic Saline Nasal Irrigation for Chronic Sinonasal Symptoms". Otolaryngology - Head and Neck Surgery. 133 (1): 3–8. doi:10.1016/j.otohns.2005.03.002. PMID 16025044. 
  4. ^ Tomooka LT, Murphy C, Davidson TM (2000). "Clinical Study and Literature Review of Nasal Irrigation". The Laryngoscope. 110 (7): 1189–1193. doi:10.1097/00005537-200007000-00023. PMID 10892694. 
  5. ^ a b Rabago, David (1 June 2008). "The Use of Saline Nasal Irrigation in Common Upper Respiratory Conditions". U.S. Pharmacist. Archived from the original on 16 December 2009. 
  6. ^ Rabago D, Zgierska A (November 2009). "Saline nasal irrigation for upper respiratory conditions". Am Fam Physician. 80 (10): 1117–9. PMC 2778074Freely accessible. PMID 19904896. 
  7. ^ Rabago D, Zgierska A, Mundt M, Barrett B, Bobula J, Maberry R (December 2002). "Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: a randomized controlled trial". The Journal of Family Practice. 51 (12): 1049–55. PMID 12540331. 
  8. ^ Rabago D, Pasic T, Zgierska A, Mundt M, Barrett B, Maberry R (July 2005). "The efficacy of hypertonic saline nasal irrigation for chronic sinonasal symptoms". Otolaryngol Head Neck Surg. 133 (1): 3–8. doi:10.1016/j.otohns.2005.03.002. PMID 16025044. 
  9. ^ a b c d e Brown CL, Graham SM (February 2004). "Nasal irrigations: good or bad?". Curr Opin Otolaryngol Head Neck Surg. 12 (1): 9–13. doi:10.1097/00020840-200402000-00004. PMID 14712112. 
  10. ^ Sarah-Anne Schumann; John Hickner (July 2008). "Patients insist on antibiotics for sinusitis? Here is a good reason to say "no"" (PDF). The Journal of Family Practice. 57 (7). 
  11. ^ King D, Mitchell B, Williams CP, Spurling GK (20 Apr 2015). "Saline nasal irrigation for acute upper respiratory tract infections". Cochrane Database Syst Rev (4): CD006821. doi:10.1002/14651858.CD006821.pub3. PMID 25892369. 
  12. ^ "Sinus Rinsing & Neti Pots | Prevention & Control | Naegleria fowleri | CDC". Retrieved 2017-03-26. 
  13. ^ Osguthorpe JD, Hadley JA (1999). "Rhinosinusitis. Current concepts in evaluation and management". The Medical clinics of North America. 83 (1): 27–41, vii–viii. PMID 9927958. 
  14. ^ Hermelingmeier, Kristina E.; Weber, Rainer K.; Hellmich, Martin; Heubach, Christine P.; Mösges, Ralph (2012-09-01). "Nasal irrigation as an adjunctive treatment in allergic rhinitis: a systematic review and meta-analysis". American Journal of Rhinology & Allergy. 26 (5): e119–125. doi:10.2500/ajra.2012.26.3787. ISSN 1945-8932. PMC 3904042Freely accessible. PMID 23168142. 
  15. ^ King, D; Mitchell, B; Williams, CP; Spurling, GK (20 April 2015). "Saline nasal irrigation for acute upper respiratory tract infections". The Cochrane Database of Systematic Reviews. 4: CD006821. doi:10.1002/14651858.CD006821.pub3. PMID 25892369. 
  16. ^ a b Harvey, Richard J.; Psaltis, Alkis; Schlosser, Rodney J.; Witterick, Ian J. (2010-06-01). "Current concepts in topical therapy for chronic sinonasal disease". Journal of Otolaryngology - Head & Neck Surgery. 39 (3): 217–231. ISSN 1916-0216. PMID 20470665. 
  17. ^ Pynnonen MA, Mukerji SS, Kim HM, Adams ME, Terrell JE (2007). "Nasal Saline for Chronic Sinonasal Symptoms: A Randomized Controlled Trial". Archives of Otolaryngology - Head and Neck Surgery. 133 (11): 1115–1120. doi:10.1001/archotol.133.11.1115. PMID 18025315. 
  18. ^ a b Olson DE, Rasgon BM, Hilsinger RL (2002). "Radiographic Comparison of Three Methods for Nasal Saline Irrigation". The Laryngoscope. 112 (8): 1394–1398. doi:10.1097/00005537-200208000-00013. PMID 12172251. 
  19. ^ "What Is a Neti Pot? And Why Would You Use One?". Mayo Clinic.
  20. ^ Keen, Mark; Foreman, Andrew; Wormald, Peter-John (2010-10-01). "The clinical significance of nasal irrigation bottle contamination". The Laryngoscope. 120 (10): 2110–2114. doi:10.1002/lary.21031. ISSN 1531-4995. PMID 20824637. 
  21. ^ Davidson, Terence M. Handbook of Nasal Disease, Part III, Nasal Irrigation
  22. ^ Davidson, Terence M. Handbook of Nasal Disease, Part III, Nasal Irrigation
  23. ^ a b c Tomooka LT, Murphy C, Davidson TM (2000). "Clinical study and literature review of nasal irrigation". Laryngoscope. 110 (7): 1189–93. doi:10.1097/00005537-200007000-00023. PMID 10892694. 
  24. ^ UWHealth
  25. ^ Thaler, Erica; Kennedy, David W. (2009). Rhinosinusitis: A Guide for Diagnosis and Management. Springer Science & Business Media. p. 82. ISBN 9780387730622. 
  26. ^ a b c "Is Rinsing Your Sinuses Safe?". FDA. Sep 4, 2013. Retrieved 24 June 2015. 
  27. ^ Centers for Disease Control and Prevention. "Parasites – Naegleria". Retrieved 16 December 2011. 
  28. ^ Cetin, N; Blackall, D (19 April 2012). "Naegleria fowleri meningoencephalitis". Blood. 119 (16): 3658. doi:10.1182/blood-2011-06-353136. PMID 22645743. 

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