Overview

Sinusitis, or rhinosinusitis, is the inflammation of nasal cavities called sinuses. It results in fluids building up in these structures, which are usually filled with air. The obstructed sinuses cause runny nose, cough, facial pain, and headaches, among other associated symptoms. Sinusitis often manifests after a cold, respiratory infections, seasonal allergies, exposure to smoke, nasal structural problems, or a debilitated immune system. Individuals who suffer from sinusitis often experience it recurrently, in some cases even becoming a chronic issue.^1,2 

Nasal irrigation has been used for at least 200 years to relieve sinusitis symptoms, way before scientific evidence of its benefits for such purpose. The procedure is simple, inexpensive, and possible to be done at home. The individual flushes a proper solution into the nasal cavities, both clearing it from residual materials and moisturizing. Through the years, especially since 1990, nasal irrigation has been observed to improve the quality of life of patients with various sinonasal conditions besides sinusitis. Not only were the results satisfactory, but patients showed adherence to the procedure, maintaining the routine at home.³ 

Understanding nasal irrigation

Symptoms from sinusitis are commonly related to the inflammatory response in the mucociliary layer within the nasal cavities. This structure is the respiratory system's first line of defence, retaining particles that are potentially harmful and facilitating its expulsion from the sinuses.³ 

Irrigating the mucociliary layer provides a number of benefits that can potentially improve and restore its protective function, such as thinning and removing the mucus; reducing viral or bacterial load in the sinuses; removing pro-inflammatory cells and substances; improving mucociliary clearance; and decreasing oedema from the inflammation.⁴

Benefits 

Benefits of nasal irrigation include:

• Symptom relief - Helps to alleviate nasal congestion, runny nose, sinus pressure, and heavy breathing
• Non-invasiveness - Safe to perform without medical supervision by following the guidelines
• Ease to use and accessibility - Easily accessible at regular drug stores or online; these affordable tools are simple to use at home, encouraging routine use and improving patient adherence for better results

Types of nasal irrigation

Nasal irrigation can be performed through different devices and methods, often varying on volume, pressure, and preparation of the saline solution. A few of the most common types are:

Neti pot

Neti pot, also called a nasal pot, is shaped like a teapot with elongated spouts. The format makes it easy to fit into the opening of the nose. The individual tilts its head, and the solution drips from one nostril to the other, providing a gentle rinse. It provides a high volume of rinsing solution through low pressure. It is one of the “gold standards” for nasal irrigation.^4,5

Squeeze bottles

This is a bottle filled with a solution. Squeezing the bottle will send a flush of solution from one nostril to the other. Differently from the neti pot, this method is more likely to push out mucus, forcing a more assertive cleaning. However, it is classified as a low-pressure procedure, delivering a high volume of solution. It is also, one of the “gold standards” for nasal irrigation.^4,5 

Saline sprays

Saline sprays are pressurised cans filled with a specific solution with a thin tip to attach to the nose. Easily portable and simple to use, some brands have detachable and reusable nozzles, each one allowing different functions to the mist, such as moistening, hydrating, and/or washing the nasal cavities. Saline sprays deliver a low volume of solution.^4,5

Bulb syringes

Bulb syringes are especially used for babies, and a few drops of the solution are placed directly into the baby's nose. Before any contact with the nostril, the bulb is squeezed to release air, creating a vacuum. Then, the tool is attached to the nose and released, creating suction that carries away the mucus.⁶ 

Nasal irrigation machines

Nasal irrigation machines are battery-operated pulsed water devices, which provide an intense nasal irrigation cleansing. From simply providing a steady flow to enabling pressure solution and flow regulation, there are various models in different price ranges. Specific models even have a tip that sprays the solution, while in the other nostril, a suction tip collects the residue.⁵

Practical recommendations

Consulting with a healthcare provider is highly advised before starting any routine of nasal irrigation, especially if the individual has underlying health conditions, pressure in one or both ears, a nostril completely blocked, or inflamed sinuses affecting other tissues and organs.^7,8

Saline solution

Most of the methods and tools for nasal irrigation require a saline solution, usually providing the pre-mixed powder for the individual to add water at home. It is important to note that the water used in this solution should be filtered or boiled to avoid the risk of infection in internal nasal structures. Also, for both safety and comfort, the solution must be lukewarm before use.⁵ 

The saline solution is an important factor for nasal irrigation. Variations in the sodium chloride concentration, minerals, oligo-elements, and minerals serve different purposes, and there is no consensus on the ideal composition. Besides, medications like steroids, may be added, acting within the nasal cavities, but must not be administered without medical orders.⁴

Overall steps

Directions to nasal irrigation may vary depending on the method chosen; manufacturer's guides should always be consulted. Below is a step-by-step guide to a high-volume nasal irrigation, the most common and recommended:⁸

• Prepare your saline solution. Add the pre-mixed powder from the kit to the proper amount of filtered or boiled water. Water should boil for 5 minutes to be adequate for use. For a homemade saline solution, add half a tablespoon of non-iodised salt to two cups of filtered or boiled water 
• Pour the saline solution into the teacup or bottle. If you use boiling water, wait for it to cool down before handling it
• Position yourself. Lean forward on the sink, so your head is slightly facing down. Tilt your head a little, so one year is slightly towards the sink. Position the tip of the container on the nostril further from the sink. The position should allow you to pour the solution from the upper nostril to the other, making it drip in the sink below
• Time for irrigation. Breathe through your mouth and operate the chosen container as recommended. If it is a teacup, softly tilt it on the upper nostril, letting gravity carry the solution to the other nostril. If it is a squeeze bottle, squeeze the solution in the upper nostril in a steady and gentle stream. No matter what the method chosen, on that step the solution must flow through the path between one nostril and the other, sometimes causing a soft burning or thick sensation. Use half of the solution, reposition yourself to the other side, and use the remaining half starting from the nostril that was below before
• Blow your nose. Get rid of any residual solution or mucus

Additional tips

Different methods follow different guidelines, but some evidence-based tips can be kept in mind:⁷

• Disinfection - Regular and careful tool cleanings, according to manufacturer’s directions
• High volume - Methods that require 200 ml of solution or more, like squeeze bottles and a sort of battery-operated devices are more assertive and recommended for a wider range of complaints 
• Posture - Most nasal irrigations, especially the high-volume ones, require a head down-and-forward position
• Frequency - Although studies are not conclusive on the most effective frequency, in order to maintain the practice affordable and doable, doctors recommend nasal irrigation to be performed once to twice a day through the duration of symptoms

Summary

Inflammation in the nasal cavities is referred to as sinusitis and can have a high impact on a person’s quality of life. Symptoms such as head pressure, face swelling, congested and runny nose can persist enough to impact sleep, social life, and productivity, even becoming a chronic issue if prolonged. It can be triggered by respiratory infections, seasonal allergies, exposure to smoke, and many factors that might irritate the nose structures.

 Nasal irrigation has been used for a long time to alleviate these symptoms, especially when combined with established treatments (whether medicinal or surgical). Performing a cleansing of the nasal cavities is believed to dilute and thin the mucus, remove inflammatory mediators and pathogens (viruses or bacteria), and moisturise the mucosa. Many tools can be used to perform nasal irrigation. Depending on the chosen method, it can be a simple and affordable procedure, usually well-received by patients. Sticking to the routine of nasal irrigation, especially while the symptoms last, is crucial to experience improvement. Many studies have been building evidence to understand the mechanisms and correlation between nasal irrigation and sinusitis management. This exploration is not yet a conclusive body of work. Still, a lot is known about observed outcomes and safe practices, which makes it a reliable procedure under the proper guidelines. Empiric studies are optimistic about the adhesion of nasal irrigation as an ally in treating sinusitis.