Best practices for Safe Nasal Irrigation

nasal douching

Nasal irrigation, (also termed as nasal rinsing, washout, douching or lavage) is a personal hygiene practice in which a person’s nasal cavity is washed with saline water to flush out debris and mucus from the nose and nasal sinuses.

Nasal douching can be performed safely by people of all ages to support daily nasal hygiene. The practice is reported to have good beneficial outcomes with only minor side effects. It works best to relieve symptoms of dry, thick, and crusty mucus.

Recent case report about death of a 69 year old female from Seattle, due to a brain infection by a rare group of amoeba Balamuthia mandrillaris (primary amebic meningoencephalitis) has created a panic among patients regarding the safety of nasal irrigation.

In this article, we are discussing about the purpose of nasal irrigation, the medical indications, the pros and cons of it and the method of practicing safe nasal irrigation at home.

How nasal irrigation works?

During normal breathing, micro-organisms like bacteria, viruses, pollen, dirt and dust particles are trapped inside the nasal cavity by the tiny hair cells and the mucus secretions with in the nose. This is a natural defense mechanism of the body to avoid entry of harmful organisms into body.

In patients with chronic sinusitis, allergy etc. the consistency of mucus is harder and thick, preventing natural clearance of these trapped pathogens. When this transportation through the nose becomes slow, inflammation can increase as a result of mucus stagnation which will further leads to frequent sinus infections.

Nasal irrigation helps in thinning out the stagnant mucus and makes it’s natural clearance more easier. It also helps in flushing out of bacteria, allergens and other irritants from the sinus passages.

Medical Indications for nasal douching

Following are some of the most common medical indications for regular nasal douching

  • After nasal surgeries: Surgeries inside nasal cavity like endoscopic sinus surgery (FESS), Septoplasty etc. makes the surface raw and sore. This causes dry, crust and scab formation. Nasal douching can help in removing these crusts and scabs from nasal cavity.
  • After epistaxis (nose bleeds): Nasal douching help in removing crusts formed after nasal bleeding.
  • Rhinitis: Patients who suffer from acute or chronic rhinosinusitis, allergic or seasonal rhinitis can keep their nasal airway clear and free from allergens and debris, and prevent infection by regular douching. Nasal irrigation has often been used as both a solo and an adjunctive treatment in chronic sinus problems.
  • Muco-ciliary dysfunctions: Patients with muco-ciliary dysfunction diseases (Cystic fibrosis, Kartagner syndrome etc.) rely on frequent nasal irrigation to clear the clogged nasal passages and to breath freely again.
  • Frequent nasal douching is adviced in some special conditions like – treatment of rhinitis in pregnancy (where medications are contraindicated), atrophic rhinitis, empty nose syndrome etc.
  • Nasal irrigation is often advised 10-20 minutes before using a other medications like corticosteroid nasal spray. This will increase the efficacy of other drug as it ensures that your sinuses will absorb the medicines you take.

Devices and Solutions

Wide range of product types are available for performing nasal irrigation and to make the whole procedure easier. These include bulb syringe, squeeze bottle or neti pot, and battery-operated pulsed water devices. With the basic devices, the user has to manually pour or spray a mixture of salt and water into one nostril. In higher end models, the solution is propelled into the nose, allowing the user to control the spray and pressure.

Neti pots are the most commonly used  devices. They look like little teapots with long spouts. Neti pots rely on gravity and head position in order to rinse the sinus cavities. The fluid flows through one of the nasal cavity and comes out through the other nostril.

Most commonly distilled/sterile saline solution is used for nasal washing. But many people prefer to use tap water because of the easiness and low cost availability. In a Canadian study, it was found that half (48%) of patients in a Canadian rhinology practice use tap water for rinses, with “convenience” being the most common reason tap water is used.

Direct tap water should not be used because of the chance of infections associated with it. Tap water may contains microorganisms like bacteria, protozoa, amoebas etc. These microorganisms may be safe to swallow because stomach acid kills them; but when used in nasal cavities, these organisms can stay alive in nasal passages and may cause potentially serious infections.

If using tap water, Center for Disease Control (CDC) has given following recommendations:

  • First preferred choice: Use boiled, luke warm water – boil the water for 3 to 5 minutes and then cool until it is lukewarm. Previously boiled water can be stored in a clean, closed container for use within 24 hours.
  • Second preferred choice: Use special filters – those filters which are labelled  “NSF 53” or “NSF 58” or  “absolute pore size of 1 micron or smaller” or contain the words “cyst removal” or “cyst reduction”.
    Some manufacturers of nasal rinsing devices recommend using 0.2 micron absolute pore size. Follow the manufacturer recommendations if 0.2 micron absolute filters are recommended.
  • Third preferred choice: Use disinfected water – Chlorine bleach used at the right level and time will work as a disinfectant against Naegleria germ. More details on how to disinfect water to ensure it is safe from Naegleria can be found from CDC website.

Things needed for Homemade nasal irrigation

  • Table Salt (non-iodised) : one quarter of a teaspoon (1.25mL)
  • Bicarbonate of soda (sodium bicarbonate) – often referred to as baking soda is sold from the cooking section of most general food stores: one quarter of a teaspoon (1.25mL)
  • Distilled / Boiled tap water that has been cooled down to room temperature : 240ml
  • Teaspoon, Measuring jug, Mug, Tissues
  • Access to a sink.
  • Additional ingredients like sodium borate etc as advised by practitioner in special situations like empty nose syndrome, atrophic rhinitis etc.

How to do nasal douching?

Nasal douching can be performed in the morning and/or evening, or more frequently if the patient has a severe rhinosinusitis infection or as advised by the practitioner.

Information included with the irrigation device might give more specific instructions about its use and care. In general, following procedure can br adopted for safe and efficient nadal irrigation.

Procedure

  1. Wash your hands, clean with soap, and dry before holding any correctly treated water.
  2. Measure out the dry ingredients into a measuring jug.
  3. Mix the dry ingredients with 240mL of water well.
  4. Ensure the dry ingredients have dissolved before proceeding and ensure the solution is room temperature.
  5. Lean over the sink, keeping your head bent forward; this will close and block the back of your throat to prevent swallowing or choking on the solution.
  6. Method 1
    1. Bring mug of solution to nose
    2. Sniff a small amount of the fluid into the nose for approximately two to three seconds. Alternatively use cupped hands pouring solution into hand and sniff from hand. Do not sniff large amounts of liquid / do not swallow liquid.
    3. Take nose away from the mug and allow the liquid to run back out of nose into the sink.
    4. To cleanse both sides of the nasal cavity it may be necessary to block each nostril alternatively as you sniff.
  7. Method 2Saline nasal syringing
    1. A twenty ml syringe (without needle) may be used to squirt the solution into the nose rather than sniffing it up.
  8. Method 3
    1. Rotate your head (about 45 degrees) so that one nostril is above the other.
    2. Gently insert the spout of the nasal irrigation pot into the uppermost nostril so that it forms a comfortable seal. (Do not press the spout against the “middle”, or septum, of the nose).
    3. Breathe through your mouth and raise the handle of the filled nasal irrigation pot so that the solution enters the upper nostril and drains through the lower nostril.
    4. Repeat the procedure, tilting your head sideways, on the other side.
  9. Method 4
    1. Using a squeezy bottle is a high-volume, low-pressure system. The solution is squirted into one nostril allowing it to run out of the other nostril and has been found to be a very effective delivery device.
    2. Stand in front of the sink, bend forward and tilt your head face down about 45 degrees so that you are looking down into the sink.
    3. The mouth is kept open to breathes through whilst performing the process.
  10. Method 5
    1. A douching spray is a ready mixed solution in a canister needing no preparation.
  11. Do not worry if you swallow some of the solution as it will not cause you any harm.
  12. Repeat the irrigation steps several times as tolerated, using up as much of the solution as possible. Your nose may run naturally after nasal douching; this should be expected, since the natural cleansing processes of the nose will be stimulated by douching.
  13. After nasal douching, blow your nose into a tissue. Do this gently so as not to cause over stimulation or damage inside your nose.
  14. Rest your nose for 10-20 minutes before using any treatment spray. If a nasal treatment is used while your nose is running, the treatment spray will be washed out of your nose, reducing its effectiveness.
  15. Rinse the irrigation device after each use and dry the inside with a paper towel or let it air dry between uses.
  16. Repeat multiple times in a day.

Notes:

  • If any solution remains, do not keep it for longer than 24 hours.
  • Do not store the solution in the fridge or heat it in the microwave.
  • Nasal irrigation is often advised 10-20 minutes before using a other medications like corticosteroid nasal spray. This will increase the efficacy of other drug as it ensures that your sinuses will absorb the medicines you take.
  • If you are living in an altitude of above 6500 feets, the water needs to be boiled for longer than 3 minutes.
  • A stronger hypertonic solution may be required for some patients, such as those with chronic rhinosinusitis infection. This solution can be made by doubling the salt and bicarbonate of soda content to 2.5mL for each ingredient, and mixing them with 240ml of water.
  • Once a week, sterilize the bottle with 1:1 water + hydrogen peroxide or 1:1 water + bleach.

Benefits of nasal irrigation

Following are some of the benefits of nasal irrigation

  • Nasal douching helps in clearing the clogged nasal passages, reduces nasal congesion.
  • Nasal irrigations removes irritants, debris and particles that keep the passages and airways blocked
  • Moisturize and soothe dry, irritated nasal membranes
  • Prevents upper respiratory tract infections
  • Improve sense of smell and taste
  • Get rid of thick mucus and reduce congestion in the nose
  • Helps sinuses drain freely to eliminate bacteria, viruses, contaminants, irritants and allergens
  • Minimize coughing and postnasal drip
  • Reduces snoring
  • Nasal irrigation reduces need for FESS and CT imaging in cases of chronic rhinosinusitis.

Cons of nasal irrigation

The most commonly reported adverse events of nasal irrigation include post-irrigation nasal discharge and initial discomfort. Rare cases of nosebleeds and stinging have been reported. These adverse effects are usually well tolerated. Many studies have concluded that benefits of nasal irrigation outweighs its adverse effects.

Though not proved scientifically, in a presentation at the annual meeting of the American College of Allergy, Asthma and Immunology (ACAAI), researcher Talal M. Nsouli explained that, daily long-term nasal rinsing may create more harm than benefits. The idea behind this finding is that, by washing the nose, the good mucus which contains the antimicrobial agents also get flushed out which can result in increased frequency of acute infections. Irrespective of this, Nsouli doesn’t advise stopping nasal irrigation altogether. He only suggests using it in moderation.

The most dreaded complication, reported in association with use of nasal douching was risk of amoebic brain infections when the water is not sterile or the device is not cleaned after use. The pathogenesis of this disease centers on migration of amoeba along the olfactory neuroepithelial tract leading to intracranial infection, and which is nearly always fatal.

Four amoeba genera are known to be associated with human disease: Acanthamoeba spp, Balamuthia mandrillaris, Naegleria fowleri, and Sappinia diploidea.

In 2018, a lady from Seattle, was reported to have contracted Balamuthia mandrillaris after using tap water during nasal irrigation. Although the source of the infection has not been proven in case of this lady, it is speculated that it came from the tap water she used in her neti pot for nasal irrigation.

Naegleriasis is a very deadly infection. Of 133 people known to be infected in the United States from 1962–2014, only three people have survived. Of these two infections where reported from Louisiana in 2012, due to use of contaminated tap water for nasal irrigations. One case of primary amoebic meningitis from N fowleri was reported in the US Virgin Islands in 2012 after ablution during prayer that included nasal rinsing with well water and rain water.

No cases of amoebic meningitis from nasal irrigation with Acanthamoeba or Sappinia as the causative pathogen have been reported.

References

  1. ARIA, Allergic Rhinitis and its Impact on Asthma (2007). Full Text documents and resources: http://www.whiar.org
  2. Gutiérrez-Cardona, N., Sands, P., Roberts, G., Lucas, J. S., Walker, W., Salib, R.,  Ismail-Koch, H. (2017). The acceptability and tolerability of nasal douching in children with allergic rhinitis: A systematic review. International Journal of Pediatric Otorhinolaryngology, 98, 126–135.
  3. Taccariello M, Parikh A, Darby Y, Scadding G. Nasal douching as a valuable adjunct in the management of chronic rhinosinusitis. Rhinology. 1999 Mar;37(1):29-32.
  4. Bartle, J., & Millington, A. (2017). How to perform nasal douching. Nursing Standard, 31(49), 41–45.
  5. J.S. Yoder, S. Straif-Bourgeois, S.L. Roy, T.A. Moore, G.S. Visvesvara, R.C. Ratard, et al. Primary amebic meningoencephalitis deaths associated with sinus irrigation using contaminated tap water Clin Infect Dis, 55 (2012), pp. e79-e85
  6. Smith, T. L., Beswick, D. M., Kennedy, D. W., Ramakrishnan, V. R., & Soler, Z. M. (2019). Deadly amoeba infections from nasal and sinus irrigation: how should we discuss with our patients? International Forum of Allergy & Rhinology. doi:10.1002/alr.22294
  7. Pham, V., Sykes, K., & Wei, J. (2013). Long-term outcome of once daily nasal irrigation for the treatment of pediatric chronic rhinosinusitis. The Laryngoscope, 124(4), 1000-7.

Meet the author

Dr Sanu P Moideen is an Indian-born oto-rhino-laryngologist (ENT) based in Cochin, Kerala, India. He is currently working as Post-Doctoral Fellow in Head and Neck Oncology at Regional Cancer Center, Trivandrum, Kerala.

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