Irrigation

The single most effective self-help measure you can take to prevent or treat sinusitis is to wash your sinuses daily with salt water. Sinus washing, commonly called sinus irrigation and medically called sinus lavage (and sometimes called nasal washing or nasal douching), is an age-old practice. Historically, it's been used more in the East than in Western societies, though this is changing as irrigation is increasingly being recognized by doctors and in medical literature for its health benefits. Some general practitioners and even ENTS, however, still have little knowledge of sinus irrigation or regard it as unproven folk medicine, despite numerous studies of it described in medical literature, and they don't mention it to their patients.

What irrigating with saline (salt) solution does is help your sinuses do what they're supposed to do themselves -- flush away cold viruses, bacteria, allergens, and fungi. If you have chronic sinusitis, your sinuses have lost some or all of their ability to filter out these invaders. Irrigation is compensation for this.

Irrigation Techniques

There are a range of irrigation methods to choose from, some more effective than others. Least effective is splashing water up your nose at the sink or in the shower and sniffing it in. Plain tap water stings -- the same feeling as getting water up your nose when swimming.

More effective is a bulb irrigator, also called an ear syringe, used with salt water. Its chief benefits are that it's inexpensive, easily available, and easily transportable. Ear syringes are available in most pharmacies.

Next up the effectiveness ladder is the neti pot, which looks a bit like a small watering can. It's easier to use than an ear syringe -- you're less likely to splash or leak water over yourself -- and it's easier to regulate the flow of saline, but it's harder to find. One source is Sinus Survival Products, at 888-434-0033, where it's called the SinuCleanse System.

The most effective technique is pulsatile (pulsating) irrigation. When liquid pulsates, it does a better job of cleaning -- it digs out the dirt. In the sinuses, pulsation is also thought to stimulate the action of the cilia, part of the sinuses' natural defenses, and to remove IgE antibodies, which play a key role in allergic reactions. Irrigation also suctions out mucus that the saline doesn't reach directly through vacuum action (the Venturi effect).

There are a number of pulsatile nasal irrigation devices available. One is the EMCUR Nasal Douche. The most popular is the Grossan Hydro Pulse Nasal & Sinus Irrigation System, invented by Dr. Murray Grossan, an ENT.

You can obtain the Grossan system in some pharmacies (Bergen Brunswig part number 344-598, McKesson part number 1443217), directly through Grossan's company HydroMed at 800-560-9007, through distributors such as Health Solutions Medical Products, or in Europe from Inmunotek.

Before 2002 it was common to attach a Grossan Sinus Irrigator Tip to a Teledyne Water Pik in order to slow the pulsation to a level appropriate for the sinuses. But since then Teledyne redesigned the Water Pik, making it less expensive but eliminating much of its functionality for use in irrigating the sinuses. Instead of being able to choose a speed over a continuous range, as you could before, you can now choose only two or more settings, depending on the model.

To compensate for this, Hydro Med now sells a Water Pik-like device, which it calls the Hydro Pulse pulsating pump base unit, that's designed specifically for sinus irriagation. The entire system isn't inexpensive at $89, but it's worth it. Some insurance companies reimburse for the cost of the Grossan system and similar devices, as they're FDA listed for Nasal/Sinus Irrigation. Grossan irrigation is more complicated as well for sinus irrigation than other methods, but it does a better job of cleaning out sinuses.

Many people warm the saline before irrigating, though some people prefer cooler temperatures. Warming it helps it break up mucus, encourages blood flow to the area, and usually just feels better. Anywhere near body temperature is ideal. One technique for warming saline is to simply place the water or solution in a glass and put it in a microwave oven for a minute.

The most common way to irrigate is to bend over the sink and tilt your head to the side to help the irrigation solution drain out. You place the irrigation tip in the upper nostril and let the irrigation solution drain out of the lower nostril. However, if you find this clogs up your ears, hold your head straight, without tilting it. If you want to help the irrigation solution reach further into the frontal sinuses, bend over further, tilting your head downward. You can tilt your head far to the side to allow the irrigation solution to reach sinus tissue it wouldn't reach otherwise, but be careful about not clogging up your ears. One more technique is to allow the irrigation solution to pass from your sinuses into your throat and spit it out, which reaches still more tissue.

Immediately after irrigating, with the irrigation solution still in your sinuses, you can optionally tilt your head back to force it into other sinus cavities. Just clinch your nose shut with your fingers as you remove the irrigation tip.

It's recommended that you irrigate your sinuses two times a day when you're experiencing sinus or allergy symptoms or if you have a cold, or three times a day if you're producing a lot of mucus. If you have chronic sinusitis with only mild symptoms, you should irrigate once a day. If you're trying to prevent a cold or allergy flare-up during cold or allergy season, you can irrigate once a day. If you have no symptoms, you typically don't need to irrigate, though some people irrigate anywhere from every other day to once a week as preventive medicine. Over-irrigating can compromise the sinuses' disease-fighting capabilities -- it removes from the sinuses the enzyme lysozyme, which kills bacteria.

Keeping the Grossan system clean helps keep common household dirt and other contaminants out of your sinuses, where they do no good. After irrigating, run filtered or tap water through the system, and rinse off the irrigation tip using warm tap water. Place a small sheet of aluminum foil over the base unit between irrigations. Some people advocate running a small amount of diluted chlorine bleach or hydrogen peroxide solution through the irrigator periodically to kill germs. You can also periodically run vinegar through it to clear out deposits from water that over time can clog the unit. Don't use alcohol to flush out the unit because it can flush out the lubricant around the motor and pump.

Saline Solution

There are a number of ways of obtaining saline solution for irrigation. First, you can mix it yourself. The optimal salinity is obtained by adding one level teaspoon of salt to a U.S. pint of water (a U.S. pint is 16 ounces or 0.47 liter). Alternately, you can add one-quarter teaspoon of salt to 4 ounces (0.12 liter) of water. This creates an isotonic solution -- same salinity as human blood and other body fluids. Some people prefer a saltier (hypertonic) solution, up to two teaspoons of salt to a pint of water, which can pull moisture out of the sinuses and help shrink swollen mucous membranes. In some people, however, hypertonic saline solution can impair the cilia and dry out the sinuses, compromising their disease-fighting ability.

It's best to use canning, pickling, or kosher salt rather than table salt or sea salt, as they contain fewer impurities, and to use filtered or distilled water for the same reason. You can obtain canning, pickling, or kosher salt in some supermarkets and health food stores. Some people do fine, though, with tap water and table salt.

Some people find that saline solution itself burns from its slight acidity. You can neutralize this by adding a pinch of baking soda (sodium bicarbonate) to the saline.

The second way to obtain saline is by buying it prepackaged, which is more convenient though slightly more expensive. Sinus Survival Products, at 888-434-0033, sells 80 packs of saline mixed with baking soda for $5.95, or from about 15 cents per irrigation. Canning salt is used, at a ratio of four parts salt to one part baking soda, according to a spokesperson at the company. Each packet contains a half teaspoon of salt, so add it to eight ounces of water.

The latest development in saline solution for sinus irrigation is the use of Ringer's solution, which has been used intravenously for many years. Along with sodium chloride (salt) and sodium bicarbonate (baking soda), Ringer's solution also contains potassium chloride and calcium chloride. One new study (Boek WM. Laryngoscope, 109(3):396-9 1999 Mar) has shown that salty (hypertonic) saline solution can completely paralyze the cilia and that even isotonic solution can slow cilia down, which is the exact opposite of what irrigation is supposed to do. The study also showed, however, that adding potassium chloride and calcium chloride can prevent the cilia from slowing. The theory is that the addition of these ingredients allows the irrigation solution to approximate not only the salinity of blood and tissue, but also their complete electrolyte composition.

HydroMed, at 800-560-9007, sells a product based on Ringer's solution called Breathe Ease. It's convenient but somewhat expensive, costing $14.95 per package, enough for about 30 irrigations, which makes the cost per irrigation about 50 cents. In Europe you can obtain a similar product called SinuSal from Inmunotek at http://www.inmunotek.com/xcitekindex.htm

You can experiment with making your own Ringer's solution. You need only a tiny amount each of potassium chloride and calcium chloride -- about 1/30th of a teaspoon per U.S. pint (16 ounces of water), or just a pinch (there are different formulations of Ringer's solution, so the amount added doesn't have to be exact). Some people use saline solution packaged for use with contact lenses, though this is expensive, and contact lens solutions made with preservatives can potentially damage the sinuses' cilia.

Irrigation Additives

Some people are experimenting with, and some ENTs are recommending, other additives you can include with the saline solution when irrigating. You need to be careful, though, because small amounts of these additives are absorbed into the bloodstream through the sinuses' mucous membranes and there's a possibility of swallowing the solution when irrigating.

Two irrigation additives that are commonly used are Alkalol and Betadine. Alkalol is an old-time, traditional remedy that can be found or ordered from pharmacies or from Web sites such as MediChest.com for about $3 a bottle. It's a solution of eucalyptus oil, pine needle extract, other plant oils and extracts, and a tiny amount of alcohol, ingredients that together are thought to act as a mucus solvent. Some people find it soothing, others stimulating, others irritating. It's better to start with a small amount rather than the 50/50 ratio of Alkalol to saline indicated in the Alkalol directions.

Betadine (and its generic equivalents) is an iodine-based antiseptic used primarily on superficial skin wounds, though some doctors recommend it to help kill off the pathogens that cause sinus infections. It's best to use only a small amount -- from a few drops to a teaspoon -- to avoid potential harm to the thyroid or the kidneys. One technique is to first irrigate with Betadine and immediately afterward to irrigate again without it to wash it away. Some people are sensitive to iodine and should avoid Betadine altogether.

Some people are experimenting with other irrigation additives, including tea tree oil (Melaleuca alternifolia), available at health food stores and used for many years in Australia, where it originates. It's described as a germicide, fungicide, and antiseptic, and it's usually used for superficial skin wounds, vaginal candidiasis, foot fungus, and acne. It's very strong, so you need to dilute it -- one study found a 2 percent solution effective. Some people are sensitive to the byproducts created when it breaks down (photooxidizes) -- apparently it breaks down quickly and many commercial products contain these byproducts. Finally, some doctors advise against using it or any oil-based product in the sinuses, since any product in the sinuses can wind up in the lungs, and oil, Vaseline, etc., in the lungs can cause pneumonia.

Some ENTs are experimenting with antibiotics such as Bactroban (mupirocin) and gentamycin as irrigation additives. Ask your ENT about this.

Risks

Daily saline irrigation of the sinuses when done correctly is thought to be no more risky than daily hand washing. Problems can arise, however, if you do it incorrectly. Use too much salt and you can dry out your sinuses and impair the cilia. Use too little salt and you can increase swelling. Use too much baking soda and you may be left with an ammonia odor. Use water that's too hot or too cold and you can increase swelling. Use a Water Pik without an attachment, set the attachment too high, or use a bulb irrigator and squeeze too hard or when your clogged, and you can spread infection to other parts of your sinuses or to your ears. Irrigate too frequently and you may promote infection by removing from your sinuses the enzyme lysozyme, which acts as a natural defense against bacteria.

The benefits of irrigation, even frequent irrigation, are thought to be far greater than the risks, particularly if you have symptoms.

You can also damage your sinuses and spread infection by blowing your nose too hard. Some doctors in fact feel this is the most common cause of chronic sinusitis. In response, some people have advocated not blowing at all, just swallowing or spitting out mucus, but most doctors find this an extreme precaution (and swallowing too much mucus can cause nausea and potentially other gastrointestinal problems). When blowing, just be gentle. Many people find that unscented white tissues that contain lotion, such as Puffs Plus With Lotion, are best, as they prevent the outside of the nose from getting irritated.

After irrigating, you'll have to blow your nose to rid your sinuses of saline (and remaining mucus), preventing the saline from leaking or rushing out later, often without warning. The most effective technique has been called the "whale blow." Standing up, bend over with your head down for 20 to 30 seconds. Alternately, you can lie down on a bed and hang your head over the side. Have a paper towel or tissue in hand. Slowly rotate your head, moving one nostril upward while keeping the other nostril closed. When your nostril is as high as it will go (like a whale's blow hole breaking through the surface of the ocean), blow gently. Then do the same for the other nostril.

Optionally, you can then lie on your back, which can force any remaining saline and mucus to slide into your throat -- it's always best to spit this stuff out rather than swallow it. Sniff in, though not too hard. This can be a very effective way to complete the process of cleaning out your sinuses.