You are leaving Medscape Education
Cancel Continue
Log in to save activities Your saved activities will show here so that you can easily access them whenever you're ready. Log in here CME & Education Log in to keep track of your credits.


Nasal Saline Irrigation May Relieve Chronic Sinonasal Symptoms

  • Authors: News Author: Laurie Barclay, MD
    CME Author:
    Désirée Lie, MD, MSEd
  • CME/CE Released: 11/26/2007
  • Valid for credit through: 12/12/2009
Start Activity

Target Audience and Goal Statement

This article is intended for primary care clinicians, otolaryngologists, infectious disease specialists, allergists, and other specialists who care for patients with chronic rhinosinusitis.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Compare the effect of nasal irrigation vs nasal spray on symptom frequency and severity in patients with chronic rhinosinusitis.
  2. Compare the use of medications, adverse effects, and compliance with nasal irrigation vs nasal spray in patients with chronic rhinosinusitis.


As an organization accredited by the ACCME, Medscape, LLC requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


  • Laurie Barclay, MD

    Laurie Barclay, MD, is a freelance reviewer and writer for Medscape.


    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.


  • Brande Nicole Martin

    Brande Nicole Martin is the News CME editor for Medscape Medical News.


    Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

CME Author(s)

  • Désirée Lie, MD, MSEd

    Clinical Professor, Family Medicine, University of California, Orange; Director, Division of Faculty Development, UCI Medical Center, Orange, California


    Contributor: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.

Accreditation Statements

    For Physicians

  • Medscape, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

    Medscape, LLC designates this educational activity for a maximum of 0.25 AMA PRA Category 1 Credit(s) . Physicians should only claim credit commensurate with the extent of their participation in the activity. Medscape Medical News has been reviewed and is acceptable for up to 300 Prescribed credits by the American Academy of Family Physicians. AAFP accreditation begins 09/01/07. Term of approval is for 1 year from this date. This activity is approved for 0.25 Prescribed credits. Credit may be claimed for 1 year from the date of this activity. AAFP credit is subject to change based on topic selection throughout the accreditation year.

    AAFP Accreditation Questions

    Contact This Provider

    For Nurses

  • This Activity is sponsored by Medscape Continuing Education Provider Unit.

    Medscape is an approved provider of continuing nursing education by the New York State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

    Awarded 0.25 contact hour(s) of continuing nursing education for RNs and APNs; None of these credits is in the area of pharmacology.

    Provider Number: 6FDKKC-PRV-05

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. Medscape encourages you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 5 years; at any point within this time period you can print out the tally as well as the certificates by accessing "Edit Your Profile" at the top of your Medscape homepage.

*The credit that you receive is based on your user profile.


Nasal Saline Irrigation May Relieve Chronic Sinonasal Symptoms

Authors: News Author: Laurie Barclay, MD CME Author: Désirée Lie, MD, MSEdFaculty and Disclosures

CME/CE Released: 11/26/2007

Valid for credit through: 12/12/2009


November 26, 2007 — Large-volume, low positive-pressure nasal irrigation with saline was more effective than saline sprays for the treatment of chronic nasal and sinus symptoms in a community-based population, according to the results of a prospective, randomized controlled trial published in the November issue of the Archives of Otolaryngology–Head Neck Surgery.

"Many otolaryngologists recommend use of irrigations for a wide array of sinonasal conditions," write Melissa A. Pynnonen, MD, from the University of Michigan Health System in Ann Arbor, and colleagues. "Nasal saline sprays are often used as an alternative to saline irrigations because saline spray is often perceived to be equivalent to and better tolerated than irrigation. . . . The present study was designed to compare the efficacy of saline spray with saline irrigation with respect to disease-specific quality of life change in a general population of patients with chronic nasal and sinus complaints."

In a community setting, 127 adults with chronic nasal and sinus symptoms were randomized to receive saline irrigation performed with large volume and delivered with low positive pressure
(n = 64) or saline spray (n = 63) for 8 weeks. The primary endpoints were change in severity of symptoms, which was reflected in a mean 20-Item Sino-Nasal Outcome Test (SNOT-20) score; change in frequency of symptoms measured with a global question; and change in medication use.

Of the 127 patients enrolled in this study, 121 were evaluable. At all 3 time points, the irrigation group had lower SNOT-20 scores vs the spray group: 4.4 points lower at 2 weeks (P = .02), 8.2 points lower at 4 weeks (P < .001), and 6.4 points lower at 8 weeks (P = .002). In symptom frequency, 40% of patients in the irrigation group reported symptoms "often or always" at 8 weeks, as did 61% in the spray group (absolute risk reduction, 0.2; 95% confidence interval, 0.02 - 0.38;
P = .01). Both groups had similar differences in sinus medication use.

Overall compliance was high in both groups, but participants in the spray group were more compliant than those in the irrigation group (P = .04). Adverse effects were common in both groups, but most were minor, and none led to discontinuation of treatment.

"Nasal irrigations performed with large volume and delivered with low positive pressure are more effective than saline sprays for treatment of chronic nasal and sinus symptoms in a community-based population," the study authors write. "The greater efficacy of irrigation over saline spray may be due to greater volume, increased delivery pressure, and mechanical debridement achieved with irrigations."

Limitations of the study include slightly insufficient power to detect change in medication use or to evaluate the potential heterogeneous subgroups of patients with nasal symptoms, lack of blinding, and the possibility for patient over-reporting of compliance.

"Our findings also suggest that the benefit of saline irrigations as adjunctive therapy for chronic nasal and sinus-related symptoms could be expanded beyond the otolaryngologist's armamentarium and incorporated into the general practice of other clinical health care providers who frequently evaluate patients with such symptoms," the study authors conclude. "Primary care physicians and physician extenders may prove to be essential in explaining the benefits and usefulness of saline irrigations to patients in the community."

NeilMed Pharmaceuticals, the maker of Sinus Rinse, the saline irrigation used in the study, supported this study. Three of the study authors have received funding. The remaining study authors have disclosed no relevant financial relationships.

Arch Otolaryngol Head Neck Surg. 2007;133:1115-1120.

Clinical Context

Chronic rhinosinusitis (CRS) affects 36 million Americans each year, and allergic and nonallergic forms of rhinitis affect millions more. Therapy is usually directed at the underlying cause and includes antibiotics, antihistamines, and anti-inflammatory drugs. Nonallergic rhinitis frequently coexists with allergic rhinitis, and nasal irrigation has been recommended to cleanse the nasal passages, with 2 recent trials demonstrating the efficacy of nasal irrigations in nonsurgical patients. Use of nasal saline may exert local effects of decreased viscosity of secretions; removal of debris; and decreased edema, allergens, and inflammatory mediators by a mechanical lavage action, but it is unclear whether nasal spray or nasal irrigation is more efficacious.

This is an 8-week randomized, open trial comparing the effects of nasal irrigation and nasal spray with use of normal saline solutions on the symptoms of CRS for 2 to 8 weeks of treatment.

Study Highlights

  • Included were adults aged 18 years or older who reported 1 or more of the following symptoms on 4 or more days per week for at least 15 days in 1 month: nasal stuffiness, nasal dryness or crusting, nasal congestion, and discolored or thick nasal discharge.
  • Excluded were those with recent upper respiratory tract infection, recent sinus surgery, or use of either intervention within 4 weeks.
  • Patients completed baseline and follow-up surveys at weeks 0, 2, 4, and 8 after randomization to either nasal irrigation (n = 64) or nasal spray (n = 63).
  • The surveys consisted of the SNOT-20, which is a measure of symptom severity; a global question about symptom frequency; and a medication diary.
  • The SNOT-20 measured physical problems, functional limitations, and emotional consequences on a scale of 0 to 100 points, with 100 indicating worse symptoms.
  • The question about symptom frequency measured frequency of symptoms with 5-point scale responses from "never" to "always."
  • The medication diary included all prescription and nonprescription medications for nasal and sinus symptoms.
  • Patients also reported compliance and adverse effects.
  • After randomization, patients were instructed in the use of nasal lavage for the irrigation group and nasal spray for the spray group and were asked to do the assigned treatment twice daily for 8 weeks.
  • Nasal irrigation was performed with large volume and delivered with low positive pressure.
  • Patients were permitted to continue taking their usual medications.
  • Outcomes were derived by mailed self-report questionnaires, and telephone calls were used to collect missing data.
  • Mean age of the participants was 47 years, one third were men, 75% were white, 14% were current smokers, and one third had quit smoking.
  • 45% had symptoms often and 49% had symptoms always, with 92% having symptom duration of 7 to 12 months.
  • Baseline SNOT-20 scores were similar in the 2 groups, and both groups improved at 8 weeks (P < .001 for each week), but the irrigation group showed consistently lower (better) scores at each follow-up point.
  • The decrease in SNOT-20 scores from baseline was 6.7 for the spray group, and the irrigation group had additional decreases of 4.4 points at week 2, 8.2 points at week 4, and 6.4 points at week 8 (all statistically significant).
  • At week 8, 40% of the irrigation group vs 61% of the nasal spray group reported having frequent symptoms, and frequent symptoms were significantly less likely among the irrigation group.
  • The odds of frequent symptoms for the irrigation vs the spray group were 0.49, and the absolute risk reduction was 0.2 for a number needed to treat of 5.
  • The absolute reduction in symptom severity for the irrigation vs the spray group was 0.15 for a number needed to treat of 7.
  • Both groups were more likely to use oral than nasal medications at all time points.
  • There was no significant difference in medication use between the 2 groups, and medication use decreased for both groups.
  • Compliance was higher in the spray vs the irrigation group (97%, 93%, and 93% at weeks 2, 4, and 8 vs 92%, 81%, and 79%, respectively).
  • Adverse effects were common and similar in both groups (25% for the spray and 43% for the irrigation group), and post treatment nasal drainage was the most common adverse effect.
  • The authors concluded that nasal irrigation was more effective than spray for CRS and that the intervention could be recommended by primary care clinicians.

Pearls for Practice

  • Use of nasal irrigation vs nasal spray in patients with CRS is associated with reduced symptom severity and frequency at 8 weeks.
  • Use of nasal irrigation vs nasal spray is associated with poorer compliance, similar adverse effects, and no difference in medication use at 8 weeks.


  • Print