Allergy and Asthma Source

ADJUNCTIVE THERAPY refers to something used together with the primary treatment or to aid the primary treatment. The article by no means suggests that nasal saline by itself is sufficient as treatment for chronic rhinosinusitis. Primary treatment for chronic rhinosinusitis often involves allergen avoidance/ medications/ immunotherapy, Sinus surgery, long-term antibiotic therapy, systemic steroids, and even antifungal therapy or a combination of these in addition to the nasal saline.
Patients with this condition should see an allergist and a sinus surgeon for comprehensive evaluation and management.

Nasal Saline May Be Effective for Chronic Rhinosinusitis

from Medscape Medical News
News Author: Laurie Barclay, MD

July 20, 2007 — Nasal saline is effective as sole treatment of chronic rhinosinusitis and as adjunctive therapy, according to the results of a meta-analysis published online in the July 18 issue of the Cochrane Database of Systematic Reviews.

“The use of nasal irrigation for the treatment of nose and sinus complaints has its foundations in yogic and homeopathic traditions,” write Richard Harvey from John Radcliffe Hospital in Oxford, United Kingdom, and colleagues. “There has been increasing use of saline irrigation, douches, sprays and rinsing as an adjunct to the medical management of chronic rhinosinusitis.”

The authors note that treatment regimens may incorporate nasal saline irrigation used once to more than 4 times daily, typically requiring much patient effort. However, it has been difficult to distinguish any additional benefit from saline vs that of other therapeutic interventions used in the regimen.

Using the Cochrane Ear, Nose, and Throat Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials through 2006, MEDLINE from 1950 to 2006, and EMBASE from 1974 to 2006, the authors searched through November 2006 for randomized controlled trials of saline irrigation vs no treatment or placebo, as an adjunct to other treatments, or compared with other treatments. They also compared findings with hypertonic saline vs isotonic saline solutions.

Using Cochrane criteria, the authors evaluated the methodologic quality of trials. Symptom scores comparing saline treatment with no treatment were pooled for statistical analysis, as were symptom and radiologic scores from the hypertonic group vs isotonic group, and the other findings were described in narrative fashion.

Of 8 trials meeting the inclusion criteria, 3 compared saline irrigation with no treatment, 1 compared saline irrigation with placebo, 1 evaluated saline irrigation as an adjunct to intranasal steroid spray, 1 compared it with an intranasal steroid spray, and 2 studies compared different hypertonic solutions with isotonic saline.

The meta-analysis suggested that saline alleviated the symptoms of chronic rhinosinusitis when used alone as treatment, and some data also supported the use of saline as adjunctive therapy. However, saline was not superior to a reflexology “placebo,” and it was less effective than an intranasal steroid.

Some evidence suggested that hypertonic solutions improved objective measures, but the effect on symptoms was not as clear. No recommendations could be made regarding specific solutions, dosage, or delivery.

“Saline irrigations are well tolerated,” the authors write. “Although minor side effects are common, the beneficial effect of saline appears to outweigh these drawbacks for the majority of patients. The use of topical saline could be included as a treatment adjunct for the symptoms of chronic rhinosinusitis.”

The authors note that there is considerable variability in the tools used to evaluate outcomes of treatment of rhinosinusitis and that additional research is needed in this area.

“Validated and accurate patient-centered outcome tools should always be preferred over ad hoc or customised questionnaires,” the authors conclude. “A review of evidence for the physiological impact of saline that might explain the beneficial effect, most appropriate delivery technique, tonicity, frequency and volume of topical nasal saline is also required.”

This review had no sources of support. The authors have disclosed no relevant financial relationships. One author has disclosed being supported by Oxford Nufeld Medical Fellowship UK.

Cochrane Database Syst Rev. Published online July 18, 2007.

From the American Academy of Allergy, Asthma, and Immunology:  

Topic of the Month: December 2006: Sinusitis FAQs

AAAAI Sinusitis Video

Pediatric Sinusitis Video

What is sinusitis?
Sinusitis is an inflammation of one or more of the paranasal sinuses, the hollow cavities within the cheek bones found around the eyes and behind the nose. The primary functions of these sinuses are to warm, moisten and filter the air in the nasal cavity. They also play a role in our ability to vocalize certain sounds.

Sinusitis can affect the nose, eyes, or middle ear. Symptoms of sinusitis include some or all of the following:

• Thick yellow-green nasal discharge
• Bad-tasting post-nasal drip
• Cough
• Head congestion and an accompanying headache
• Nasal congestion
• Feeling of facial swelling and pressure
• Toothache
• Constant tiredness

Are there different kinds of sinusitis?
Sinusitis can be divided into acute, chronic and recurrent. The classifications are based on length of symptoms, or the specific sinus involved, or both. The classification is as follows:

• Acute sinusitis: symptoms for less than 4 weeks consisting of some or all of the following: persistent symptoms of an upper respiratory tract infection, purulent rhinorrhea, postnasal drainage, anosmia, nasal congestion, facial pain, headache, fever, cough, and purulent discharge.
• Chronic sinusitis: symptoms for 12 weeks or longer of varying severity consisting of the same symptoms as seen in acute sinusitis. In chronic sinusitis there should be abnormal findings on CT or MRI. Some patients with chronic sinusitis might present with vague or insidious symptoms.
• Recurrent sinusitis: three or more episodes of acute sinusitis per year. Patients with recurrent sinusitis might be infected by different organisms at different times.

Who gets sinusitis?
Sinusitis is one of the most diagnosed diseases in the United States. It affects approximately 16% of the adult population and is responsible for nearly $5.8 billion in health care costs annually.

Although colds are the most common cause of acute sinusitis, it is more likely that people with other allergic diseases such as allergies or asthma, will develop sinusitis. Allergies can trigger inflammation of the sinuses and nasal mucous linings. This inflammation prevents the sinus cavities from clearing out bacteria, and increases your chances of developing sinusitis. The incidence of sinusitis in asthma patients ranges from 40%-75% as well.

If you test positive for allergic disease, your allergist/immunologist can suggest the appropriate treatments to control your symptoms, and thus reducing the risk of developing an infection. People with sinus problems should avoid environmental irritants such as tobacco smoke and strong chemical odors, which may increase symptoms.

Another cause of sinusitis is structural problems in the nose - such as narrow drainage passages, tumors or polyps, or a deviated nasal septum (the bone and cartilage between the left and right sides of the nose) - may be another cause of sinusitis. Surgery is sometimes needed to correct these problems, but only after all other medical treatments have failed.

Who diagnoses sinusitis?
Allergist/immunologists diagnose sinusitis based on a combination of clinical history, physical examination, imaging studies, and/or laboratory tests. An allergist/immunologist will be able to help you manage your sinusitis, and will determine if an allergic disease is contributing to your condition. He/she will also determine what triggers your symptoms, as well as other triggers that may be causing sinus obstruction, and recommendations on how to treat that infection. An allergist/immunologist can also determine if a visit with an ENT/Otolaryngologist is needed for consideration of surgery for the sinusitis.

Allergist/immunologists are specialists trained in evaluating for all possible conditions related to sinusitis. These physicians use a management strategy to not only treat current infections, but to also provide management that lowers the risk for future sinus infections. Allergist/immunologists can also help to determine when surgery is indicated as part of the overall management. If you have questions about any of these treatments, be sure to ask your allergist/immunologist for more information.

The AAAAI’s How the Allergist/Immunologist Can Help: Consultation and Referral Guidelines Citing the Evidence provide information to assist patients and health care professionals in determining when a patient may need consultation or ongoing specialty care by the allergist/immunologist. Patients should see an allergist/immunologist if they:

• Have chronic or recurrent infectious rhinosinusitis.
• Have other types of chronic rhinosinusitis
• Have allergic fungal rhinosinusitis.

What are treatments for sinusitis?
Sinusitis generally requires a combination of therapies. Allergist/immunologists should withhold from prescribing antibiotics for 10-14 days, unless severe symptoms develop such as fever, facial pain or tenderness, or swelling around the eye. An allergist/immunologist may also prescribe a medication to reduce blockage or to control allergies to help keep the sinus passages open. This medicine may be a decongestant, a mucus-thinning medicine or a cortisone nasal spray. Antihistamines, cromolyn and topical steroid nasal sprays help control allergic inflammation. Other treatments that can be helpful to control and reduce symptoms of sinusitis include, breathing in hot, moist air, applying hot packs, and washing the nasal cavities with salt water.

How can sinusitis be prevented?
If you have predisposing conditions that lead to excess mucus and inflammation of the nose, such as allergic disease, structural problems or are in a profession that leads to greater risk for developing these conditions, you are more likely to develop sinusitis and should contact an allergist/immunologist for prevention methods.

Any of kind of predisposing factors makes it important to have a long-term management plan to help control allergic diseases and to keep the nasal inflammation well controlled with medications between sinusitis episodes, and consideration of surgical repair of structural abnormalities, if present and all other medical treatments have failed.

Additional Resources:

• Allergy Asthma Source: Sinusitis