I have a sinus infection.
And I have been thinking a lot about three conversations I have had recently about neti pots. One of them was with someone wholly un-skeptical, who assured me that he has fewer sinus infections since he started using the neti pot. I asked how he knew he was having fewer sinus infections or that it was specifically the neti pot which was preventing them. He gave me an uncertain look, and I dropped it (because I really hadn’t looked into neti pots myself and did not have much to offer by way of evidence for or against them, although my instinct was to be skeptical of their efficacy). The second conversation was with a fellow skeptic, who said she swears by them. Again, I did not have anything to offer the conversation, but moved neti pots up on my prioritized mental list of “Things that I need to research more deeply.” A few days ago, a fellow biologist who suffers from severe allergies also promoted the use of a neti pot for flushing out the sinuses.
So I set about to answer a couple of questions pertaining to neti pot usage:
What is the history of neti pot usage?
Is the use of a neti pot harmful, neutral or beneficial?
Is neti pot usage a valid therapy to prevent the occurrence of sinusitis (sinus infections)?
And to be honest, I was all ready to write up a post about how a true skeptic changes her mind when the evidence is compelling. I wanted to shout from the roof tops that I was initially wrong, but that I have educated myself and now understand! Instead, and I will reveal the punch line now, I remain unconvinced either way.
What is the history of neti pot usage?
My first stop was Wikipedia
. Not by choice, but because it is invariably one of the top hits you get when searching for anything these days. Wikipedia was helpful in confirming the proper spelling of “neti” and (in addition to this awesome picture) provided me with additional search terms “saline nasal irrigation” and “nasal lavage.” Well, that sounded much less fruity to me, and I soon learned that the neti pot is just one of many tools for successful nasal irrigation. This technique is originally a Yogic and Ayurvedic treatment and describes the simple technique of pouring saline into one nostril and letting it run out through the other. Blech, but if it helps, I’m totally down to try it. So, if this technique has been floating around this long, AND has a fancy modern term to describe it, there must be LOADS of clinical research into the technique’s possible benefits… Eh, not so much.
I didn’t read much of the Wikipedia entry; instead, I scrolled to the bottom and looked through the list of references. Wikipedia cited some well known medical journals, some less well-known academic journals, and a few sketchy websites. A mixed bag of citations; not bad, but not great. Off to the literature for me.
Is saline nasal irrigation harmful, neutral or beneficial?
Almost every article I read attested to the safety of the treatment. Side effects, like a burning sensation or nasal irritation, are mild and rarely reported. One study had patients irrigating 2 to 6 times a day![1] It would appear that most studies agree that saline nasal irrigation is not harmful. Neutral or beneficial seems to be the key question…
Is it a valid therapy to prevent the occurrence of sinusitis (sinus infections)?
Side note: I have access to a library with institutional licensing for academic journals; if you do not, I highly recommend befriending someone who does. Everyone who calls themselves a skeptic needs to make an effort to read the primary literature whenever they can, otherwise you will always be dependent upon others’ interpretation.
So first I had to learn a bit about what a sinus infection is:
Healthy people’s respiratory tracts are protected from airborne contagion and debris by a mucociliary layer that lines the sinonasal cavity. This layer consists of columnar, ciliated epithelial cells and goblet cells bathed in mucus. Foreign particles are trapped in the sticky layer of mucus, and ciliary action propels the entire mucous layer out of the sinuses toward the nasopharynx. When this transport mechanism fails, rhinosinusitis occurs, usually in response to a virus, bacterium, irritant, or allergen.[2]
Blech. Rhinosinusitis is near the top of the list of most common disorders for which antibiotics are prescribed, and perhaps over prescribed. Rhinosinusitis accounts for huge health care costs and a large loss in productivity due to missed days of school or work.[3] It is a big problem that affects loads of people.
But somewhat surprisingly, there really isn’t a vast body of literature on the topic of nasal irrigation. The first problem with researching this technique is, how do you create a sham procedure to give to a control population? How do you fake shoving water up someone’s nose? Suggestions from the peanut gallery?
Therefore, the majority of studies assessing nasal irrigation have relied on qualitative data collected by interviewing patients on their perceptions of nasal irrigation usage and their self-reported changes in their symptoms. There are several types of questionnaires that get at quantifying the symptoms of rhinosinusitis and how they impact the patient’s quality of life; one of these is cheekily named the Sino-Nasal Outcome Test (SNOT20). I read several of these studies and was subjected to data such as one patient’s report that, “for me this is the magic cure for my sinuses.”[4]Really, that was an honest example of the data collected by this study. Then I found a neat meta-analysis that analyzed these types of studies, choosing only those few that met rigorous design standards (maybe one day Lisa will talk about the pit-falls of the meta-analysis, but they have many merits).[5] Long story short, their conclusions were that:
- Science Speak: Saline irrigation was better than no treatment for improving symptoms and disease specific quality of life scores. Plain English: Shoving water up your nose was better than doing nothing at all. Studies reported that patients viewed nasal irrigation as empowering because they had full control over the treatment. My main concern is that many of these studies lasted only a few weeks, and none of them lasted longer than 6 months, so there was very little control of the effect that seasons can have on your sinuses. If I filled out a SNOT20 today, and a few weeks from now, chances are my acute sinusitis attack will have cleared up and my scores would improve.
- Science Speak: Saline irrigation did not improve disease specific quality of life scores over a placebo treatment. Plain English: We compared nasal irrigation to other silly treatments, like reflexology, and they were all about the same.
- Science Speak: Saline irrigation improves disease specific quality of life scores as an addition to oral antihistamine therapy. Plain English: If you do this in addition to taking drugs, you will feel better, but this doesn’t tell us any more than the first conclusion did.
So, nasal irrigation with saline water makes people “feel” better. It leaves patients with the sense that their symptoms have improved, a finding that is supported by statistics. And there is some indication that using nasal irrigation translates to fewer days taking medication and few doctor visits. All very positive.
But what I really wanted to know is whether or not washing my nose with salt water prevents bugs and nasties from setting up house. What I was hoping to see was a comparison of two populations that suffer from chronic rhinosinusitis, one that used nasal irrigation and one that did not. Follow those groups for a couple years, and tell me if the group that is diligent about flushing water up their noses has fewer incidents of acute sinusitis attacks, after controlling for season, age, individual variation, etc. There was only one study that I found to be suggestive of the benefits of nasal irrigation, and interestingly, it was rejected from the meta-analysis because it was not a randomized controlled trial. This lone, not-yet replicated study showed that saline nasal irrigation reduced histamine concentrations in snot for up to 6 hours after treatment when compared to baseline histamine concentrations.[6]Histamine concentrations are indicators of mast cell activation indicative of infection or inflammation. A very tenuous link between sinus health and nasal irrigation, but perhaps the first step in collecting some compelling evidence.
Now this little lit review I have done here is far from exhaustive, but for me, it was far from convincing. So, I won’t nay-say if someone tells me using their neti pot makes them feel better, evidence suggests that is absolutely true. However, neti pots as a “magic cure for my sinus,” I think not. For now, the technique requiring use multiple times a day just doesn’t seem worth the trouble (if you would like some not-yet-agreed-upon clinical guidelines, check out the Mayo Clinic or U. Wisconsin Department of Family Health). I’ll stick to using tissues and decongestants.
____________________________________________
References
[1] Seppey M, Schweri T, Hausler R. Comparative randomised clinical study of tolerability and efficacy of Rhinomer Force 3 versus a reference product in post-operative care of the nasal fossae after endonasal surgery. ORL J Otorhinolaryngol Relat Spec 1996;58(2):87-92.
[2] Papsin B, McTavish A. Saline nasal irrigation: Its role as an adjunct treatment. Can Fam Physician. 2003 Feb; 49:168-73.
[3] Ray NF, Baraniuk JN, Thamer M, et al. Healthcare expenditures for sinusitis in 1996: contributions of asthma, rhinitis and other airway disorders. J Allergy Clin Immunol 1999;103:408 –14.
[4] Rabago D, BarrettB, Marchand L, Maberry R, Mundt, M.Qualitative aspects of nasal irrigation use by patients with chronic sinus disease in a multimethod study. Annals of Family Medicine 2006;4(4):295–301.
[5] Harvey R, Hannan SA, Badia L, Scadding G. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD006394.
[6] Georgitis, JW. Nasal hyperthermia and simple irrigation for perennial rhinitis. Changes in inflammatory mediators. Chest. 1994 Nov;106(5):1487-92 .
Hey P- sorry about the sinus infection. I got one a few years ago, and was told to ‘expect’ them annually. Apparently once the nasties have set up house, you are more susceptible in the future. I now use a neti at the first inkling of a cold, and haven’t had to be treated for a sinus infection since. Yay! More vague, negative results for you! My gut feeling is that it is helpful, when I get on it right away, my colds don’t seem to go to my nose as much as when I’m lazy about it. It’s also helpful for allergies. I can delay starting allergy meds in the spring if I am good about doing the neti.
Well if it helps one feel better then the productivity loss is mitigated, so the benefit is apparent.
even if it is a placebo of sorts, that still is effective to some degree. placebos have a well documented beneficial effects for the many who are convinced by their efficacy.
So…
If there is documented result of people feeling better, why stick to tissues? perhaps because this is pretty yucky, and while making you feel better, the neti-yuck effect will reduce productivity in those around you.
Spray coming in gushes out of your nose is just… ewww
then again, maybe its beneficial to household plants.
[...] skeptical take on neti pots came in handy battling some ridiculous forwards about them being good prophylactics against [...]
I don’t usually publish trackbacks in the comment section, but this one brought my attention to the fact that in online forums, the neti pot technique is recommended to prevent h1n1 flu virus. Ummmm, yikes. There is definitely no clinical evidence to back that up!
There’s a similar issue with testing various drugs that have obvious side effects, especially when the side effects are very unpleasant — such as with cancer drugs that cause severe nausea.
In the case of drug studies, researchers can sometimes deal with this by testing combinations: group 1 gets drug X, group 2 gets X + Y, and we see whether adding Y to the protocol improves things or not. But there are limits to that, and it’s really hard to find out whether X alone is better than nothing, when X makes you feel horrible for a couple of weeks or more. It’s not really ethical to give a set of your
victimsvolunteers something that you know won’t help them and will make them wish they’d stayed home.Here, of course, it’s even harder, because there’s something physical going on. Recent acupuncture studies have used the fact that “true” acupuncture has defined places to put the needles, so one group can get needles in the “wrong” places (and, hey, it turns out that it works just as well that way). There have also been studies where they’ve figured a way to touch the needles to the volunteers and make them think they’re being pushed in, when they’re not.
None of that can apply here. I can’t figure any way to “blind” this one.
I actually think the research is extremely inconclusive… all it shows is that there have not been many studies. That they don’t prove anything one way or the other. And it seems odd that having concluded that it is agreed that Neti Pots make you feel better you wouldn’t want to experience the anecdotal evidence for yourself.
The actual claim is simply that the irrigation removes irritants and relieves swelling. And that healthy mucous membranes fight infection better than irritated swollen mucous membranes. This seems extremely logical to me. My dentist (and most dentists) is a huge proponent of salt water rinses for the mouth for exactly the same reasons. So there are no claims that Neti pots “cure” anything… but simply that they create a healthier environment.
Beth makes a good point: One of the common problems with “alternative medicine” is that there are claims of efficacy, but no plausible medical explanation of the mechanism by which the therapy might work. We hear things about “toxins”, “energy paths”, “chi”, and so on. But in this case, there is a reasonable explanation. We can still be skeptical, but one of the mail skeptic “red flags” is absent.
Also, in this, as with pain, sleep, and other very subjective things, placebos arguably do work. If you have a malignant tumor, and you just think it’s gone, it’ll still kill you. If you have pain, nasal congestion, insomnia, and you think it’s gone… it’s gone, for any purpose that matters.
No question Neti pot works. If you don’t allow the critical mass of bacteria to build up in your nose, it is less likley to cause problems in your nose, or drip down to your trachea.
Mechanical removal of pollen and dirt from the nose helps minimize the allergic and inflammatory reactions. Re-wetting dry nasal tissues prevents cracking, bleeding, and would minimize inflammation.
Saline nasal sprays can do that. Doesn’t have to be a hand-crafted neti pot.
i tried a neti pot when i was sick because my sister swears by them. getting the salt water up my nose did help loosen up the congestion and kept me feeling clearer. this is especially good for me, since i’m nursing, and try to avoid cold medication.
unfortunately, one of my ears got all plugged up after using the neti pot. there was fluid in there, it was really painful, and took a few weeks to really get back to normal. this has never happened to me before or since, so i’m convinced it was the neti. i could be the world’s biggest idiot and incapable of doing it properly, but it’s convinced me that there is a potential for harm here. which is too bad, i’m a big fan of salt water. maybe people like me should just stick to the nasal sprays.
Any saline nasal irrigation will do, but just squirting some saline wont do the trick. It is all about volume. you have to wash out the pollen, allergins, mucus, and bacteria. The neti pot happens to be a handy way to do the nasal irrigation. Also it takes some time (a few weeks) to get the technique down, but once you do it is worth it. You will never see a well done study on Neti pots (unless it is done by the NIH ) because noone can make money off of such a study. The clogged ears does happen, it is matter of adjusting your technique.
The sad thing is that I did a journal club on an article that looked at nasal saline lavage in the treatment of sinusitis, but I can’t find the article nor the authors. What I remember that we concluded was that the benefit to harm ratio of nasal saline lavage was sufficiently low that if a patient wanted to try it, that it would unlikely to harm them and likely help.
That said, the other thing I remember from the journal club was that the authors had done a small study looking at nasal saline lavage as a preventative measure. The study was stopped early because the patients were developing ear infections at a higher rate. So it seems that if you’re going to do nasal saline lavage, do it when sick and not healthy.
I occasionally use a neti pot. But only to help rinse out when I am feeling stuffed up, to thin the mucus. With all the home remodeling we have been doing there can be quite a lot of dust stirred up. And when I had a cold it seemed to help get it drained. I don’t find it is of much benefit on a daily basis if I’m not having sysptoms.
Great post!
I love my neti pot! I use it to relieve congestion and pressure in my sinuses that result from colds or allergies. I don’t care if it prevents sinusitis or not, just getting that mucous flowing and out of my forehead is worth the price of ten neti pots.
My ENT cautioned me to wash it between uses (duh) because apparently a lot of people let them sit around for a long time and thus culture bacteria.
I am wondering not so much about whether this prevents sinus infections as if it provides relief after you’ve had a cold or sinus infection, when you feel like there’s dried out or thick mucus still sitting in your sinuses. I can often feel when there is a hard chunk of ick and eventually it will come out when I blow my nose. I’ve tried squirting nasal saline solution spray up my nose and it does help loosen stuff which I can then blow out. So usually after a cold, for several weeks, I’m left blowing globs of stuff out of my sinuses.
So what I’m wondering is if pouring the liquid in will clear out my sinuses more efficiently in the weeks after a bad cold, and thus make me more comfortable.
I wouldn’t claim sinus irrigation is a “magical” cure for all sinus ills. However, I can throw one more little bit of anecdotal evidence onto the pile:
1. I have personally found nasal irrigation very effective during pollen season in Atlanta, which can be brutal for allergy sufferers. In past years, I would need antihistamines every day for three months to avoid acute suffering. Using a neti pot twice a day has alleviated symptoms, to the point that I take antihistamines only one or two days out of the entire season.
2. I have also found it useful for symptom relief when I am suffering from a common head cold. I don’t claim it shortens the duration of the cold (compared to what?), or that it is any way a “cure”. It does help me keep my sinuses clear without decongestants, of which I’ve never been particularly fond.
For over 20 years, I had averaged six sinus infections a year due to chronic sinusitis. I’m one of those who laughs at homeopathy, and rolled my eyes when my new GP, fresh out of med school, told me to use a Neti pot while being treated for a sinus infection. But I figured it cost very little to try it, and if it hurried my recovery even a little it was worth a try. I did the sinus wash (using a baking soda/salt packet a little plastic teapot) in conjunction with the same antibiotics and same nasal spray I always used.
That was 12 months ago. I haven’t caught another cold or sinus infection since. I used it every day while being treated with the antibiotics and nasal spray, and then backed down to once a week (on the admittedly half-baked theory that this would keep the crust from re-accumulating). Maybe this was just the magic 83rd time of taking that combination of drugs, but I have to suspect that the wild card of adding the sinus wash played a role in pushing the efficacy of the treatment to a higher level.
I called the doc to discuss it with her, and her take was that the saline wash a) physically clears the sinuses (including gradually removing the crust you mention); b) the baking soda helps make the pH level less hospitable to bacteria, and c) the salt helps shrink swollen mucous membranes.
I had no expectation of the sinus wash working, so I don’t think the placebo effect played a significant role in my recovery; in fact, I only realized after about 3 months that I had been well for the longest stretch of time since my teens, and looked back then and decided there might be something to this sinus wash business after all.
“How do you create a sham procedure to give to a control population? How do you fake shoving water up someone’s nose?”
A simple option for a sham procedure would be to give people cotton swabs that you claim are treated with medicine and have them stick one up their nostril for a couple seconds each day instead of using a neti pot. This would likely be enough to invoke a placebo response, which should be sufficient to act as a sham procedure.
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In my experience the neti pot worked out wonderfully. I was a skeptic at first too, pouring saline solution up your nose? Thats ridiculous. Then I landed myself with a sinus infection, had no insurance to go to a doctor and all the meds I tried to clear the pressure and congestion didn’t work. I would blow my nose and it would come out clean but I still had trouble breathing and my teeth were so achy I could feel it with every step. So I bit the bullet and bought a neti pot and tried it out. did so daily for a week and my teeth were no longer hurting, I had productive nose blows and so I slowed down to every 3 days or so and now I just use it when I get sick, the air is super dry or allergies are having me wake up all uncomfortable.