Is nasal saline irrigation all it is cracked up to be?

The Role of Seawater and Saline Solutions in Treatment of Upper Respiratory Conditions

The history of saline nasal irrigation (SNI) is indeed a long one, beginning from the ancient Ayurvedic practices and gaining a foothold in the west at the beginning of the 20th century. Today, there is a growing number of papers covering the effects of SNI, from in vitro studies to randomized clinical trials and literature overviews. Based on the recommendations of most of the European and American professional associations, seawater, alone or in combination with other preparations, has its place in the treatment of numerous conditions of the upper respiratory tract (URT), primarily chronic (rhino)sinusitis, allergic rhinitis, acute URT infections and postoperative recovery. Additionally, taking into account its multiple mechanisms of action and mounting evidence from recent studies, locally applied seawater preparations may have an important role in the prevention of viral and bacterial infections of the URT. In this review we discuss results published in the past years focusing on seawater preparations and their use in clinical and everyday conditions, since such products provide the benefits of additional ions vs. saline, have an excellent safety profile and are recommended by most professional associations in the field of otorhinolaryngology.

Hypertonic saline and seawater solutions damage sinonasal epithelial cell air-liquid interface cultures

BACKGROUND

Nasal irrigation (NI) is commonly used to treat several sinonasal diseases, including chronic rhinosinusitis with nasal polyps (CRSwNP); however, the effects of NI on the sinonasal epithelium are not fully known. The aim of this study was to investigate the effects of commonly used NI solutions on epithelial mucociliary and barrier functionality in primary cultured human nasal epithelial cells (HNECs).

METHODS

HNECs from control subjects and patients with CRSwNP were established as air-liquid interface (ALI) cultures. Differentiated cultures were treated with different NI solutions, including isotonic 0.9% and hypertonic 3.0% saline, isotonic and hypertonic seawater, and Ringer lactate solution. The changes in ciliary beat frequency (CBF), numbers of ciliated and goblet cells, and cytotoxicity were measured. Epithelial barrier functionality was assessed by measuring the transepithelial electric resistance (TER), paracellular flux, and expression of tight junction protein zonula occludens-1 (ZO-1) and occludin.

RESULTS

Isotonic saline, isotonic seawater, and Ringer lactate solutions did not affect epithelial mucociliary and barrier function in either control or CRSwNP-derived ALI cultures; however, hypertonic saline induced a significant disruption of these cell functions in both cultures. Hypertonic seawater caused a transient decrease of CBF and TER in CRSwNP-derived ALI cultures, in contrast to inducing an obvious mucociliary and barrier dysfunction and cytotoxicity in control ALI cultures.

CONCLUSION

Although isotonic NI solutions appear to not affect epithelial mucociliary and barrier function in control and CRSwNP-derived ALI cultures, hypertonic saline and seawater solutions damaged sinonasal epithelial cells in ALI cultures. The safety and efficacy of these solutions requires further investigation.

[Nasal irrigation: opportunities and disadvantages]

RELEVANCE

Despite the widespread use of nasal irrigation in routine medical practice and a significant list of salt solution for nasal irrigation on the pharmaceutical market, contradictions remain in understanding of process essence, when salt solution acts on the mucous membrane of nasal cavity and evaluation of their effectiveness.

AIM

analysis of current data of frequency, methods and efficiency of systematic nasal irrigation and effect of salt solution at the mucous membrane of nasal cavity.

RESULTS

In review the authors generalized and analyzed recent information about meaning of nasal irrigation for upper respiratory tract disease, about role of nasal mucus at maintaining homeostasis in nasal cavity and initial respiratory tract in general. Describes the data about effect of nasal irrigation on antinfectious protect of mucous membrane of nasal cavity.

Supervised Nasal Saline Irrigations in Otitis-Prone Children

Objectives: To retrospectively investigate the impact of supervised daily nasal saline irrigations (NSI) with 0. 9% saline solution in children with a history of recurrent acute otitis media (RAOM). Methods: A retrospective pilot study was planned to evaluate the possible effect of supervised NSI in reducing the number of acute otitis media (AOM) episodes in otitis-prone children aged 1-5 years, compared to children not instructed to correct NSI performance. Results: Analysis was based on the data contained in 173 charts (57.3% males, mean age of 30.9 ± 7.3 months). 52.0% of children had not been instructed to perform NSI, while the remaining (48.0%) patients had received supervised NSI. At the 4-months follow-up visit a significant reduced number of AOM episodes (1.03 ± 0.14 vs. 2.08 ± 0.16; p < 0.001) as well as antibiotic treatments (1.48 ± 0.17 vs. 2.59 ± 0.18; p < 0.001) was documented in children receiving supervised NSI compared to those not instructed for NSI performance. Conclusions: These data suggest that NSI should be considered in the therapeutic management of children with RAOM, and should be routinely prescribed as a daily adjunctive treatment to reduce acute infectious exacerbations in otitis-prone patients. Accurate parents training is crucial in order to improve children compliance and treatment effectiveness.

The effects of nasal irrigation with various solutions after endoscopic sinus surgery: systematic review and meta-analysis

Background

Nasal irrigation is commonly performed in patients with chronic rhinosinusitis after functional endoscopic sinus surgery. This study systematically assessed the clinical efficacy of nasal irrigation from the medical literature.

Methods

The PubMed, Embase and Cochrane Central Register of Controlled Trials databases were searched using a comprehensive strategy, limited to English-language articles, published from October 1971 to March 2017, and comprising human subjects.

Results

A total of 824 trials were identified, 5 of which, involving 331 participants, were included in this systematic review. After selection, only three trials were eligible for inclusion in a meta-analysis. Nasal irrigation using normal saline and various solutions was found to be effective in reducing symptom scores and endoscopic scores for chronic rhinosinusitis patients after functional endoscopic sinus surgery. Comparison of outcome measures, such as eosinophil count reduction, revealed that various solutions are more effective than normal saline alone; however, no statistical significance was found in terms of reduced symptom or endoscopic scores.

Conclusion

Based on the current limited evidence, nasal irrigation is an effective therapy for chronic rhinosinusitis patients after functional endoscopic sinus surgery. However, when comparing various solutions with normal saline, no significant difference was found in symptom scores or endoscopic scores.

Effect of the temperature of nasal lavages on mucociliary clearance: a randomised controlled trial

BACKGROUND

The respiratory epithelium is mainly constituted by caliciform (produces mucus, responsible of keeping moisture and trapping particles) and ciliated cells (transports mucus into the pharynx, by the movement of multiple cilia). For centuries, nasal lavages have been used for different rhinosinusal conditions. Some studies suggest not only a direct effect on the mobilisation of secretions, but also an improvement in mucociliary clearance rates. To our knowledge, the impact of temperature in nasal lavages has been scarcely studied.

METHODOLOGY/PRINCIPAL

We used the saccharin test-applying it in the inferior turbinate and timing the detection of its taste-, to estimate mucociliary clearance rates before and after nasal lavages with saline solution at room (20 °C) or body (37 °C) temperatures.

RESULTS

78 healthy subjects were studied, with a mean saccharin test time of 13.88 min. Then, a nasal lavage was performed, half with 20 °C saline and the other with 37 °C. In both, times improved from baseline (from 13.66 to 11.59 and 14.06 to 9.4 min, respectively) with p values < 0.05.

CONCLUSIONS

Nasal lavages with saline solution improve mucociliary clearance as measured by saccharin test. Temperature seems to matter, which should be taken into account when indicating nasal lavages to our patients.

Saline irrigation for allergic rhinitis

BACKGROUND

Allergic rhinitis is a common condition affecting both adults and children. Patients experience symptoms of nasal obstruction, rhinorrhoea, sneezing and nasal itching, which may affect their quality of life.Nasal irrigation with saline (salty water), also known as nasal douching, washing or lavage, is a procedure that rinses the nasal cavity with isotonic or hypertonic saline solutions. It can be performed with low positive pressure from a spray, pump or squirt bottle, with a nebuliser or with gravity-based pressure in which the person instils saline into one nostril and allows it to drain out of the other. Saline solutions are available over the counter and can be used alone or as an adjunct to other therapies.

OBJECTIVES

To evaluate the effects of nasal saline irrigation in people with allergic rhinitis.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the ENT Trials Register; CENTRAL; Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 November 2017.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing nasal saline irrigation, delivered by any means and with any volume, tonicity and alkalinity, with (a) no nasal saline irrigation or (b) other pharmacological treatments in adults and children with allergic rhinitis. We included studies comparing nasal saline versus no saline, where all participants also received pharmacological treatment (intranasal corticosteroids or oral antihistamines).

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Primary outcomes were patient-reported disease severity and a common adverse effect - epistaxis. Secondary outcomes were disease-specific health-related quality of life (HRQL), individual symptom scores, general HRQL, the adverse effects of local irritation or discomfort, ear symptoms (pain or pressure) and nasal endoscopy scores. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included 14 studies (747 participants). The studies included children (seven studies, 499 participants) and adults (seven studies, 248 participants). No studies reported outcomes beyond three months follow-up. Saline volumes ranged from 'very low' to 'high' volume. Where stated, studies used either hypertonic or isotonic saline solution.Nasal saline versus no saline treatmentAll seven studies (112 adults; 332 children) evaluating this comparison used different scoring systems for patient-reported disease severity, so we pooled the data using the standardised mean difference (SMD). Saline irrigation may improve patient-reported disease severity compared with no saline at up to four weeks (SMD -1.32, 95% confidence interval (CI) -1.84 to -0.81; 407 participants; 6 studies; low quality) and between four weeks and three months (SMD -1.44, 95% CI -2.39 to -0.48; 167 participants; 5 studies; low quality). Although the evidence was low quality the SMD values at both time points are considered large effect sizes. Subgroup analysis showed the improvement in both adults and children. Subgroup analyses for volume and tonicity were inconclusive due to heterogeneity.Two studies reported methods for recording adverse effects and five studies mentioned them. Two studies (240 children) reported no adverse effects (epistaxis or local discomfort) in either group and three only reported no adverse effects in the saline group.One study (48 children) reported disease-specific HRQL using a modified RCQ-36 scale. It was uncertain whether there was a difference between the groups at any of the specified time points (very low quality). No other secondary outcomes were reported.Nasal saline versus no saline with adjuvant use of intranasal steroids or oral antihistamines Three studies (40 adults; 79 children) compared saline with intranasal steroids versus intranasal steroids alone; one study (14 adults) compared saline with oral antihistamines versus oral antihistamines alone. It is uncertain if there is a difference in patient-reported disease severity at up to four weeks (SMD -0.60, 95% CI -1.34 to 0.15; 32 participants; 2 studies; very low quality) or from four weeks to three months (SMD -0.32, 95% CI -0.85 to 0.21; 58 participants; 2 studies; very low quality). Although none of the studies reported methods for recording adverse effects, three mentioned them: one study (40 adults; adjuvant intranasal steroids) reported no adverse effects (epistaxis or local discomfort) in either group; the other two only reported no adverse effects in the saline group.It is uncertain if saline irrigation in addition to pharmacological treatment improved disease-specific HRQL at four weeks to three months, compared with pharmacological treatment alone (SMD -1.26, 95% CI -2.47 to -0.05; 54 participants; 2 studies; very low quality). No other secondary outcomes were reported.Nasal saline versus intranasal steroidsIt is uncertain if there was a difference in patient-reported disease severity between nasal saline and intranasal steroids at up to four weeks (MD 1.06, 95% CI -1.65 to 3.77; 14 participants; 1 study), or between four weeks and three months (SMD 1.26, 95% CI -0.92 to 3.43; 97 participants; 3 studies), or indisease-specific HRQL between four weeks and three months (SMD 0.01, 95% CI -0.73 to 0.75; 83 participants; 2 studies). Only one study reported methods for recording adverse effects although three studies mentioned them. One (21 participants) reported two withdrawals due to adverse effects but did not describe these or state which group. Three studies reported no adverse effects (epistaxis or local discomfort) with saline, although one study reported that 27% of participants experienced local discomfort with steroid use. No other secondary outcomes were reported.

AUTHORS' CONCLUSIONS

Saline irrigation may reduce patient-reported disease severity compared with no saline irrigation at up to three months in both adults and children with allergic rhinitis, with no reported adverse effects. No data were available for any outcomes beyond three months. The overall quality of evidence was low or very low. The included studies were generally small and used a range of different outcome measures to report disease severity scores, with unclear validation. This review did not include direct comparisons of saline types (e.g. different volume, tonicity).Since saline irrigation could provide a cheap, safe and acceptable alternative to intranasal steroids and antihistamines further high-quality, adequately powered research in this area is warranted.

Cytokine-Ion Channel Interactions in Pulmonary Inflammation

The lungs conceptually represent a sponge that is interposed in series in the bodies’ systemic circulation to take up oxygen and eliminate carbon dioxide. As such, it matches the huge surface areas of the alveolar epithelium to the pulmonary blood capillaries. The lung’s constant exposure to the exterior necessitates a competent immune system, as evidenced by the association of clinical immunodeficiencies with pulmonary infections. From the in utero to the postnatal and adult situation, there is an inherent vital need to manage alveolar fluid reabsorption, be it postnatally, or in case of hydrostatic or permeability edema. Whereas a wealth of literature exists on the physiological basis of fluid and solute reabsorption by ion channels and water pores, only sparse knowledge is available so far on pathological situations, such as in microbial infection, acute lung injury or acute respiratory distress syndrome, and in the pulmonary reimplantation response in transplanted lungs. The aim of this review is to discuss alveolar liquid clearance in a selection of lung injury models, thereby especially focusing on cytokines and mediators that modulate ion channels. Inflammation is characterized by complex and probably time-dependent co-signaling, interactions between the involved cell types, as well as by cell demise and barrier dysfunction, which may not uniquely determine a clinical picture. This review, therefore, aims to give integrative thoughts and wants to foster the unraveling of unmet needs in future research.

The acceptability and tolerability of nasal douching in children with allergic rhinitis: A systematic review

BACKGROUND

Allergic rhinitis (AR) is a significant issue in children. Treatment options include allergen avoidance, pharmacotherapy and immunotherapy. The use of nasal saline douching (NSD) in children has recently gained acceptability. However, there is limited data regarding the acceptability and tolerability of NSD in children with AR.

METHODS

A search was conducted using Medline and Embase databases from January 1946 until June 2015 on the use of NSD in children aged 4-12 years with AR. All publications identified that assessed the beneficial effects, acceptability and tolerability were included.

RESULTS

40 studies were analyzed. Data varied considerably in terms of saline solutions used, modality of application, participant numbers, study design, follow up and outcomes. Factors that appear to influence the acceptability and tolerability of NSD include parental and health professionals' preconceptions, and characteristics of the solution.

CONCLUSIONS

Nasal saline douching appears to be effective, being accepted and tolerated in the majority of children (78-100%). NSD has a significant positive impact on the quality of life in children with allergic rhinitis. When used as an adjunctive treatment having mainly a cleansing property, NSD potentiates the effects and may reduce the dose required of AR medications. Among the principal factors that influence the acceptability and tolerability of NSD are the child's age, delivery system and method, and tonicity. Nasal saline douching provides an accessible, low cost, low morbidity, easy to use treatment in children with allergic rhinitis.

Normal saline solution nasal-pharyngeal irrigation improves chronic cough associated with allergic rhinitis

BACKGROUND

Upper airway inflammation is one of the most commonly identified causes of chronic cough, although the underlying mechanism is not clear. This study compared normal saline solution nasal-pharyngeal irrigation (NSNPI) and fluticasone propionate nasal spray (FPNS) treatment for chronic cough associated with allergic rhinitis (AR).

METHODS

Patients with suspected AR to house-dust mite were enrolled, and the symptom of cough was assessed by a cough symptom score and the Leicester Cough Questionnaire, and cough response to capsaicin was evaluated. AR was assessed by using the visual analog scale (VAS) and the Mini Juniper Rhinoconjunctivitis Quality of Life Questionnaire (MiniRQLQ). Mediators, including histamine, leukotriene C4, and prostaglandin D2, and the major basic protein from nasal lavage fluid (NLF) were examined. The patients were treated with NSNPI (the NSNPI group) or FPNS (the FPNS group) for 30 days, after which they were reassessed.

RESULTS

Forty-five of 50 patients completed this study. The scores of the cough symptom and the Leicester Cough Questionnaire, and the capsaicin cough threshold all improved statistically after NSNPI but did not change after FPNS. There were statistically significant changes in the evaluations of the MiniRQLQ and the mediators, including histamine and leukotriene C4, in the NLF in the NSNPI group. However, significant changes were found in the assessments of VAS, MiniRQLQ, and all above mediators including histamine, leukotriene C4, and prostaglandin D2, and the major basic protein in the NLF of the FPNS group. Furthermore, the assessments of VAS and all the mediators were reduced more in the FPNS group compared with those in the NSNPI group.

CONCLUSION

The patients with suspected AR to house-dust mite reported a better relief of the cough symptom after 30 days of treatment with NSNPI compared with that after nasal corticosteroid.

Variations in peak nasal inspiratory flow among healthy students after using saline solutions

Introduction

Nasal hygiene with saline solutions has been shown to relieve congestion, reduce the thickening of the mucus and keep nasal cavity clean and moist.

Objective

Evaluating whether saline solutions improve nasal inspiratory flow among healthy children.

Methods

Students between 8 and 11 years of age underwent 6 procedures with saline solutions at different concentrations. The peak nasal inspiratory flow was measured before and 30 min after each procedure. Statistical analysis was performed by means of t test, analysis of variance, and Tukey's test, considering p < 0.05.

Results

We evaluated 124 children at all stages. There were differences on the way a same concentration was used. There was no difference between 0.9% saline solution and 3% saline solution by using a syringe.

Conclusion

The 3% saline solution had higher averages of peak nasal inspiratory flow, but it was not significantly higher than the 0.9% saline solution. It is important to offer various options to patients.

Intranasal spray medications for maintenance therapy of allergic rhinitis

BACKGROUND

Intranasal sprays are recommended as targeted therapy for allergic rhinitis (AR) by providing direct delivery of medication to the nasal mucosa, reducing the potential for systemic adverse effects, decreasing burden of disease, and improving quality of life.

OBJECTIVE

To review currently available intranasal sprays indicated for maintenance therapy of AR in the United States: intranasal antihistamines (INAH); intranasal corticosteroids (INCS); and MP-AzeFlu, a single formulation nasal spray of the INAH, azelastine hydrochloride, and the INCS, fluticasone propionate.

METHODS

MEDLINE searches were conducted to identify placebo-controlled studies of commercially available prescription nasal sprays at U.S.-approved doses and indications, and published after an earlier systematic review of AR treatment. Inclusion criteria were ≥20 subjects; duration of ≥2 weeks for seasonal (or episodic) AR, ≥4 weeks for perennial (or persistent) AR, and reporting a total nasal symptom score as a primary or secondary outcome.

RESULTS

Twenty studies met the inclusion criteria: 4 pediatric, 16 adult/adolescent. There were 4 perennial AR studies (381 children, 1607 adults) and 16 seasonal AR trials (3081 children, 6548 adults). In these studies, 2451 subjects (481 children, 1970 adults) received an INCS, 3001 (1116 children, 1885 adults) received an INAH, and 346 adult subjects received MP-AzeFlu. All active treatments were well tolerated and effective as measured by the reduction in nasal symptoms. Head-to-head comparisons were only available for MP-AzeFlu versus the individual active agent components. MP-AzeFlu provided significantly greater symptom relief than either azelastine or fluticasone propionate alone and with an onset starting at 30 minutes after the dose.

CONCLUSION

The most recent addition to intranasal sprays for the maintenance therapy of AR is MP-AzeFlu, a single formulation nasal spray of azelastine hydrochloride and fluticasone propionate in an advanced delivery system. Analysis of clinical data showed this to be the first new intranasal medication that provides greater clinical benefit than an INCS in treating AR.

Food and environmental allergies

Immunoglobulin E-mediated allergic responses to food and environmental allergens can cause symptoms ranging from mild allergic rhinitis and rashes to gastrointestinal distress and, most seriously, anaphylaxis. The diagnosis can be difficult, as it relies on complex interplay between patient history and diagnostic tests with low specificity. Adding to the difficulty in confirming the diagnosis is an increased public interest in food intolerances, which can be inappropriately attributed to an allergic response. Treatment of allergic diseases with avoidance strategies and pharmacologic treatments can improve quality of life and control of other chronic conditions, such as asthma and eczema.

Nasal saline irrigation has no effect on normal olfaction: a prospective randomized trial

BACKGROUND

Nasal saline irrigation is a safe treatment for chronic rhinosinusitis; however, its effect on olfaction is unclear. Cyclic adenosine monophosphate (cAMP) is a key second messenger in the mechanism of olfaction and has been shown to be associated with smell function. In animal studies, olfactory cilia may be harvested by simple saline preparations. This study aimed to characterize the effect of nasal saline irrigation on smell function.

METHODS

Volunteers with normal olfaction were randomized into a control or irrigation cohort. In the initial appointment, subjects completed a University of Pennsylvania Smell Identification Test (UPSIT) and nasal samples were obtained by 2 methods: the nasal curette and cytobrush. The irrigation cohort performed daily nasal saline irrigations. Both cohorts then returned in 1 week. The UPSIT and nasal cell collection were repeated, and each subject completed a subjective olfactory transition scale. Nasal samples were processed for cAMP levels using a commercial assay.

RESULTS

Thirty-two subjects were enrolled and randomized into each cohort. Control and postirrigation mean UPSIT scores were 36.8 and 36.7 (p = 0.48). No subjects reported a subjective smell loss. Ten pairs of nasal samples were assayed. Using the curette, control and postirrigation cAMP levels were 509 and 490 fmol/(mg/mL), respectively (p = 0.94). Using the cytobrush, respective cAMP levels were 424 and 449 fmol/(mg/mL), respectively (p = 0.94).

CONCLUSION

Nasal saline irrigation has no subjective or objective effect on olfaction. It also does not appear to affect cAMP levels, a potential marker of smell function.

The normative value of inflammatory cells in the nasal perfusate of Chinese adults: a pilot study

OBJECTIVE

To establish stable, well-accepted nasal perfusion and a normative value of classifying cells in the nasal perfusate of Chinese adults.

METHODS

A total of 500 healthy adults were divided into two groups of 250 people per group (group A, 16-30 years old and group B, 31-60 years old; male-to-female ratio, 1:1). All volunteers were non-smokers; they were irrigated with saline, and multiple inflammatory cells in the perfusate were analyzed.

RESULTS

Irrigation was successfully performed in 479 cases, a success rate of 95.80%. The types of inflammatory cells showed a skewed distribution. The median number and interquartile range (IQR) of eosinophils were 0 and 0.2, respectively. These values were 0.4 and 2.2, respectively, for neutrophils and 0 and 0, respectively, for both lymphocytes and macrophages. There was no significant difference between males and females (P>0.05). There was a significant difference in the numbers of neutrophils and lymphocytes in the different age groups (P=0.000), but there was no significant difference in the numbers of eosinophils and macrophages (P>0.05). The 95% unilateral upper limited values (UULVs) of eosinophils and neutrophils in the nasal perfusates were 2.99 and 14.94, respectively, for group A and 1.41 and 17.08 for group B. As a result, the total 95% UULVs of eosinophils and neutrophils in the nasal perfusate were 2.00 and 16.80.

CONCLUSIONS

We established stable, well-accepted nasal perfusions and normal values for classifying the cells in the nasal perfusate of Chinese adults; the normative values of the inflammatory cells in nasal perfusate are 2.00 for the 95% UULV of eosinophils and 16.80 for neutrophils. Age might be one of the factors affecting the cells in rhinitis.

Nasal saline irrigation in preschool children: a survey of attitudes and prescribing habits of primary care pediatricians working in northern Italy

Background

It has been shown that nasal saline irrigation (NSI) alone can be effective in children with infectious and/or allergic respiratory problems, but no study has assessed the awareness or clinical use of NSI among practising pediatricians. The main aim of this study was to evaluate the use of NSI in pre-school children by primary care pediatricians working in northern Italy.

Methods

Nine hundred randomly selected National Health Service primary care pediatricians with an e-mail address were sent an e-mail asking whether they were willing to respond to a questionnaire regarding the use of NSI. The 870 who answered positively were sent an anonymous questionnaire by post and e-mail that had 17 multiple-choice items.

Results

Completed questionnaires were received from 860 of the 870 primary care pediatricians (98.8%). NSI was used by almost all the respondents (99.3%), although with significant differences in frequency. It was considered both a prophylactic and a therapeutic measure by most of the respondents (60.3%), who prescribed it every day for healthy children and more frequently when they were ill. Most of the primary care pediatricians (87%) indicated an isotonic solution as the preferred solution, and the most frequently recommended administration devices were a nasal spray (67.7%) and bulb syringe (20.6%). Most of the pediatricians (75.6%) convinced parents to use NSI by explaining it could have various beneficial effects, and two-thirds (527/854; 61.7%) thought that most of the parents agreed about the importance of NSI. Analysis of possible associations between NSI prescribing behaviour and the demographic data revealed an associations with age and gender, with pediatricians aged <50 years prescribing NSI more frequently than their older counterparts (p < 0.01), and females prescribing NSI more frequently than males (p < 0.01).

Conclusions

In Northern Italy, most primary care pediatricians prescribe NSI for both the prophylaxis and therapy of upper respiratory tract problems in pre-school children. However, many aspects of the procedure are not clarified, and this reduces parental compliance. Given the medical and economic advantages of NSI, this situation should be changed as soon as possible.

Chronic rhinosinusitis in children

Chronic rhinosinusitis (CRS) affects nearly 37 million people in the United States each year and accounts for approximately $6 billion in direct and indirect health care costs. Despite its prevalence and significant impact, little is known about its exact cause and pathophysiology, and significant controversy remains regarding appropriate treatment options. Basic science research, however, has shown recent promise toward improving understanding of the innate and environmental factors underlying the pathophysiology of CRS. The hope is that this will also lead to advances in treatment for children adversely affected by this common yet complicated disease.

Chronic rhinosinusitis and emerging treatment options

This review describes the epidemiology and various treatments in chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). Evidence for short-term use of systemic corticosteroids has been shown to be favorable in CRSwNP, but still limited in CRSsNP. Topical corticosteroids improve symptom scores in both CRS subgroups. The role of microbes in CRS is still controversial. Culture-directed antibiotics are recommended for CRSsNP with exacerbation. Long-term use of low dosage antibiotics is recommended for CRSsNP for their anti-inflammatory effects. Other emerging treatment options are also discussed.