Role of
nasal douching in chronic allergic rhinitis
Saxena R.K.1, Bamaniya H.2,
Bhuie H.S.3
1Dr. Rajiv Kumar Saxena, Associate Professor, 2Dr. Hemendra
Bamaniya, Associate Professor, 3Dr. H.S. Bhuie, Professor, all
authors are affiliated with Department of ENT, Ananta Institute of Medical
Sciences, Rajsamand, Rajasthan, India.
Corresponding Author: Dr. Hemendra Bamaniya, Associate Professor,
Department of ENT, Ananta Institute of Medical Sciences, Rajsamand,25+26-C,
Rama Vihar, Meera Nagar, Behind Banera Castle Garden, Shobhagpura 100 Feet
Road, Bhuwana, Udaipur (Rajasthan). E-mail: dr_hemendra83@yahoo.com
Abstract
Objective: The present study was carried out to
evaluate the role of nasal douching in the treatment of allergic rhinitis using
daily allergic rhinitis symptom score.Material
& Methods: 120 patients of chronic allergic rhinitis who attended
otorhinolaryngology outdoor of Ananta Institute of Medical Sciences, Rajsamand,
Rajasthan were included in the study.patients were divided into two equal
groups viz. group A (n=60) in which
patients were treated with antihistamincs, leukotriene receptor antagonists and
intranasal steroid sprays and group B
(n=60) in which isotonic saline nasal douching was advised to the patients
three times a day as an adjunctive to the medical treatment. Patients were
followed up after 2 week and 4 weeks. Mean daily allergic rhinitis symptom score
were calculated at each follow up and compared between the two groups. Results: out of 120 patients, 63 were
male and 57 were female. Age of the patients ranges from 20 to 60 years with
the mean age of 36.5 years. Mean daily rhinitis scores of group A and group B
were 14.6±1.6 and 14.3±2.0 respectively (p value- 3.661) which was reduced to
8.9±2.1 and 7.1±1.8 respectively and the difference was found to be
statistically significant ( p value <0.0001). At 4th week follow up, the scores
of were further reduced to 3.8±1.7 and 2.2±0.9 respectively and the difference
was found to be statistically significant (p value <0.0001). Conclusion: Nasal douching is an
effective method to manage symptoms of allergic rhinitis when used along with
other medical treatment including intranasal steroids, antihistaminics and
leukotriene receptor antagonists.
Keywords: Allergic Rhinitis, Nasal irrigation, Rhinorrhoea, Intranasal
steroids, Allergen.
Author Corrected: 14th May 2019 Accepted for Publication: 18th May 2019
Introduction
Rhinitis
is defined as an inflammation of nasal mucosa and is characterized by symptoms
like nasal itching, clear rhinorrhoea, nasal obstruction and sneezing.
When symptoms of
rhinitis are triggered by an allergen, the resulting condition is referred to
as allergic rhinitis. Allergic rhinitis may be seasonal, perennial, or may
occur sporadically after specific exposures. Allergic rhinitis can be
intermittent (< four days/week or four weeks/year) or persistent (>four
days/week, or four weeks/year).
Allergic rhinitis
leads to a significant impairment in the quality of life of the patients when
measured by various quality of life instruments [1, 2].It can also lead to fatigue
and daytime sleepiness, reduced work productivity, impaired cognitive
functioning, reduced learning abilities, and impaired sleep[1, 3-10].
Nasal douching
(also known as nasal irrigation, nasal lavage) is a procedure to rinse the
nasal cavity with saline solution. It is an old practice for cleaning and care
of upper respiratory tract that was originated in the Ayurvedic medical
tradition [11]. Since then the procedure is accepted worldwide as an effective
method to treat and prevent upper respiratory tract diseases [12-17].
Nasal saline
irrigation is believed to work through making the mucus thinner, making it easy
to remove and also by removing some of the allergens from the nasal cavity and
by enhancing the mucociliay mechanism. Solution for nasal douching can be
isotonic saline (0.9% NaCl) and hypertonic saline (1.5% to 3% NaCl). Both are
acidic solutions, with pH varying from 4.5 to 7.
In present study,
we used isotonic saline solution for douching purpose.
Material & Methods
The present study is a prospective study carried out in Department of
Otorhinolaryngology, Ananta Institute of Medical sciences, Rajsamand, Rajasthan
during the period from February 2017 to February 2019.
Setting: Tertiary care
Type of study: Prospective, longitudinal study
Participants: 120 patients attended ENT OPD with the
symptoms of allergic rhinitis (sneezing, rhinorrhoea, itching in nose) were
included in the study. Complete ENT examination of the patients was carried
out.
Types of participants: All the 120 patients included in the study were
divided into following two groups:
Group A (n=60): patients were treated with
antihistamincs, leukotriene receptor antagonists and intranasal steroid sprays.
Group B (n=60): isotonic saline nasal douching was
advised to the patients three times a day as an adjunctive to the treatment
with antihistaminics, leukotriene receptor antagonists and intranasal steroids.
Type of intervention: Participants of group B were advised to
perform nasal douching using isotonic nasal solution three times a day.
An easy home remedy was told to all the patients to prepare isotonic
solution: mix 250 ml of boiled and cooled water with ¼ teaspoonful common salt
(NaCl) and ¼ teaspoonful baking soda (NaHCO3). Patients were advised to use the
freshly prepared solution every time and were taught to perform nasal douching
using 20cc syringe.
Exclusion criteria
1. Non-allergic rhinitis
2. Acute and chronic rhinosinusitis
3. Cystic fibrosis
4. Previous history of nasal surgery i.e.
turbinate reduction/ FESS/ Septoplasty
5. Immunotherapy started within last year
6. Age <20 years > 60 years
Follow-up and outcome measure: Patients were followed up after 2 week and 4
week. Patients were told to calculate and record their Mean daily rhinitis
score on diary card given to them. Allergic rhinitis symptoms included: 1.
Sneezing, 2. Rhinorrhoea, 3. Nasal Obstruction and 4. Nasal itching.
Intensity of these four symptoms were rated as per a 5 graded scale: 0-
no symptom, 1- slight, 2- mild, 3- moderate, 4- severe. Total score ranges from
0 to 16. Mean score of these daily data were calculated on each follow up.
Scoring system used: Mean daily rhinitis score [18].
Consent: Well informed, written consent was taken from
all the patients included in the study.
Ethical permission: clearance from institutional ethical
committee was taken.
Statistical analysis: statistical analysis was performed by using
student’s t-test for independent samples and X2 analysis to compare two groups.
Results
A total of 120
patients were included in present study out of which 63 were male and 57 were
female.Age of the patients ranges from 20 to 60 years with the mean age of 36.5years.All
the 120 patients included in the study were divided into following two groups:
Group A (n=60): patients were treated with
antihistamincs, leukotriene receptor antagonists and intranasal steroid sprays.
Group B (n=60): isotonic saline nasal douching was advised to the patients
three times a day as an adjunctive to the treatment with antihistaminics,
leukotriene receptor antagonists and intranasal steroids
Both the groups
were matched for age, gender and severity of symptoms.
Patients were followed up after 2 week and 4 week. Patients were told to
calculate and record their daily allergic rhinitis symptom score on diary card
given to them. Intensity of theses four symptoms were rated as per a 5 graded
scale: 0- no symptom, 1- slight, 2- mild, 3- moderate, 4- severe. Total score
ranges from 0 to 16. Mean score of these daily data were calculated on each
follow up. The results are depicted in table.1
Initially, Mean
daily rhinitis scores of group A and group B were 14.6±1.6 and 14.3±2.0
respectively and the difference was not significant (p value- 3.661).
At 2nd week follow
up, mean daily rhinitis scores of group A and group B were reduced to 8.9±2.1
and 7.1±1.8 respectively. Similarly, at 4th week follow up, mean daily rhinitis
scores of group A and group B were further reduced to 3.8±1.7 and 2.2±0.9
respectively. The difference was found to be statistically significant (p value
<0.0001) during each follow up.
Table-1: Mean daily score of group A and
group B at start of therapy and at each follow up
|
|
|
Group A |
Group B |
P- value |
|
Mean Daily Rhinitis Score (Mean± SD) |
At start of therapy |
14.6± 1.6 |
14.3± 2.0 |
0.3661 |
|
At 2nd week follow-up |
8.9± 2.1 |
7.1± 1.8 |
<0.0001 |
|
|
At 4th week follow-up |
3.8± 1.7 |
2.2± 0.9 |
<0.0001 |
Group A: patients were treated with antihistamincs,
leukotriene receptor antagonists and intranasal steroid sprays. Group B: isotonic saline nasal douching
was advised to the patients three times a day as an adjunctive to the treatment
with antihistaminics, leukotriene receptor antagonists and intranasal steroids
Discussion
Allergic rhinitis
leads to a significant impairment in the quality of life of the patients when
measured by various quality of life instruments. Besides this, allergic
rhinitis also increases the healthcare cost because the treatment requires
multiple consultations and chronic medical therapy.
Nasal irrigation is
a procedure to rinse the nasal cavity with saline solution. It is now accepted globally
as an effective method to treat and prevent recurrent upper respiratory tract
infection and allergies. Nasal irrigation works by many physiological effects
including 1. Cleaning the nasal cavity as saline thins and removes the mucus
and crusts, 2. Removal and decrease
production of various inflammatory mediators like histamine, prostaglandins,
leukotriens etc. 3. Enhancing the
mucociliary clearance mechanism [19-24].
In present study,
we advised the patients of allergic rhinitis to perform isotonic saline nasal
douching three times a day as an adjunctive to the medical treatment (group B)
and the results were assessed in form of mean daily rhinitis score and compared
with other group of patients who were treated with medical treatment only
(group A).
Patients were
followed up after a period of 2 week and 4 week and the mean daily rhinitis
score were calculated during each follow up.
Mean daily rhinitis
scores of group A and group B were 14.6±1.6 and 14.3±2.0 respectively (p value-
3.661).At 2nd week follow up, mean daily rhinitis scores of group A and group B
were reduced to 8.9±2.1 and 7.1±1.8 respectively and the difference was found
to be statistically significant (p value <0.0001)
At 4th week follow
up, mean daily rhinitis scores of group A and group B were further reduced to
3.8±1.7 and 2.2±0.9 respectively and the difference was found to be
statistically significant (p value <0.0001).
The results are
suggestive that isotonic saline irrigation is very effective in treatment of
allergic rhinitis when used as an adjunctive to the treatment with
antihistaminics, leukotriene receptor antagonists and intranasal steroids.
Similar study done
in the past on the woodworkers (n=45), exposed to varying level of wood dust,
were advised to perform isotonic saline nasal irrigation daily and demonstrated
significant improvement in sinus symptoms, mucociliary clearance and expiratory
nasal flow[25].
In present study,
we used isotonic saline solution (0.9% NaCl) for nasal irrigation three times a
day for 4 weeks. Previous studies have been done with hypertonic solution (>
0.9% NaCl).
Shose you et al found
that hypertonic saline is effective in treatment of allergic rhinitis but its
use can lead to inflamed nasal mucosa due to local irritation [26]. Similar
study done by Baraniuk et al suggested that hypertonic saline irrigation leads
to release of substance P and glandular secretion due to stimulation of
nociceptive nerves, which causes pain to the patient[27]. Such types of side
effects are not seen with isotonic saline solution.
Other studies done
in the past also reported the reduction in nasal symptoms after long term use
of nasal irrigation [28, 29] except one study done by Nsouli et al, who
hypothesized that daily nasal irrigation in healthy adults, could lead to an
increase in the number of upper respiratory tract infections [30].
Conclusion
Nasal irrigation with isotonic saline solution is a safe, inexpensive
and effective method to manage symptoms of allergic rhinitis when used along
with other medical treatment including intranasal steroids, antihistaminics and
leukotriene receptor antagonists. Isotonic solution has no side effects and it
helps in decreasing the healthcare cost by reducing the need of medicines and
improves in quality of life of the patients.
What this study adds to existing knowledge? The present study used the nasal symptom
score to assess the results of using isotonic saline irrigation in patients of
allergic rhinitis. The score is a very simple and valid instrument to diagnose
and to monitor the treatment of allergic rhinitis. The use of this score in
routine practice is desirable. The practice of advising isotonic saline
irrigation in allergic rhinitis should be enhanced because it is an easy, well
tolerated and effective complementary therapy with no adverse effects.
Author contributions
· Concept and design, Patient care, approval
for final print: Dr. Rajiv Kumar Saxena
· Data collection, interpretation of data,
write up, data analysis: Dr. Hemendra Bamaniya
· Guidance, final revision: Dr. H.S Bhuie
Conflict of interests: The author(s) declared no potential conflicts
of interest.
Funding: The author received no financial support for
the research or publication of this article.
References
How to cite this article?
Saxena R.K, Bamaniya H, Bhuie H.S. Role of nasal douching in chronic allergic rhinitis. Ophthal Rev: Tro J ophtha & Oto. 2019;4(2):109-113.doi: 10.17511/ jooo.2019.i2.07