TO THE EDITOR: In the two-part arti...

TO THE EDITOR: In the two-part article forward acute bacterial rhinosinusitis (ABRS), (12) the authors correctly identified the challenges in diagnosing acute bacterial rhinosinusitis. They noted that although up to 98 percent of physicians prescribe antibiotics for patients with rhinosinusitis, greatest in quantity cases are viral or allergic rather than bacterial, and that in the greatest degree patients really want recommendations for symptom relief. (1)

Nasal irrigation is an adjunctive therapy for ABRS and is noted to be "possibly effective" for the relief of sinus symptoms. (2) We believe the potential benefits of nasal irrigation outweigh the negligible risks, and that it should be considered for more patients with rhinosinusitis, especially those with returning symptoms for whom effective medical treatment repeatedly is difficult. Nasal irrigation has been associated with decreased sinus symptom severity and freshly was identified as "an important component part in the management of greatest in number sinonasal conditions" that is "effective and underutilized." (3)

Nasal irrigation is an inexpensive, patient-controlled therapy that flushes the nasal cavity with saline solution, facilitating a wash of the mode of buildings within. Benefits from nasal irrigation may accrue from removal of nasal discharge and crusts, mucus thinning, (3) and enhanced mucociliary clearance of nasal secretions. Nasal irrigation also may decrease mucosal inflammation osmotically.

Randomized controll trials (RCTs) have assessed hypertonic saline nasal irrigation for several sinus-related conditions, including acute sinusitis (three studies), chronic sinus symptoms (two studies), and chronic sinusitis (three studies). Each reported improvement in sinus symptoms and onward surrogate measures such as quality-of-life scales. None reported significant adverse events

Our form into groups recently reviewed the literature and assessed nasal irrigation for renewed and chronic sinus symptoms in a RCT (4) We set up significant improvement in quality-of-life scores and sinus symptoms, and decreased antibiotic and nasal spray use. Side general intents were few, and patient satisfaction was high; reported adherence to daily nasal irrigation was 87 percent Patients continued to note symptomatic improvement across 18 months. (5) in a qualitative consideration (6) subjects reported that their use of nasal irrigation, especially at the storming of sinus symptoms, accounted for decreased medication use and physician visits, and may have obstructed future episodes of rhinosinusitis.

Instructing patients is easy and brief. we ready the rationale for hypertonic saline nasal irrigation as part of the treatment plan; if the patient is interested, we explain the technique with an illustrated patient handout (http://www.fammed.wisc.edu/research/ projects/nasalirrigation.html). we commend using nasal irrigation once daily from the first brunt of sinus symptoms until resolution. Nasal irrigation tankards are available at most pharmacies.

The literature present to views that even with the best clinical evaluation, we are likely to misdiagnose ABrS. Nasal irrigation can help make symptoms while the illness declares itself or deciphers Questions about exact salinity, ph and frequent occurrence of nasal irrigation require further thought however, the data show that nasal irrigation is effective, safe, and tolerable for patients with sino-nasal symptoms. Nasal irrigation should be considered for more patients with rhinosinusitis (including ABRS), especially those patients with intermittent and chronic symptoms who frequently have few effective treatment options.

DAVID RABAGO, MD

BRUCE BARRETT, MD PHD

LUCILLE MARCHAND, MD

University of Wisconsin

Department of Family Medicine

777 s Mills St.

Madison, WI 53715

REFERENCES

(1) Scheid DC Hamm RM Acute bacterial rhinosinusitis in adults: part I. Evaluation. Am Fam Physician 2004;70:1685-92

(2) Scheid DC Hamm RM Acute bacterial rhinosinusitis in adults: part II. Treatment. Am Fam Physician 2004;70:1697-704

(3) Brown CL Graham SM Nasal irrigations: proper or bad? Curr Opin Otolaryngol Head Neck Surg 2004;12:9-13

(4) Rabago D Zgierska A, Mundt M Barrett B Bobula J Maberry R Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: a randomized controll trial. J Fam Pract 2002;51:1049-55

(5) Rabago D Pasic T Zgierska A, Mundt M Barrett B Maberry R The efficacy of hypertonic saline nasal irrigation for chronic sinonasal symptoms. Otolaryngol Head Neck Surg 2005;133:3-8

(6) Rabago D Barrett B Marchand L Maberry R Hypertonic saline nasal irrigation for chronic sinus symptoms: a qualitative inquiry (Poster Presentation). Society of Teachers of Family Medicine Annual discourse 2005. Accessed online May 24 2005 at: http://www.stfm.org/annualconf/an05/annual05web.pdf.

IN REPLY: We thank Dr Rabago and colleagues for their observations and agree that nasal irrigation is an adjunctive therapy that should be considered for patients with returning or chronic sinus symptoms. However, the focus of our review was acute bacterial rhinosinusitis. We reviewed the literature, which includes the articles cited by dint of Dr. Rabago and colleagues, and ground evidence that nasal irrigation was effective for relief of sinonasal symptoms in patients with chronic, haunt recurrent sinusitis; recent intranasal or sinus surgery; allergic rhinitis; and age-related rhinitis. We erect only two randomized controlled trials (RCTs) of nasal irrigation in adults. (12) Contrary to the claim of Dr Rabago and associates that all studies of nasal irrigation have shown a benefit, united RCT (1) that included patients with gelids and rhinosinusitis found no advantage of hypertonic saline nasal irrigation or normal saline nasal irrigation athwart observation. In another RCT, (2) six clusters of 50 patients with acute sinusitis received single of three antibiotics and either a nasal decongestant or nasal irrigation. The meditation (2) found no differences among collections except for delayed radiologic healing in patients receiving cephradine (Velosef) plus a nasal decongestant. Although the findings of Dr Rabago's research, the relevance in his findings are interesting, the relevance of the findings to acute bacterial rhinosinusitis are unclear.