Neti pots have moved from the fringe to the mainstream over the past few years. Traditionally used to treat sinus problems, their popularity exploded in 2007 when Oprah covered them on her show. Requests flooded the pharmacy I worked at. The pharmacy’s owner ordered in a case, and they disappeared in days. Given Oprah’s poor record at identifying credible sources of medical information, I was skeptical. But given the limited efficacy of drugs for congestion, physical removal with water seemed reasonable, whether with a neti pot, or simply snorting water out of the sink. It was clear to me that uncontrolled sinus congestion problems were not rare, because pouring a cupful of water into your nostril isn’t something one will do on a whim.

Pictured above is a neti pot I picked up at a pharmacy conference, where the vendor encouraged me to take it home and give it a try. (More on that later.)

History

Neti pots (and other forms of nasal irrigation) have been around for a long time, apparently used for centuries in India. It’s closely associated with yoga practices. But nasal rinsing has a long history as treatment in North America, too. This 1872 advertisement, courtesy of the fantastic blog The Quack Doctor, illustrates a similar product, but with the less attractive name of “Nasal Douche”. (Catarrah refers to mucus and white blood cells that accumulate with sinus infections.) It’s clear that people have been rinsing their sinuses for hundreds of years. But old treatments don’t mean beneficial treatments, nor does it mean they’re effective. It just means they’re old.

Sinus congestion and traditional treatment

There are several causes of stuffy noses. Allergies are a big factor. Non-allergic congestion (rhinitis) is another. Rhinosinusitis is an inflammatory condition of the nasal passages and sinuses that is the result of infection or allergic inflammation. Infection can be viral, bacterial, and even fungal. Rhinosinusitis causes a lot of illness – and a lot of antibiotic prescriptions, many of them potentially unnecessary. Infections can be short-term (acute) or prolonged (chronic), and are typically managed with drugs like antibiotics, decongestants, and corticosteroids. Rinsing the nasal passages is routinely recommended along with typical treatments, to clear out mucus and sooth inflammation. It’s also thought to help clear out bacteria, debris, and allergens and help the cilia (tiny hairs) work more effectively. It’s rhinosinusitis that has been the focus of the majority of reasearch with nasal rinsing.

The Cochrane Review

There are several studies that have considered nasal rinses for rhinosinusitis, and they’ve been summarized in a Cochrane review. The authors found eight trials that met quality standards – and this was a generous standard, because these were small trials. They were also very different: some studied sprays, and some used irrigation (neti pots). The trials varied with respect to the flushing liquid. With nasal rinses, you really cannot have a true “placebo” but some studies varied the amount of sodium in the flushing liquid. Overall, dropout rates in the studies were high, suggesting that many patients didn’t like the irrigation. The evaluation of benefit varied as well, with no trial using the same scale to measure the effect.

Despite all the limitations and the admitted “modest quality” of the studies, the authors concluded that saline irrigations are generally well tolerated, and that side effects are rare. While there is no evidence that saline rinses are more effective than drug therapy, the authors concluded the beneficial effects seemed to outweigh the drawbacks for most patients. No conclusions could be drawn about the delivery type (spray vs. neti), frequency of use, or type or volume of liquid that should be used.

The Pynnonen Trial

Pynnonen et al examined nasal saline for chronic sinonasal symptoms in a non-specific group of patients with sinus problems. This trial is quite relevant to pharmacists and consumers, as it considered a community-based population with non-specific nasal and sinus symptoms: The typical patient without obvious signs of an infection, who wants try something for persistent congestion and sinus problems. In the trial, patients were assigned to a salt water nasal spray, or larger volume salt water irrigation. Using the cleverly-named (and apparently validated) Sinus Nasal Outcome Test (SNOT-20) scoring system, they evaluated 121 patients over eight weeks. Both groups of patients improved from their baseline, but the large volume irrigation seemed to be more effective than saline nasal spray. The degree of improvement seemed clinically meaningful. The authors concluded that large volume irrigation was superior to nasal sprays. Criticisms of this study include the observation that the regular medication use by patients did not decrease in the study. It should also be noted that the trial was sponsored by the company that manufactured the large volume irrigation device.

Cause for Concern?

Once you get over the initial “ick” factor, many people with chronic sinus problems seem to like nasal rinses. In the name of science, I tried out the neti myself when I had a bad cold. Here’s my completely anecdotal comment: The sensation is a bit bizarre, and afterwards, I felt like I’d had a surfing accident. I could breathe clearly, but my eustachian tubes became plugged, and they were crackling for several days afterwards. However, I don’t have to deal with chronic congestion, sinus infections, or constant medication use. If I did have chronic congestion or sinusitis, I might be more willing to trade one for the other. For the occasionally stuffiness due to colds, it might be less attractive a treatment.

Is there any evidence of long-term harm? New data have emerged suggesting that long-term use of neti pots may actually be detrimental to some patients. In a study presented at the American College of Allergy, Asthma and Immunology, researchers studied 68 people with sinusitis who used neti pots for a year, and then discontinued use. The number of cases of sinusitis actually decreased (by 62.5%) after neti pot use was discontinued – suggesting that while use may temporarily clear up symptoms, daily use may actually increase problems.

This is disappointing, as that’s similar to what we see with nasal decongestant sprays – they’re fantastic for a day or two, if you need to breathe. But after a few days, the congestion comes back – worse than before.

So why might symptoms worsen? It could be that recurrent use might affect normal nasal defence mechanisms. Or it could be that the neti pot isn’t sterile, and is introducing bacteria.

Analysis

Rinsing the nasal passages to help with congestion and infections has been practiced for hundreds of years. At a minimum, it physically clears out the mucus, opening the nasal passages. It may also reduce inflammation and sinus pain. In comparison, drug treatments for sinus congestion are only modestly effective. Nasal rinsing is low cost, and reasonably free of short-term and long-term side effects. Its use also appears to be supported by physicians – one review reported 87% recommend neti pots.

Summary

Neti pots seem to be a reasonable addition to, or substitute for, drug therapy for chronic sinus problems. For acute problems, they may offer symptom relief, without the side effects associated with drug therapy. For chronic problems, they seem to offer benefits, but also some drawbacks. Patients using neti pots regularly, who continue to experience sinus problems, could try stopping use to see if symptoms improve.

Neti pots are a good example of a traditional “healing” method that’s been (somewhat) validated by science. Given the few recognized downsides, and low cost, neti pots look like a reasonable option for patients seeking relief for chronic congestion and sinus problems.

UPDATE as of September 3, 2012: The FDA has issued a caution about the water source used for neti pots following two deaths. Tap water that is not filtered, treated, or processed in specific ways is not safe for use as a nasal rinse.

For more information

Patient Instructions and a demonstration video from the University of Wisconsin

Harriet Hall reviews neti pots over at Science-Based Medicine

Neti Pots or Nutty Pots from NYC Skeptics

Harvey R., Hannan SA., Badia L., & Scadding G. (2007). Nasal saline irrigations for the symptoms of chronic rhinosinusitis Cochrane Database of Systematic Reviews (3) DOI: 10.1002/14651858.CD006394.pub2

Pynnonen, M., Mukerji, S., Kim, H., Adams, M., & Terrell, J. (2007). Nasal Saline for Chronic Sinonasal Symptoms: A Randomized Controlled Trial Archives of Otolaryngology – Head and Neck Surgery, 133 (11), 1115-1120 DOI: 10.1001/archotol.133.11.1115