Chronic or recurrent sinusitis is very prevalent, and the impact on quality of life is similar to that of major chronic diseases. Previous small trials have shown important benefits from nasal irrigation.

In the SNIFS trial, by 6 months, significantly more patients who were advised to use nasal irrigation maintained a 10-point clinically important improvement in the primary outcome, the Rhinosinusitis Disability Index. They also used fewer medications and fewer intended to consult the doctor.

A very brief pragmatic intervention of a video showing patients how to use saline nasal irrigation is useful; it can improve symptoms and help enable people to manage the problem. The evidence of reduced medicalization is also important in the longer term given most consultations result in an antibiotic prescription with the attendant dangers of antibiotic resistance. However, the effectiveness of nasal irrigation was less than that seen in the smaller previous studies, and this may be because those studies used more intensive coaching. It is also possible that steam inhalation may work if done more intensively; but, until there is better evidence for steam inhalation, given previous randomized trial evidence of the minor harm when using steam inhalation, it should probably not be advocated.

The bottom line: provide brief advice about how to do nasal irrigation to your patients with chronic or recurrent sinusitis but do not advocate steam inhalations.

Abstract

BACKGROUND

Systematic reviews support nasal saline irrigation for chronic or recurrent sinus symptoms, but trials have been small and few in primary care settings. Steam inhalation has also been proposed, but supporting evidence is lacking. We investigated whether brief pragmatic interventions to encourage use of nasal irrigation or steam inhalation would be effective in relieving sinus symptoms.

METHODS

We conducted a pragmatic randomized controlled trial involving adults (age 18-65 yr) from 72 primary care practices in the United Kingdom who had a history of chronic or recurrent sinusitis and reported a “moderate to severe” impact of sinus symptoms on their quality of life. Participants were recruited between Feb. 11, 2009, and June 30, 2014, and randomly assigned to 1 of 4 advice strategies: usual care, daily nasal saline irrigation supported by a demonstration video, daily steam inhalation, or combined treatment with both interventions. The primary outcome measure was the Rhinosinusitis Disability Index (RSDI). Patients were followed up at 3 and 6 months. We imputed missing data using multiple imputation methods.

RESULTS

Of the 961 patients who consented, 871 returned baseline questionnaires (210 usual care, 219 nasal irrigation, 232 steam inhalation and 210 combined treatment). A total of 671 (77.0%) of the 871 participants reported RSDI scores at 3 months. Patients’ RSDI scores improved more with nasal irrigation than without nasal irrigation by 3 months (crude change -7.42 v. -5.23; estimated adjusted mean difference between groups -2.51, 95% confidence interval -4.65 to -0.37). By 6 months, significantly more patients maintained a 10-point clinically important improvement in the RSDI score with nasal irrigation (44.1% v. 36.6%); fewer used over-the-counter medications (59.4% v. 68.0%) or intended to consult a doctor in future episodes. Steam inhalation reduced headache but had no significant effect on other outcomes. The proportion of participants who had adverse effects was the same in both intervention groups.

INTERPRETATION

Advice to use steam inhalation for chronic or recurrent sinus symptoms in primary care was not effective. A similar strategy to use nasal irrigation was less effective than prior evidence suggested, but it provided some symptomatic benefit.

Story Source

Journal Abstract