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evidence of significant harmful side effects (22). Other suggested benefits of nasal saline irrigation include enhanced ciliary beat activity, removal of antigen, biofilm, or inflammatory mediators, and a protective role on sinonasal mucosa (23). Nasal irrigation is also particularly useful after endoscopic sinus surgery to clear crusts and thick mucus that are common postoperatively (5). Daily saline irrigation may also be useful in the secondary prevention of rhinosinusitis exacerbations. In a prospective, randomized trial, Rabago and colleagues (24) used daily saline nasal irrigation and found that patients using irrigation had fewer 2-week blocks with nasal congestion, sinus headaches, and frontal pain and pressure, and used fewer antibiotics and nasal sprays than the control group. In a 12-month follow-up study, the patients using irrigation reported continued improvement of sinonasal symptoms and quality of life (25). Hypertonic and Isotonic Saline Several different saline tonicities have been described for use in nasal irrigation. Talbot and colleagues (26) showed that buffered hypertonic saline nasal irrigation improved mucociliary clearance, whereas buffered physiological saline had no effect on mucociliary clearance. The authors also suggested that hypertonic saline might have the added benefit of decongesting the nose through an osmotic mechanism. Hauptman and Ryan (27) looked at nasal patency and mucociliary clearance time in 80 patients treated with either physiological or hypertonic saline. The authors found that both solutions improved saccharine clearance times and improved nasal stuffiness and nasal obstruction. In this study, hypertonic saline caused increased burning and irritation compared with buffered saline. Tomooka and colleagues (28) evaluated the use of pulsatile hypertonic saline nasal irrigations for patients with sinonasal disease and found statistically significant improvements in 23 of 30 nasal symptoms. Patients in this study reported improvements in nasal congestion, postnasal drip, allergies, and nasal discharge. However, other studies have raised questions about the longer-term effects of hypertonic nasal irrigation on the cilia and the potential for cilia damage. Steroid Nasal Irrigation Budesonide Respules (Pulmicort; Astra Zeneca, Wilmington, DE) have been added to nasal irrigation as an adjuvant method of treating sinus inflammation. Budesonide, as an aqueous nasal spray, has been shown to be beneficial for those with CRS and allergic rhinitis (29). The theory behind use of the budesonide Respules in irrigation is that much higher concentrations of steroids can be topically delivered to sinus mucosa than what is available as a prescription nasal steroid spray. In a pilot study involving 18 patients over 8 weeks, the addition of budesonide suspension to twice-daily nasal saline irrigations provided significant improvements in sinus symptoms, including the sense of smell (30). There were also improvements in both radiographic and nasal endoscopy objective measures. Seventy-five percent of patients in this small study had complete regression of nasal polyps, and there were trends toward improvement in asthma symptoms. In a separate study to evaluate for systemic absorption of the steroid, Bhalla and colleagues (31) found no suppression of the hypothalamic-pituitary-adrenal axis after 8 weeks of budesonide nasal irrigation. Yu and coworkers (32) studied the use of topical budesonide Respules after functional endoscopic sinus surgery and found decreased mucosal inflammation, shortening the stage of epithelization and accelerating the recovery of mucosa after functional endoscopic sinus surgery. The available literature suggests that steroid nasal
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