Nasal lavage

Nasal Irrigation
in Sjogren’s Syndrome
Robert Fox, MD., Ph.D.
Rheumatology Clinic
Scripps Memorial and Research Foundation
(adapted from Dr. Peter Belafsky, Head of ENT, formerly at
Scripps but now at University California Davis)
Nasal irrigation (also called "nasal lavage" or "nasal
douching") is an ancient and widespread practice. Keeping the
sinuses moist and “happy” is very useful in patients with
Sjogren’s syndrome, where “stuffy” nose needs to mouth

breathing and particularly increased symptoms of mouth
dryness at night. We have found that nasal irrigation is
particularly useful in several situations:

dry mouth, particularly at night. A humidifier can also
be placed in the bedroom (or office) along with an air
purifier to remove allergens and pollutants
patients with recurrent “upper respiratory” infections,
who may be able to reduce their use of antibiotics
people who have nasal dryness during the day, which may
vary with season in areas such as southern California
where periodic Santa Ana winds or pollution may irritate
the sinuses.

During the day, patients might use a “portable” sinus lavage such as “Ocean Plus” nasal spray and in some situations to follow by the use of an inhaled nasal steroid (such as verimyst or the formulary equivalent such as nasonex, as each insurance has preferentially covers only certain inhalers). Benefits and risks of nasal irrigation/oral rinses. These
practices are most commonly prescribed for one of three
purposes: to reduce tissue swelling (edema
), to help clear
tenacious mucus from the throat and/or nasal cavities, and to
reduce dryness.

There are no known risks associated with oral rinses, other
than the possibility of allergic reaction to one of the
components (unlikely for one of the saline rinses, but certainly
possible in the case of a commercial rinse, or if a formulated
prescription is used– for example, an antibiotic rinse.)

Nasal irrigation can alter the environment of the nasal cavities
and sinuses, making them more conducive to the growth of
certain water-loving bacteria such as Pseudomonas
. Also,
irrigation should be carefully performed if you are suffering
from acute sinusitis (an acute bacterial infection of the sinuses),
since it could facilitate spread of the infection to the other
sinuses, the eyes or throat. For these reasons, you should
let your physician know if you have an acute sinusitis as

you may require an antibiotic in conjunction.
How is Sinus Lavage Performed
Commercial oral rinses cannot be used for nasal irrigation,
with one exception (Alkalol, which is discussed below.) You can
easily prepare an appropriate rinse/irrigant at home, and I
have included a few recipes (below.) If possible, gargling and
irrigating should be performed using a solution that is as warm
as (or a bit warmer than) body temperature, but this is not

Gargling should be done "deeply" so that the rinse penetrates
deep into the throat. One way to do this is to vary the pitch of

the sound you make while gargling (high, low, high, etc.) You
will soon find a method that allows deep penetration into the
throat. Don’t worry if you swallow a bit of the rinse– none of

these solutions are harmful.
We have suggested that patients purchase online a nasal
irrigator, such as available on:
(and click link to sinus)
The commercial units prevent too much pressure from being
applied. Also, several brands of “Water Pic” devices have

adaptors for sinus lavage.
If the commercial units are not economically possible, nasal
irrigation can be accomplished by a variety of means. In
cultures where nasal irrigation is a routine daily practice,
people "snuff" (inhale through the nose) the irrigant from a

cupped hand. You could also purchase a small bulb syringe;
these are sold in pharmacies and are usually used to aspirate
mucus from the nostrils of infants, or to help irrigate wax from
the ear canals (don’t use it for wax removal without talking to
your doctor first!) The goal is to inhale (or squirt) the irrigant
deeply enough that you thoroughly wash your nasal cavities.
Once again, if a bit goes down the back of your throat don’t be
concerned. This merely indicates that you have successfully
lavaged the full length of your nasal cavity.

RECIPES and other options
Alkalol is a commercially available solution which can be used
as an oral rinse or nasal irrigant. It is made by The Alkalol
Company (Taunton, MA) and can be ordered by your

pharmacist. It is fairly inexpensive (about $3.50 per pint, on
average.) The active ingredients are salt (sodium chloride),
alum (an astringent), and baking soda (sodium bicarbonate.)

Alkalol also contains a number of natural extracts such as
menthol and eucalyptol which, as far as I can tell, are present
primarily for flavor.

The label says that Alkalol can be used at half or full strength,
but I recommend that it be used at full strength. It can be
safely used as a nasal irrigant or oral rinse.

For do-it-yourself solutions, mix the ingredients, boil, and store
the solution in a clean, air-tight container. A glass container
with a screw-on cap is ideal (if you use a Tupperware-type
container, the solution may take on an unpleasant plastic

odor.) Home-made solutions should be discarded after one
week (then prepare a fresh batch.) If the solution looks cloudy,
or if you see particulate matter floating in it, do not use it–
make yourself a fresh batch.

Isotonic saline (salt water that is about as salty as your body fluids)
1 teaspoon salt (table salt is fine)
1 teaspoon baking soda (NOT baking powder!)
1 pint of water (use distilled or filtered water if you have any concerns about the
quality of your tap water.)
Comment: baking soda (sodium bicarbonate) improves the mucus-solvent
properties of the irrigant. You can purchase sterile saline (available in the contact

lens care section of any grocery store or pharmacy) but this is more expensive, of
course, and does not have sodium bicarbonate.

Hypertonic saline (salt water that is saltier than your body fluids)
2 teaspoons of salt
1 teaspoon of baking soda
1 pint of water
Comment: this solution is well-tolerated as an oral rinse, but you will find it to be
more irritating than isotonic saline if you use it as a nasal irrigant. Nevertheless,
it is safe and very effective as a nasal irrigant. In warm coastal communities (for

example, Florida or other Gulf Coast states), many folks with sinus problems find
that swimming in seawater helps them to heal faster. "Getting a noseful" of
seawater is key– you don’t have to swim! In our area, the waters are too frigid for

most people to tolerate a quick plunge in the ocean. This hypertonic saline
irrigant is a very crude (but effective) approximation of seawater.

What about plain water?
Salt follows water, and water follows salt. Anyone who has ever
seen the effect of salt on a snail knows what happens to the
snail. Hypertonic saline will tend to draw a small amount of

water from the tissues it contacts; this is desirable if the tissues
are swollen (edematous.) Plain water, on the other hand, will
tend to enter the tissues, thereby increasing swelling (edema.)

When you sit for a long time in a bath, your fingertips wrinkle
because the water content of the skin is increasing
, so the skin
must "buckle" to accommodate the extra water.

This recommendation against plain water as an irrigant or
rinse would seem to contradict another piece of advice that
doctors give very frequently: drink more fluids! The current
recommendation for adults is to drink eight to ten 8 ounce
glasses per day of noncaffeinated, nonalcoholic beverages (at
the high end, this translates to 10 cups, or 2.4 liters per day.)
There is no contradiction, however. Assuming that you are
otherwise healthy, your kidneys will handle this volume of
fluids very well, and your body’s concentrations of various
salts will vary hardly a bit. (With certain illnesses, such as
kidney failure or congestive heart failure, aggressive hydration
can be very harmful. Discuss the question of fluid intake with
your physician if you have any doubts about the safety of
drinking 10 cups of fluids daily.)

What About mucolytic Agents—Mucinex and Saturated
Potassium Iodide?

Mucinex (the agent, guanefesen, in cough syrups) is available
over the counter and can be taken safely as 1 tablet twice to
three times a day.

An old remedy to loosen mucus is the oral ingestion of 10%
saturated potassium iodide. This is the cheapest approach.
Simply purchase some potassium iodide (available at
pharmacy) and use 3-5 drops in water twice or three times a

Additional factors that have been useful in some patients have
been the use of bactroban nasal cream which is applied daily.

How often should I use an oral rinse or nasal irrigant?
Moderation in all things; for most problems, two to three times
per day will be sufficient.


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