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Wise et al.

Page 107

In adults, all 5 studies found improvements in clinical outcomes with the use of various types of nasal saline. These studies varied in their evaluation of SAR vs PAR, as well as the type and volume of saline. Studies by Garavello et al. 151 and Rogkakou et al., 1407 found that the addition of hypertonic saline significantly improved nasal symptoms and QOL compared to not using saline. Ural et al. 1408 further compared the efficacy of hypertonic to isotonic saline irrigations, finding improved mucociliary clearance time with the isotonic solution. They postulated that in PAR, the rheologic properties of the mucus are enhanced most by isotonic saline, thus improving mucociliary clearance. Chusakul et al. 1409 also identified that buffered isotonic saline with mild alkalinity had the greatest impact on reducing nasal symptom scores and was preferred by the most patients. Finally, Cordray et al. 1406 found that Dead Sea saline spray had a significant improvement in the RQLQ compared to isotonic saline. Cordray et al. 1406 suggested that the magnesium in the Dead Sea saline may have anti-inflammatory properties, resulting in improved AR outcomes. In the pediatric population, all studies evaluating either PAR or SAR found an improvement in nasal symptoms or QOL with the incorporation of nasal saline. Both studies by Garavello et al. 1410,1411 showed a significant improvement after the addition of hypertonic saline irrigations TID when compared to no irrigations. Marchisio et al. 1413 and Satdhabudha and Poachanukoon 1414 further identified that hypertonic saline irrigations resulted in a greater improvement in nasal symptom scores in children vs isotonic saline. Finally, Li et al. 1412 and Chen et al. 1415 found an additive effect in the utilization of nasal saline spray as an adjunct to a nasal steroid spray when compared to either therapy independently. The systematic review by Hermelingmeier et al. 1416 included 10 studies of which 7 were RCTs evaluating both adult and pediatric patients. Several of these studies are also included above. 151,1406-1408,1410-1412 This review found that almost all studies showed an improvement in nasal symptoms from 3.1% to 70.5% with the addition of nasal saline. Additionally, they identified a 24.2% to 100% reduction in medication usage, as well as an improvement in QOL of 29.8% to 37.5%. This review also suggested that isotonic saline was more effective than hypertonic saline. Perhaps surprisingly, they found that nasal saline sprays resulted in greater symptom improvement than saline irrigations. Overall, they concluded that nasal saline was as effective as other frequently utilized AR pharmacologic treatments (ie, nasal antihistamines, oral antihistamines, etc.) in treatment of both SAR and PAR. Overall, there is substantial evidence to support the use of nasal saline as an adjunct treatment for SAR and PAR. It appears that in adults, a buffered isotonic spray may provide maximum benefit. However, in children, a hypertonic solution may be more effective. Some studies have suggested less intranasal irritation when using isotonic solutions rather than hypertonic. Hypotonic saline has not been studied as a treatment for AR. Adding mild alkalinity (pH 7.2 to 7.4) to the solution may further improve tolerability. 1409 Although nasal saline has been shown to improve symptoms and QOL outcomes when used alone, it is often implemented as an adjunct to other therapies including nasal steroid, antihistamine sprays, or oral antihistamines. In both adults and children, nasal saline appears to have an additive effect when used in combination with other standard AR treatments. Further, nasal saline is of relatively low cost and has an excellent safety profile. While adverse effects are rare, they

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Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.