What is the proper technique for performing a nasal sinus rinse?

Nasal Sinus Rinse Technique

Use a high-volume nasal douche (250 mL) with isotonic saline, twice daily, delivered via a squeeze bottle or Neti pot with the head positioned forward and tilted to allow gravity-assisted flow from one nostril to the other. 1

Optimal Delivery Method

Nasal douches are significantly more effective than sprays because irrigation (not spray) is superior for expelling secretions, improving quality of life, and distributing solution to the maxillary sinus and frontal recess. 1

Recommended Devices (in order of effectiveness):

• Squeeze bottle (250 mL): Most practical and effective for positive-pressure delivery 1, 2
• Neti pot: Effective gravity-based low-pressure irrigation 1
• Bulb syringe: Alternative positive-pressure device 1
• Avoid sprays and nebulizers: These deliver insufficient volume for true irrigation 1

Step-by-Step Technique

Preparation:

1. Use 250 mL of saline solution per irrigation 1
2. Choose isotonic saline (0.9%) - evidence is insufficient to support superiority of hypertonic solutions, and isotonic may be better tolerated 1
3. Ensure proper salt concentration (2-3.5%) to prevent infections and irritation 3

Irrigation Procedure:

1. Lean forward over a sink and tilt your head to one side (or kneel with head on floor for maximum distribution to sinuses) 1
2. Insert the nozzle just inside one nostril 1
3. Apply gentle positive pressure (squeeze bottle) or allow gravity flow (Neti pot) 1, 2
4. Allow solution to flow through the nasal cavity and drain from the opposite nostril 1
5. Do not sniff hard during or immediately after irrigation 1
6. Repeat on the opposite side 1
7. Gently blow nose to clear remaining solution (not explicitly stated but standard practice)

Frequency and Duration

• Perform twice daily for chronic rhinosinusitis 1
• Continue for at least 3-12 months for sustained benefit in chronic conditions (longer duration studies showed better outcomes than short-term use) 1
• Start within 24-48 hours after sinus surgery if postoperative 4

Solution Preparation

Commercial vs. Homemade:

• Both are acceptable, but homemade solutions are significantly cheaper 1
• If making at home: Use distilled, sterile, or previously boiled water (cooled) to prevent rare but serious infections 3
• Clean irrigation device thoroughly after each use to prevent bacterial contamination 3

Common Pitfalls to Avoid

Critical safety issue: Never use tap water directly - only use distilled, sterile, or boiled (then cooled) water to prevent potentially fatal infections. 3

Do not confuse saline spray with irrigation - sprays deliver insufficient volume (typically 2 mL vs. 250 mL needed for irrigation) and are far less effective. 1

Avoid aiming toward the nasal septum (middle of nose) - this applies more to steroid sprays but the principle of directing flow laterally helps prevent irritation. 1

Expected minor side effects include fluid dripping from the nose after irrigation - this is normal and not a reason to discontinue. 1

Clinical Context

Nasal saline irrigation provides symptomatic relief through multiple mechanisms: mechanical removal of mucus and crusts, enhanced ciliary activity, disruption of biofilms and inflammatory mediators, and direct mucosal protection. 1

The evidence shows large effect sizes (SMD -1.32 to -1.44) for symptom improvement in both adults and children with chronic rhinosinusitis, with excellent safety profiles and no serious adverse events reported. 5

Irrigation is less effective than intranasal corticosteroids when compared directly, but its excellent safety profile makes it an attractive sole therapy or adjunctive treatment. 1