Nasal irrigation with Glycyrrhiza glabra extract for treatment of allergic rhinitis - A study of in vitro, in vivo and clinical trial.

ETHNOPHARMACOLOGICAL RELEVANCE: Glycyrrhiza glabra, a family of licorice and a traditional Chinese medicine with sweet taste and favorable smell, has anti-inflammatory, anti-allergic and immunomodulatory functions. AIM OF THE STUDY: We developed a licorice extract (LE) by using glycyrrhiza glabra and administered it through nasal irrigation to treat allergic rhinitis (AR). MATERIALS AND METHODS: LE was prepared into extract powder, and the anti-inflammatory effect of the LE was evaluated by calcium ionophore-induced activated mast cell model (in vitro). Then, local passive anaphylaxis assays were applied to investigate the anti-IgE-mediated allergic reaction of the LE in mice (in vivo). A developed LE was administered through nasal irrigation to treat AR in clinic settings. A total of 60 participants diagnosed with AR were included in this clinical trial; they were randomly assigned to three interventions: licorice nasal irrigation (LNI), corticosteroid nasal irrigation (CNI), and saline nasal irrigation (SNI). They performed nasal irrigation once a day for 1 month. Both subjective questionnaires (22-item Sino-Nasal Outcome Test [SNOT-22] and visual analog scale [VAS]) and objective examinations (acoustic rhinometry and nasal endoscopy) were used for effectiveness assessments. RESULTS: All three interventions could improve SNOT-22 scores, but the effects of LNI and CNI were more significant. According to VAS scores for nasal blockage, rhinorrhea, sneezing, nasal pruritus, postnasal discharge, and olfactory disturbance, the effect of LNI was superior to those of CNI and SNI. The results of rhinometry revealed that LNI significantly improved nasal resistance. Endoscopic analysis showed that both LNI and CNI, but not SNI, could significantly improve turbinate hypertrophy. Moreover, the best procedural comfort was found for LNI, which had no side effects or complications during the trial. CONCLUSIONS: LNI is a natural, safe, and innovative therapy that can effectively treat AR. Its effect is superior to those of CNI and SNI, and it has greatly improved procedural comfort.

Hypertonic saline and seawater solutions damage sinonasal epithelial cell air-liquid interface cultures.

BACKGROUND: Nasal irrigation (NI) is commonly used to treat several sinonasal diseases, including chronic rhinosinusitis with nasal polyps (CRSwNP); however, the effects of NI on the sinonasal epithelium are not fully known. The aim of this study was to investigate the effects of commonly used NI solutions on epithelial mucociliary and barrier functionality in primary cultured human nasal epithelial cells (HNECs). METHODS: HNECs from control subjects and patients with CRSwNP were established as air-liquid interface (ALI) cultures. Differentiated cultures were treated with different NI solutions, including isotonic 0.9% and hypertonic 3.0% saline, isotonic and hypertonic seawater, and Ringer lactate solution. The changes in ciliary beat frequency (CBF), numbers of ciliated and goblet cells, and cytotoxicity were measured. Epithelial barrier functionality was assessed by measuring the transepithelial electric resistance (TER), paracellular flux, and expression of tight junction protein zonula occludens-1 (ZO-1) and occludin. RESULTS: Isotonic saline, isotonic seawater, and Ringer lactate solutions did not affect epithelial mucociliary and barrier function in either control or CRSwNP-derived ALI cultures; however, hypertonic saline induced a significant disruption of these cell functions in both cultures. Hypertonic seawater caused a transient decrease of CBF and TER in CRSwNP-derived ALI cultures, in contrast to inducing an obvious mucociliary and barrier dysfunction and cytotoxicity in control ALI cultures. CONCLUSION: Although isotonic NI solutions appear to not affect epithelial mucociliary and barrier function in control and CRSwNP-derived ALI cultures, hypertonic saline and seawater solutions damaged sinonasal epithelial cells in ALI cultures. The safety and efficacy of these solutions requires further investigation.

Topical corticosteroid irrigations in chronic rhinosinusitis.

BACKGROUND: Chronic rhinosinusitis (CRS) has previously been thought to occur secondary to infectious or obstructive etiologies. However, in recent years, primary CRS has been more discretely defined as diffuse airway inflammation, similar to asthma. Adequate medical and surgical therapy are needed to control the inflammation. Our purpose in this study was to evaluate the efficacy and safety of topical corticosteroid treatment. METHODS: A focused literature review was conducted and we identified 11 original articles from the years 2013-2018 evaluating safety or efficacy of topical corticosteroid irrigations. RESULTS: Eleven articles were identified. One study found significant benefit between corticosteroid irrigations versus corticosteroid sprays. Two studies found significant benefit between corticosteroid irrigations compared to saline irrigations while two did not. One study found significant improvement in certain patient populations when using corticosteroid irrigations compared to no irrigation. Five studies found no significant increase in risk of adverse side effects with the use of topical corticosteroids. CONCLUSION: Many factors are associated with efficacious and adequate treatment of primary CRS. The pathology must be correctly diagnosed and be inflammatory in nature. The treatment paradigm should include wide and complete endoscopic sinus surgery for the adequate delivery of topical therapy. Topical therapy should be delivered in large-volume, low-pressure devices with adequate dosing. Although there is some systemic absorption, multiple studies have demonstrated that long-term, daily use of topical corticosteroids does not increase intraocular pressure, suppress the hypothalamic-pituitary-adrenal axis, or increase the risk of subcapsular cataracts. Therefore, topical corticosteroid irrigations should be considered a part of first-line medical treatment in postsurgical CRS patients.

Fatal Balamuthia mandrillaris brain infection associated with improper nasal lavage.

We report the case of a 69-year-old female who presented with a chronic nasal skin rash, new onset focal seizure, and a cerebral ring-enhancing lesion after a year of improper nasal irrigation. Despite aggressive and novel anti-amoebic treatment, she died as a result of a Balamuthia mandrillaris brain infection.

Nasal saline irrigation in pediatric rhinosinusitis: A systematic review.

OBJECTIVE: To determine the efficacy of nasal saline irrigation (NSI) in reducing symptoms and improving quality of life in pediatric patients with acute (ARS) or chronic (CRS) rhinosinusitis. DATA SOURCES: We searched the PubMed/MEDLINE and Embase electronic databases (indexed January, 1950 through April, 2017). REVIEW METHODS: Studies assessing the efficacy of NSI in pediatric patients with ARS or CRS were selected for analysis. Outcome measures, including symptom scores and parental surveys, were analyzed. Two independent reviewers evaluated each abstract and article. RESULTS: Of the 272 articles identified using our search strategy, only 1 study, focusing on the use of NSI in pediatric ARS, met all inclusion criteria. No studies investigating NSI in pediatric CRS were included for analysis. In general, studies demonstrated significant improvement of symptom scores with the use of NSI in pediatric rhinosinusitis; but, the use of varied outcome measures, control treatments, and NSI delivery made including studies and drawing conclusions difficult. No quantitative meta-analysis could be performed. CONCLUSION: NSI may provide benefit for ARS in children; however, additional high-quality studies with defined outcome measures are needed to determine the quantitative efficacy of this therapy in the pediatric patients with rhinosinusitis-especially in pediatric CRS.

The acceptability and tolerability of nasal douching in children with allergic rhinitis: A systematic review.

BACKGROUND: Allergic rhinitis (AR) is a significant issue in children. Treatment options include allergen avoidance, pharmacotherapy and immunotherapy. The use of nasal saline douching (NSD) in children has recently gained acceptability. However, there is limited data regarding the acceptability and tolerability of NSD in children with AR. METHODS: A search was conducted using Medline and Embase databases from January 1946 until June 2015 on the use of NSD in children aged 4-12 years with AR. All publications identified that assessed the beneficial effects, acceptability and tolerability were included. RESULTS: 40 studies were analyzed. Data varied considerably in terms of saline solutions used, modality of application, participant numbers, study design, follow up and outcomes. Factors that appear to influence the acceptability and tolerability of NSD include parental and health professionals' preconceptions, and characteristics of the solution. CONCLUSIONS: Nasal saline douching appears to be effective, being accepted and tolerated in the majority of children (78-100%). NSD has a significant positive impact on the quality of life in children with allergic rhinitis. When used as an adjunctive treatment having mainly a cleansing property, NSD potentiates the effects and may reduce the dose required of AR medications. Among the principal factors that influence the acceptability and tolerability of NSD are the child's age, delivery system and method, and tonicity. Nasal saline douching provides an accessible, low cost, low morbidity, easy to use treatment in children with allergic rhinitis.

Safety and tolerability of surfactant nasal irrigation.

BACKGROUND: Abnormal mucus composition and bacterial biofilms are thought to contribute to the pathophysiology of rhinosinusitis. Addition of a mucoactive surfactant to saline irrigation solution has been hypothesized to address these factors. We evaluated the safety and tolerability of a reformulated surfactant in a sample of normal subjects. METHODS: A total of 33 volunteers were randomly assigned to receive either surfactant solution or buffered saline at baseline in a controlled crossover study design. Each subject underwent rhinoscopic exam and in-office smell testing via the 40-question smell identification test (SIT). Those with non-normosmic results or active rhinitis symptoms were excluded. Subjects were instructed to irrigate twice daily with the selected solution for 1 week while keeping a daily diary. For week 2, treatment was stopped. During week 3, each group switched to the other treatment. Exam, SIT, and degree of congestion were assessed after each phase. RESULTS: Use of surfactant led to a marginal reduction in mean SIT score of 1.5 points, which was statistically significant (p = 0.012). A clinically meaningful reduction in SIT score, defined as ≥4 points, was observed in 18% (6/33) of subjects after surfactant vs 3% (1/33) after saline (p = 0.046). During the surfactant phase, moderate or severe congestion was reported in 29% (8/28) of subjects completing the diary. In contrast, only 6% (2/32) of subjects reported moderate congestion after the saline phase (p = 0.021). CONCLUSION: In normal volunteers, surfactant nasal irrigation may be associated with tolerability issues due to congestion. A subset may experience reduction in olfactory acuity that appears reversible.

Nasal Irrigation: An Imprecisely Defined Medical Procedure.

Nasal irrigation (NI) is an old practice of upper respiratory tract care that likely originated in the Ayurvedic medical tradition. It is used alone or in association with other therapies in several conditions-including chronic rhinosinusitis and allergic rhinitis-and to treat and prevent upper respiratory tract infections, especially in children. However, despite it being largely prescribed in everyday clinical practice, NI is not included or is only briefly mentioned by experts in the guidelines for treatment of upper respiratory tract diseases. In this review, present knowledge about NI and its relevance in clinical practice is discussed to assist physicians in understanding the available evidence and the potential use of this medical intervention. Analysis of the literature showed that NI seems to be effective in the treatment of several acute and chronic sinonasal conditions. However, although in recent years several new studies have been performed, most of the studies that have evaluated NI have relevant methodologic problems. Only multicenter studies enrolling a great number of subjects can solve the problem of the real relevance of NI, and these studies are urgently needed. Methods for performing NI have to be standardized to determine which solutions, devices and durations of treatment are adequate to obtain favorable results. This seems particularly important for children that suffer a great number of sinonasal problems and might benefit significantly from an inexpensive and simple preventive and therapeutic measure such as NI.

A Case Study of the Neti Pot's Rise, Americanization, and Rupture as Integrative Medicine in U.S. Media Discourse.

In a period of only one decade in the United States, the neti pot shifted from obscure Ayurvedic health device to mainstream complementary and integrative medicine (CIM), touted by celebrities and sold widely in drug stores. We examine the neti pot as a case study for understanding how a foreign health practice became mainstreamed, and what that process reveals about more general discourses of health in the United States. Using discourse analysis of U.S. popular press and new media news (1999-2012) about the neti pot, we trace the development of discourses from neti's first introduction in mainstream news, through the hype following Dr. Oz's presentation on Oprah, to 2011 when two adults tragically died after using Naegleria fowleri amoeba-infested tap water in their neti pots. Neti pot discourses are an important site for communicative analysis because of the pot's complexity as an intercultural artifact: Neti pots and their use are enfolded into the biomedical practice of nasal irrigation and simultaneously Orientalized as exotic/magical and suspect/dangerous. This dual positioning as normal and exotic creates inequitable access for using the neti pot as a resource for increasing cultural health capital (CHC). This article contributes to work that critically theorizes the transnationalism of CIM, as the neti pot became successfully Americanized. These results have implications for understanding global health practices' incorporation or co-optation in new contexts, and the important role that popularly mediated health communication can play in framing what health care products and practices mean for consumers.

Saline nasal irrigation for acute upper respiratory tract infections.

BACKGROUND: Acute upper respiratory tract infections (URTIs), including the common cold and rhinosinusitis, are common afflictions that cause discomfort and debilitation and contribute significantly to workplace absenteeism. Treatment is generally by antipyretic and decongestant drugs and sometimes antibiotics, even though most infections are viral. Nasal irrigation with saline is often employed as an adjunct treatment for URTI symptoms despite a relative lack of evidence for benefit in this clinical setting. This review is an update of the Cochrane review by Kassel et al, which found that saline was probably effective in reducing the severity of some symptoms associated with acute URTIs. OBJECTIVES: To assess the effects of saline nasal irrigation for treating the symptoms of acute URTIs. SEARCH METHODS: We searched CENTRAL (2014, Issue 7), MEDLINE (1966 to July week 5, 2014), EMBASE (1974 to August 2014), CINAHL (1982 to August 2014), AMED (1985 to August 2014) and LILACS (1982 to August 2014). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing topical nasal saline treatment to other interventions in adults and children with clinically diagnosed acute URTIs. DATA COLLECTION AND ANALYSIS: Two review authors (DK, BM) independently assessed trial quality with the Cochrane 'Risk of bias' tool and extracted data. We analysed all data using the Cochrane Review Manager software. Due to the large variability of outcome measures only a small number of outcomes could be pooled for statistical analysis. MAIN RESULTS: We identified five RCTs that randomised 544 children (three studies) and 205 adults (exclusively from two studies). They all compared saline irrigation to routine care or other nose sprays, rather than placebo. We included two new trials in this update, which did not contribute data of sufficient size or quality to materially change the original findings. Most trials were small and we judged them to be of low quality, contributing to an unclear risk of bias. Most outcome measures differed greatly between included studies and therefore could not be pooled. Most results showed no difference between nasal saline treatment and control. However, one larger trial, conducted with children, did show a significant reduction in nasal secretion score (mean difference (MD) -0.31, 95% confidence interval (CI) -0.48 to -0.14) and nasal breathing (obstruction) score (MD -0.33, 95% CI -0.47 to -0.19) in the saline group. However, a MD of -0.33 on a four-point symptom scale may have minimal clinical significance. The trial also showed a significant reduction in the use of decongestant medication by the saline group. Minor nasal discomfort and/or irritation was the only side effect reported by a minority of participants. AUTHORS' CONCLUSIONS: Nasal saline irrigation possibly has benefits for relieving the symptoms of acute URTIs. However, the included trials were generally too small and had a high risk of bias, reducing confidence in the evidence supporting this. Future trials should involve larger numbers of participants and report standardised and clinically meaningful outcome measures.

Infected cochlear implant after large-volume nasal irrigation.

OBJECTIVE: A patient with a well-healed, functional cochlear implant (CI) experienced a CI and mastoid infection shortly after initiating large-volume nasal irrigations after sinus surgery. The goal of this report is to bring attention to a rare complication and to question if large-volume nasal irrigation is safe in CI recipients. PATIENTS: Single patient at a tertiary care hospital. INTERVENTIONS: A CI recipient began using large-volume nasal irrigations with saline and budesonide after undergoing sinus surgery. MAIN OUTCOME MEASURES: CI infection and mastoiditis. RESULTS: Two weeks after starting nasal irrigations, the patient presented with mastoiditis and CI infection. Mastoid and intranasal middle meatal cultures both grew Group A streptococcus. CONCLUSION: Large-volume nasal irrigations may be related to our patient's CI infection, ultimately leading to explantation. Though a causal relationship cannot be definitively proven, awareness of this potential safety issue should be disseminated.

Decreasing bacterial cross-contamination with a pulsating nasal irrigation device.

BACKGROUND: The use of nasal irrigation in the management of postoperative endoscopic sinus surgery (ESS) patients is commonplace; however, the potential contamination of these bottles is concerning. The Sinugator® cordless pulsating nasal wash (NeilMed Pharmaceuticals, Inc., Santa Rosa, CA) is a battery-operated, positive pressure, pulsatile pump with a unidirectional flow. The principal aim of this study was to determine the incidence of cross-contamination using the pulsating nasal irrigation device and compare it with the traditional squeeze bottle. METHODS: Eleven post-ESS patients were given a NeilMed Sinugator nasal wash to use 3 times per day. A sterile nasal swab was obtained at the initial and second postoperative visits. A swab of the plastic irrigation reservoir was collected at the second visit. RESULTS: The overall contamination rate of bottles was found to be 45%. During the study several different organisms were cultured in the nose and bottles. The most commonly isolated organisms were coliforms and Staphylococcus aureus. We did not observe concomitant organisms in the nasal cultures and bottles in any subject. CONCLUSION: Despite using a motorized irrigation device, patients and their bottles grew positive cultures. However, no cross-contamination between the patients and bottles was identified, which can be attributed to a design that minimizes backwash.

Factors influencing the incidence of sinusitis in nasopharyngeal carcinoma patients after intensity-modulated radiation therapy.

The aim of the study was to investigate the incidence of sinusitis in nasopharyngeal carcinoma (NPC) patients before and after intensity-modulated radiation therapy (IMRT) and to analyze factors associated with the incidence of sinusitis following IMRT. We retrospectively analyzed 283 NPC patients who received IMRT in our hospital from March 2009 to May 2011. The diagnostic criteria for sinusitis are based on computed tomography (CT) or magnetic resonance imaging (MRI) findings. CT or MRI scans were performed before and after IMRT to evaluate the incidence of sinusitis. Factors influencing the incidence of sinusitis were analyzed by log-rank univariate and logistic multivariate analyses. Among the 283 NPC patients, 128 (45.2 %) suffered from sinusitis before radiotherapy. The incidence rates of sinusitis in patients with T1, T2, T3, and T4 NPC before radiotherapy were 22.6, 37.5, 46.8, and 61.3 %, respectively (χ 2 = 14.548, p = 0.002). Among the 155 NPC patients without sinusitis before radiotherapy, the incidence rates of sinusitis at the end of radiotherapy and at 1, 3, 6, 9, 12, and 18 months after radiotherapy were 32.9, 43.2, 61.3, 68.4, 73.5, 69.7, and 61.3 %, respectively (χ 2 = 86.461, p < 0.001). Univariate analysis showed that T stage, invasion of the nasal cavity, nasal irrigation, and radiation dose to the nasopharynx were associated with the incidence of sinusitis in NPC patients after IMRT (p = 0.003, 0.006, 0.002, and 0.020). Multivariate analysis showed that T stage, invasion of the nasal cavity, and nasal irrigation were influential factors for the incidence of sinusitis in NPC patients after IMRT (p = 0.002, 0.002, and 0.000). There was a higher incidence of sinusitis with higher T stage among NPC patients before radiotherapy, and the incidence of sinusitis in NPC patients after IMRT was high (45.2 %). The incidence of sinusitis increased rapidly within the first 3 months after IMRT, and the number of sinusitis cases peaked at 6-9 months after IMRT and showed a trend toward stabilization after 1 year. Advanced T stage, invasion of the nasal cavity, and nasal irrigation were positively associated with the incidence of sinusitis in NPC patients after IMRT.

Nasal saline irrigation has no effect on normal olfaction: a prospective randomized trial.

BACKGROUND: Nasal saline irrigation is a safe treatment for chronic rhinosinusitis; however, its effect on olfaction is unclear. Cyclic adenosine monophosphate (cAMP) is a key second messenger in the mechanism of olfaction and has been shown to be associated with smell function. In animal studies, olfactory cilia may be harvested by simple saline preparations. This study aimed to characterize the effect of nasal saline irrigation on smell function. METHODS: Volunteers with normal olfaction were randomized into a control or irrigation cohort. In the initial appointment, subjects completed a University of Pennsylvania Smell Identification Test (UPSIT) and nasal samples were obtained by 2 methods: the nasal curette and cytobrush. The irrigation cohort performed daily nasal saline irrigations. Both cohorts then returned in 1 week. The UPSIT and nasal cell collection were repeated, and each subject completed a subjective olfactory transition scale. Nasal samples were processed for cAMP levels using a commercial assay. RESULTS: Thirty-two subjects were enrolled and randomized into each cohort. Control and postirrigation mean UPSIT scores were 36.8 and 36.7 (p = 0.48). No subjects reported a subjective smell loss. Ten pairs of nasal samples were assayed. Using the curette, control and postirrigation cAMP levels were 509 and 490 fmol/(mg/mL), respectively (p = 0.94). Using the cytobrush, respective cAMP levels were 424 and 449 fmol/(mg/mL), respectively (p = 0.94). CONCLUSION: Nasal saline irrigation has no subjective or objective effect on olfaction. It also does not appear to affect cAMP levels, a potential marker of smell function.

The effect of intranasal fluticasone propionate irrigations on salivary cortisol, intraocular pressure, and posterior subcapsular cataracts in postsurgical chronic rhinosinusitis patients.

BACKGROUND: Intranasal corticosteroid irrigations, especially budesonide, are used increasingly in the management of chronic rhinosinusitis. In post-endoscopic sinus surgery patients, irrigations may offer improved delivery at higher doses to the paranasal sinuses than intranasal spray preparations. Fluticasone propionate may have higher potency and lower systemic bioavailability than budesonide, but there is little data on its effects as an intranasal irrigation on the hypothalamic-pituitary-adrenal axis or on ocular findings. METHODS: Adult patients who had previously undergone bilateral endoscopic sinus surgery and had not taken systemic corticosteroids in the last 6 months were prospectively enrolled. Subjects irrigated with 3 mg of fluticasone propionate in 240 mL saline solution twice daily. Salivary cortisol, intraocular pressure, and the presence of posterior subcapsular cataracts were measured before drug administration and after 6 weeks of continuous use. RESULTS: Twenty-three subjects completed the study. No subjects had salivary cortisol levels below the normal range before or after therapy, and there was no statistical difference in mean salivary cortisol levels pretreatment and posttreatment (0.294 vs 0.392 µg/dL; p = 0.27). There was no clinical or statistical difference in mean intraocular pressure before or after therapy (13.3 vs 13.3 mmHg; p = 0.86). No subjects developed a posterior subcapsular cataract. CONCLUSION: Fluticasone propionate irrigations did not suppress salivary cortisol levels or result in ocular changes. Irrigation with fluticasone propionate 3 mg in 240 mL saline twice daily may be a safe alternative to other intranasal or systemic corticosteroid treatments for chronic rhinosinusitis patients.

Intranasal myiasis: a rare complication of transnasal skull base surgery.

A 57-year-old woman with a history of atypical intracranial meningioma had undergone multiple craniotomies and endoscopic skull base procedures over several years. She presented most recently with nasal discharge consisting of intranasal larvae. Isolated organisms from the nasal cavity and maxillary sinus were identified as blow fly larvae (Calliphoridae family). The patient was treated with transnasal debridement and antibiotic therapy. The organisms were successfully eradicated and she is free from further signs of infection. Intranasal myiasis is an unusual complication of anterior skull base surgery.

Comparison of buffered and nonbuffered nasal saline irrigations in treating allergic rhinitis.

OBJECTIVES/HYPOTHESIS: We aimed to study the effect of alkalinity of isotonic nasal saline irrigation on nasal symptoms, mucociliary clearance, nasal patency, and patient's preference in patients with allergic rhinitis (AR). STUDY DESIGN: A double-blind, randomized, three-arm crossover study. METHODS: Patients with AR were enrolled. Three kinds of isotonic nasal saline irrigations: nonbuffered (pH 6.2-6.4), buffered with mild alkalinity (pH 7.2-7.4), and buffered with alkalinity (pH 8.2-8.4) were given one at a time, in different orders. Patients rinsed their nose with 240 ml of one solution twice daily for 10 days and then swapped to the others. The washout period was at least 5 days. Primary outcomes were nasal symptoms, mucociliary clearance time, and nasal patency. Outcomes were compared between baseline and posttreatment and also between various kinds of solution. Secondary outcomes were patients' preference and adverse events. RESULTS: Thirty-six subjects entered the study, and there were no dropouts. Overall nasal symptom was significantly improved from baseline (P = 0.03) only by buffered solution with mild alkalinity. Sneezing was significantly improved from baseline (P = 0.04) only by buffered solution with alkalinity. No other significant improvements were achieved by any solution. When comparing between the three nasal irrigations, there were no differences in all parameters. The patients significantly preferred the buffered solution with mild alkalinity (P = 0.02). CONCLUSIONS: Buffered isotonic saline with some degree of alkalinity may improve nasal symptoms. Isotonic saline irrigations, regardless of alkalinity, may not improve mucociliary function and nasal patency. Buffered isotonic saline with mild alkalinity is the most preferred.

Paranasal sinus exostoses: possible correlation with cold temperature nasal irrigation after endoscopic sinus surgery.

Exostoses of the external auditory canal (EEAC) are a commonly encountered clinical exam finding; however, exostoses in other locations are vanishingly rare. The postoperative paranasal sinuses are penetrated with cold water solutions, the reputed etiological agent for EEAC, and development of exostoses in this unexpected location may be observed endoscopically. The surprising appearance of these protuberant lesions within the sinuses could be mistaken for more ominous processes, subjecting the patient to biopsy, surgery, or unnecessary medical therapy. The radiologic appearance of exostoses within the paranasal sinuses is herein reported for the first time, and care is taken to distinguish these bony lesions from the osteoneogenesis of chronic inflammation.