Introduction

Neti pots are small hand-held devices used for nasal irrigation. They are sometimes affectionately referred to as ‘Aladdin’s lamp’. Reason being, that some commercially available neti pots look like a lot like the lamp that Aladdin rubbed to get his three wishes.

Ardent fans of the neti pot would have you believe that it does not just look like Aladdin’s lamp, but that it also has almost magical powers and can treat colds, allergies, sinus infections and even cure snoring. Your wish is my command.

This viewpoint is creeping into medical circles too. In fact, the neti pot has been profiled in a case study for understanding how an obscure foreign health practice became mainstreamed (1). A 2004 review paper from the Department of Otolaryngology at the University of Iowa Hospital suggests that nasal irrigation is not only effective but is under-utilised and should be upgraded to more than just adjunctive therapy (2).

Is this just wishful thinking? What does the scientific literature say about the modern day version of Aladdin’s lamp?

What Is a Neti Pot?

A neti pot is a small hand-held device with a long spout and a container for holding liquid. It looks a lot like Aladdin’s lamp but is made of a squeezable plastic and not metal. The user fills the container with fluid (usually saline), inserts the spout in one nostril, instils the saline into one nasal cavity, moves their head to allow the liquid to pour out the other nostril.

The theory is that this cleans out any mucus, bacteria, inflammatory mediators or allergens. It is also believed to increase ‘ciliary beat frequency’.

Our noses are lined with tiny hairs called cilia which beat in concert and keep our noses clean. Nasal irrigation is believed to increase the efficiency of ciliary action. The neti pot is just one of a range of devices used for nasal irrigation.

Nasal irrigation is an old practice of nasal care that involves rinsing the nasal cavity with a saline solution. It is thought that the practice of nasal irrigation originated in India as part of the Ayurvedic medical system. Logically, this makes sense as it is consistent with other Ayurvedic medical practices which focus on bodily secretions such as bowel movements.

Nasal irrigation was adopted into Western Medicine in the late nineteenth century. It can be used alone or in conjunction with other treatment modalities.

A number of devices and techniques can be used to instil the saline into the nose. Logically, as the saline has to travel against gravity, some counter gravity positive pressure needs to be used.

This can be squeezing a plastic liquid container to force the liquid against gravity. Alternatively, users can sniff to exert a negative pressure to overcome gravity.

Sprays, pumps, squirt bottles, nebulisers and the much loved neti pots are used to irrigate the nasal passages.
Syringes are not recommended as they do not make a good seal with nose which makes it more likely that users will have an ineffective technique.

Saline is usually used in nasal irrigation and is a mixture of salt and water.

Two strengths of saline are used in nasal irrigation:

isotonic and hypertonic saline. Isotonic refers to a solution which contains equal amounts of solute (salt) and solvent (water). Isotonic saline has 9 gms of sodium chloride per 1000 mls of water and is commonly referred to as 0.9% saline.

Hypertonic refers to a solution which contains more solvent (salt) than solute (water). Hypertonic saline concentrations of 4.5-7% are most commonly used in nasal irrigation.

It is generally recommended that saline concentrations of greater than 3% should not be used but some studies do look at concentrations up to 6%.

The effects of nasal irrigation are believed (unproven) to be enhanced by the addition of ions:

  • sodium and chloride to improve epithelial cell integrity and function
  • magnesium to promote cell repair and reduce inflammation
  • zinc to reduce death of nasal cells and
  • potassium as an anti- inflammatory.

Seawater contains many minerals and is often diluted with distilled water for nasal irrigation because of its mineral content.

The nasal irrigation industry is not controlled under the medical device regulation acts. These devices are easily bought in pharmacies, health food shops and online.

There are over 300 neti pot products for sale on Amazon. Generally speaking, neti pots are relatively inexpensive but you can happily spend over $100 on a ceramic neti pot or over $300 on a neti pot travel kit. After all which serious ‘netipotter’ would leave home without one?

Is There Any Research?

There are 8 publications directly related to the search term neti pots but no human clinical trials. The majority of these publications are case reports of side effects related to neti pot use. If we broaden the search term to ‘nasal irrigation’, things improve and we find 3759 publications including 584 human clinical trials. We will include studies on nasal irrigation in this post.

Does It Help Sinus Infections?

Every disease area has its own disease specific health related quality of life questionnaire. Can you guess what the acronym for the sinus health questionnaire is? It is called the SNOT score. For real. Sino-Nasal-Outcome-Test = SNOT.

Can you imagine that a group of expert adult researchers had to sit around a table to come up with that acronym? Seems like some people never grow out of that stage that seven year olds go through where they laugh at everything related to the human body.

Sinus Infections
A group of British researchers published a Cochrane review of saline irrigation for chronic rhinosinusitis in 2016 (3). This was part of six reviews looking at the primary medical management of chronic rhinosinusitis. There are two main types of chronic rhinosinsusitis: people with nasal polyps and people without nasal polyps.

Only two randomized controlled trials were identified. Even though this review was technically a meta- analysis, it is hard to meta-analyse just two studies especially when the studies involved were so different. Let’s forget the meta-analysis and look at the source data for ourselves.

Here are these two studies in some detail.

Study 1 compared large volume hypertonic (2%) saline with usual treatment over six months. The study had 76 adult study participants (4). (We will come back to the author of Study 1 shortly). The study found no difference at three months and a small difference at six months. This does not make much sense unless irrigation takes between three and six months to show an effect (which is unlikely).

The more likely explanation is the quality (or lack thereof) of the data. The authors of the meta-analysis classified the data from this study as low quality at the three month timeline and very low quality at six months.

Study 2 compared nebulized saline to intranasal steroids in 40 adults (5). This study showed that intranasal steroids outperformed nasal irrigation. But wait, there’s more. A sense of deja vu perhaps. The authors of the meta-analysis considered the evidence to be very low quality.

Research on acute sinusitis is more promising.

A study in 62 children showed that saline nasal irrigation was as effective as amoxicillin in the treatment of acute sinusitis (6). This study was a prospective randomized, blind placebo-controlled trial in Egypt which compared amoxicillin 100mg/kg/day with 0.9% saline irrigation.

Bottom Line (or Lines)

A single small study in acute sinusitis showed that nasal irrigation was as effective as oral antibiotics. The quality and quantity of research on nasal irrigation for chronic sinusitis is not (aka SNOT) adequate to judge the utility of this intervention for sinusitis.

Does a Neti Pot Help With Colds & Respiratory Tract Infections?

One of the authors of study 1 (the study with the poor quality data which is quoted above) published another paper on the use of nasal irrigation in respiratory tract infections (7). The author of these two papers comment that the data on the use of nasal irrigation for respiratory tract infections is ‘less robust’ than that for chronic sinusitis (oops maybe this researcher never read the comments of the Cochrane reviewers who annihilated his data on chronic sinusitis).

Said researcher recommends the use of nasal irrigation for respiratory tract infections but does not provide us with any data this time. Maybe no data is better than bad data?

Australian investigators carried out a Cochrane review looking at the effect of neti pots on respiratory tract infections (8). They identified five pediatric trials involving 544 children and two adult studies involving 205 adults. The trials all had small numbers, were of poor quality and could not be pooled in any meaningful way. While individual studies (especially in children) suggested that neti pots may be of benefit in respiratory tract infections, the database was insufficient to make draw any meaningful conclusions.

Bottom Line

Neti pots are unproven for colds and respiratory tract infections.

Does It Help With Allergies?

A study in 60 atopic children with sinusitis compared saline irrigation with no irrigation (9). The irrigation group reported significant improvements in eye congestion, rhinorrhea, nasal itching, sneezing, and cough symptoms compared with the non-irrigation group. There were statistically significant improvements in objective measures of nasal peak expiratory flow rate but not x-rays in the treatment arm of the study.

German investigators did a systematic review of the literature to understand the role of nasal irrigation in allergic rhinitis (10). They initially identified 50 trials but whittled this down to 10 relevant studies involving over 400 study subjects. Metrics included in the meta-analysis included primary (symptom score) and secondary parameters (medicine consumption, mucociliary clearance, and quality of life).

The investigators concluded that nasal irrigation can be recommended as complementary therapy in allergic rhinitis as it produced a 27.66% improvement in nasal symptoms, a 62.1% reduction in medicine consumption, a 31.19% acceleration of mucociliary clearance time, and a 27.88% improvement in quality of life.

Bottom Line

There are scientific studies to support a role for nasal irrigation in allergic rhinitis.

Does it help Pregnancy Related Sinus Symptoms?

An Italian paper evaluated the effect of nasal irrigation in pregnant women with seasonal allergic rhinitis (11). A total of 45 women were randomized to either intranasal lavage with hypertonic saline solution 3 times daily versus no local therapy during a 6-week period corresponding to the pollen season.

There was a statistically significant reduction in the use of antihistamines and on nasal resistance as measured by rhinomanometry (this is a specialised measure of pressure and flow during normal inspiration and expiration through the nose).

Bottom Line

A single small study suggests that nasal irrigation may help with allergic rhinitis in pregnancy.

Does it Help With Snoring?

There are no studies linking neti pots with snoring. The study looking at neti pots in children with acute sinusitis showed improvements in nasal congestion, throat itching, cough and sleep quality improved (9). Could that be extrapolated to reduced snoring? Not really. Most people are thinking of chronic snoring adults when they think of treatments for snoring.

Snoring Problems

Bottom Line

Neti pots won’t stop you (or your beloved) from snoring. Sorry.

Is a Neti Pot Safe?

Nasal irrigation is generally well tolerated. I tried out a neti pot while researching this article and found it really really hard to coordinate getting the saline in one side and out the other. I am guessing it gets easier with time. Practice makes perfect maybe?

Regardless I would not recommend netipotting ( if such a verb exists) in your wedding dress or with your make up on. Equally (and call me conservative) this is not something for a first date. There are some things that need (or should) be done in private and in my humble opinion, netipotting is one of them. It is a super messy affair.

Documented side- effects of nasal irrigation include nasal discomfort, ear pain and best of all, pooling of saline in the nasal passages with subsequent drainage (like I said, not all for your wedding day or first date)

Now we get to the part about the brain eating ameba. Naegleri fowleri is an ameba that can cause meningoencephalitis.

This pathogen is found in freshwater and is known to rarely cause infections when people dive into freshwater without a nose clip which allows the water (and ameba) to travel at force into the nasal passages. Mechanistically, diving into water is much the same as nasal irrigation.

A number of fatal cases of Nargleri fowleri infection have been reported and traced back to neti pot use. In 2011 two people from Louisiana died of Nagleri fowleri infection (12). The ameba was found in neti pots used by the two patients even though the water in both patients homes the Environmental Protection Agency standards for water.
While Nagleri fowleri is a freshwater bug that cannot survive in salt water, the concentrations of salt in nasal irrigation solutions is too low to kill this ameba.

Only 3 out of 138 cases of Nagleri infection ( from any cause) have survived. Does that mean that sterile water should be used for nasal irrigation? Experts do not uniformly agree on this topic. Some say that the nose is naturally host to bacteria and that the addition of a few extra bugs would not be clinically relevant.

As an infectious diseases physician, I would definitely recommend using sterile water and especially in people at risk eg immunocompromised or children.

Conclusion

Nasal irrigation may help with allergic rhinitis and possibly acute sinusitis.

So what is all the fuss about?

A paper published in 2016 helps us to understand the ‘Americanisation’of the neti pot (1). This is a really amazing paper and is my favourite research paper that I have read so far this year. The paper studied popular press and media relating to neti pots in the US.

They identified a 2011 Oprah-Dr Phil feature on the Louisianan Naegleri deaths as the tipping point for the popularity of the neti pot. Really?

Seems that it true that there is no such thing as bad press. The research publication comments that the dual positioning of the neti pot as part of western and oriental medicine along with it’s mystique as ‘exotic/ magical and suspect/dangerous’ led to the rise in use of the neti pot.

This is such a great and telling observation. In many ways, it summarizes the mantra of #healthybutsmart. Just because something is exotic, cultish, expensive or featured on Oprah does not necessarily mean that is works or is better than commoner gardener solutions.