Efficacy of hypertonic saline nasal irrigation in allergic rhinitis: A systematic review and meta-analysis
Main Article Content
Keywords
nasal wash, allergic rhinitis, saline irrigation, hypertonic versus isotonic saline
Abstract
Saline nasal irrigation provides symptom relief in allergic rhinitis (AR), but the optimal saline concentration remains uncertain. The comparative efficacy of 3% hypertonic saline nasal irrigation (HSNI) versus 0.9% isotonic saline is still debated. We conducted a meta-analysis to evaluate nasal symptom scores from studies comparing HSNI with control (isotonic saline or no saline) in patients with AR. Systematic search of PubMed, Scopus, and Cochrane Central was performed for randomized controlled trials (RCTs) comparing 3% HSNI with control from inception to May 8, 2024. Primary outcomes were total nasal symptom scores and antihistamine use. We pooled mean differences and odds ratios (OR) with 95% confidence intervals (CI) using a random effects model and assessed heterogeneity with I2. Nine RCTs involving 645 patients met the inclusion criteria. Follow-up ranged from 4 weeks to 2 months. The mean age was 35.49 years in adults and 9.3 years in children. HSNI significantly reduced nasal symptom scores compared with control in adults (MD = −2.09; 95% CI: −3.86 to −0.33; P = 0.02; I2 = 97%) and children (MD = −0.97; 95% CI: −1.51 to −0.44; P = 0.0004; I2 = 42%). Antihistamine use was also lower with HSNI than control (OR = 0.39; 95% CI: 0.21–0.70; P = 0.002; I2 = 14%), but no significant difference was found between HSNI and isotonic saline alone (OR = 0.69; 95% CI: 0.41–1.16; P = 0.16; I2 = 0%). HSNI appears effective in reducing symptoms and medication use in allergic rhinitis across age groups.
References
1 Skoner DP. Allergic rhinitis: Definition, epidemiology, pathophysiology, detection, and diagnosis. J Allergy Clin Immunol. 2001;108(1 Suppl):S2–8. 10.1067/mai.2001.115569
2 Genuneit J, Seibold AM, Apfelbacher CJ, Konstantinou GN, Koplin JJ, La Grutta S, et al. Overview of systematic reviews in allergy epidemiology. Allergy. 2017;72(6):849–56. 10.1111/all.13123
3 Kakli HA, Riley TD. Allergic rhinitis. Prim Care. 2016;43(3):465–75. 10.1016/j.pop.2016.04.009
4 Pearce N, Sunyer J, Cheng S, Chinn S, Björkstén B, Burr M, et al. Comparison of asthma prevalence in the ISAAC and the ECRHS. ISAAC Steering Committee and the European Community Respiratory Health Survey. International Study of Asthma and Allergies in Childhood. Eur Respir J. 2000;16(3):420–6. 10.1183/9031936.00.16337700
5 Barne M, Singh S, Mangal DK, Singh M, Awasthi S, Mahesh PA, et al. Global Asthma Network Phase I, India: Results for allergic rhinitis and eczema in 127,309 children and adults. J Allergy Clin Immunol Global. 2022;1(2):51–60. 10.1016/j.jacig.2022.01.004
6 Wheatley LM, Togias A. Clinical practice. Allergic rhinitis. N Engl J Med. 2015;372(5):456–63. 10.1056/NEJMcp1412282
7 Small P, Kim H. Allergic rhinitis. Allergy Asthma Clin Immunol. 2011;7 Suppl 1(Suppl 1):S3. 10.1186/s13223-018-0280-7
8 Wise SK, Lin SY, Toskala E, Orlandi RR, Akdis CA, Alt JA, et al. International Consensus Statement on Allergy and Rhinology: Allergic rhinitis. Int Forum Allergy Rhinol. 2018;8(2):108–352. 10.1002/alr.22073
9 Li CL, Lin HC, Lin CY, Hsu TF. Effectiveness of hypertonic saline nasal irrigation for alleviating allergic rhinitis in children: A systematic review and meta-analysis. J Clin Med. 2019;8(1):64. 10.3390/jcm8010064
10 Cordray S, Miner L, Harjo JB. Comparison of intranasal hypertonic Dead sea saline spray and intranasal aqueous triamcinolone spray in seasonal allergic rhinitis. Ear Nose Throat J. 2005;84(7):426–30.
11 Wang Y, Jin L, Liu S-X, Fan K, Qin M-L, Yu S-Q. Role of nasal saline irrigation in the treatment of allergic rhinitis in children and adults: A systematic analysis. Allergol Immunopathol (Madr). 2020;48(4):360–67. 10.1016/j.aller.2020.01.002
12 Hermelingmeier KE, Weber RK, Hellmich M, Heubach CP, Mösges R. Nasal irrigation as an adjunctive treatment in allergic rhinitis: A systematic review and meta-analysis. Am J Rhinol Allergy. 2012;26(5):e119–25. 10.2500/ajra.2012.26.3787
13 Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: A revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. 10.1136/bmj.l4898
14 Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al., editors. Cochrane handbook for systematic reviews of interventions version 6.3. [cited 2022 Feb). Cochrane, 2022. Available from: www.training.cochrane.org/handbook
15 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ. 2021;372:n71 10.1136/bmj.n71
16 Sansila K, Eiamprapai P, Sawangjit R. Effects of self-prepared hypertonic nasal saline irrigation in allergic rhinitis: A randomized controlled trial. Asian Pac J Allergy Immunol. 2020;38(3):200–7. 10.12932/AP-090618-0331
17 Singh R, Galagali JR, Kumar S, Bahurupi Y, Chandrachood M. Comparative study of intranasal hypertonic seawater saline versus intranasal normal saline in allergic rhinitis. Int J Otorhinolaryngol Head Neck Surg. 2017;3(1):104–7. 10.18203/issn.2454-5929.ijohns20164810
18 Garavello W, Somigliana E, Acaia B, Gaini L, Pignataro L, Gaini RM. Nasal lavage in pregnant women with seasonal allergic rhinitis: A randomized study. Int Arch Allergy Immunol. 2010;151(2):137–41. 10.1159/000236003
19 Di Berardino F, Zanetti D, D’Amato G. Nasal rinsing with an atomized spray improves mucociliary clearance and clinical symptoms during peak grass pollen season. Am J Rhinol Allergy. 2017;31(1):40–3. 10.2500/ajra.2016.30.4383
20 Satdhabudha A, Poachanukoon O. Efficacy of buffered hypertonic saline nasal irrigation in children with symptomatic allergic rhinitis: A randomized double-blind study. Int J Pediatr Otorhinolaryngol. 2012;76(4):583–8. 10.1016/j.ijporl.2012.01.022
21 Malizia V, Fasola S, Ferrante G, Cilluffo G, Montalbano L, Landi M, et al. Efficacy of buffered hypertonic saline nasal irrigation for nasal symptoms in children with seasonal allergic rhinitis: A randomized controlled trial. Int Arch Allergy Immunol. 2017;174(2):97–103. 10.1159/000481093
22 Rattanamaneewong K, Chinratanapisit S, Piromrat K, Thambamrung N. Efficacy of hypertonic saline irrigation for nasal symptoms in children with perennial allergic rhinitis: A randomized double-blind study. J Med Assoc Thai. 2021;104:1570–7.
23 Marchisio P, Varricchio A, Baggi E, Bianchini S, Capasso ME, Torretta S, et al. Hypertonic saline is more effective than normal saline in seasonal allergic rhinitis in children. Int J Immunopathol Pharmacol. 2012;25(3):721–30. 10.1186/1824-7288-40-47
24 Garavello W, Romagnoli M, Sordo L, Gaini RM, Di Berardino C, Angrisano A. Hypersaline nasal irrigation in children with symptomatic seasonal allergic rhinitis: A randomized study. Pediatr Allergy Immunol. 2003;14(2):140–3. 10.1034/j.1399-3038.2003.00021.x
25 König K, Klemens C, Eder K, San Nicoló M, Becker S, Kramer MF, et al. Cytokine profiles in nasal fluid of patients with seasonal or persistent allergic rhinitis. Allergy Asthma Clin Immunol. 2015;11:26. 10.1186/s13223-015-0093-x
26 Small P, Keith PK, Kim H. Allergic rhinitis. Allergy Asthma Clin Immunol. 2018;14(Suppl 2):51. 10.1186/s13223-018-0280-7
27 Pawankar R, Hayashi M, Yamanishi S, Igarashi, T. The paradigm of cytokine networks in allergic airway inflammation. Curr Opin Allergy Clin Immunol. 2015;15:41–8. 10.1097/ACI.0000000000000129
28 Scadding, G. Cytokine profiles in allergic rhinitis. Curr Allergy Asthma Rep. 2014;14:435. 10.1007/s11882-014-0435-7
29 Barham HP, Harvey RJ. Nasal saline irrigation: Therapeutic or homeopathic. Braz J Otorhinolaryngol. 2015;81:457–58. 10.1016/j.bjorl.2015.07.002
30 Bonnomet A, Luczka E, Coraux C, de Gabory L. Non-diluted seawater enhances nasal ciliary beat frequency and wound repair speed compared to diluted seawater and normal saline. Int Forum Allergy Rhinol. 2016;6:1062–68. 10.1002/alr.21782
31 Georgitis JW. Nasal hyperthermia and simple irrigation for perennial rhinitis. Changes in inflammatory mediators. Chest. 1994;106:1487–92. 10.1378/chest.106.5.1487
32 Chen J-R, Jin L, Li X-Y. The effectiveness of nasal saline irrigation (seawater) in treatment of allergic rhinitis in children. Int J Pediatr Otorhinolaryngol. 2014;78:1115–18. 10.1016/j.ijporl.2014.04.026
33 Gallant JN, Basem JI, Turner JH, Shannon CN, Virgin FW. Nasal saline irrigation in pediatric rhinosinusitis: A systematic review. Int J Pediatr Otorhinolaryngol. 2018;108:155–62. 10.1016/j.ijporl.2018.03.001
34 Rabago D, Zgierska A. Saline nasal irrigation for upper respiratory conditions. Am Fam Physician. 2009;80(10):1117–19.
35 Klimek L, Bachert C, Pfaar O, Becker S, Bieber T, Brehler R, et al. ARIA guideline 2019: Treatment of allergic rhinitis in the German health system. Allergol Select. 2019;3(1):22–50. 10.5414/ALX02120E
36 Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025. [cited 2025 May]. Available from: www.ginasthma.org
37 Ridolo E, Barone A, Nicoletta F, Paoletti G, Heffler E, Malvezzi L, et al. Intranasal corticosteroid and antihistamine combinations in the treatment of allergic rhinitis: The role of the novel formulation olopatadine/mometasone furoate. Expert Rev Clin Immunol. 2023;19(6):575–84. 10.1080/1744666X.2023.2200165
38 Fein MN, Fischer DA, O’Keefe AW, Sussman GL. CSACI position statement: Newer generation H1-antihistamines are safer than first-generation H1-antihistamines and should be the first-line antihistamines for the treatment of allergic rhinitis and urticaria. Allergy Asthma Clin Immunol. 2019;15(1):61. 10.1186/s13223-019-0375-9
2 Genuneit J, Seibold AM, Apfelbacher CJ, Konstantinou GN, Koplin JJ, La Grutta S, et al. Overview of systematic reviews in allergy epidemiology. Allergy. 2017;72(6):849–56. 10.1111/all.13123
3 Kakli HA, Riley TD. Allergic rhinitis. Prim Care. 2016;43(3):465–75. 10.1016/j.pop.2016.04.009
4 Pearce N, Sunyer J, Cheng S, Chinn S, Björkstén B, Burr M, et al. Comparison of asthma prevalence in the ISAAC and the ECRHS. ISAAC Steering Committee and the European Community Respiratory Health Survey. International Study of Asthma and Allergies in Childhood. Eur Respir J. 2000;16(3):420–6. 10.1183/9031936.00.16337700
5 Barne M, Singh S, Mangal DK, Singh M, Awasthi S, Mahesh PA, et al. Global Asthma Network Phase I, India: Results for allergic rhinitis and eczema in 127,309 children and adults. J Allergy Clin Immunol Global. 2022;1(2):51–60. 10.1016/j.jacig.2022.01.004
6 Wheatley LM, Togias A. Clinical practice. Allergic rhinitis. N Engl J Med. 2015;372(5):456–63. 10.1056/NEJMcp1412282
7 Small P, Kim H. Allergic rhinitis. Allergy Asthma Clin Immunol. 2011;7 Suppl 1(Suppl 1):S3. 10.1186/s13223-018-0280-7
8 Wise SK, Lin SY, Toskala E, Orlandi RR, Akdis CA, Alt JA, et al. International Consensus Statement on Allergy and Rhinology: Allergic rhinitis. Int Forum Allergy Rhinol. 2018;8(2):108–352. 10.1002/alr.22073
9 Li CL, Lin HC, Lin CY, Hsu TF. Effectiveness of hypertonic saline nasal irrigation for alleviating allergic rhinitis in children: A systematic review and meta-analysis. J Clin Med. 2019;8(1):64. 10.3390/jcm8010064
10 Cordray S, Miner L, Harjo JB. Comparison of intranasal hypertonic Dead sea saline spray and intranasal aqueous triamcinolone spray in seasonal allergic rhinitis. Ear Nose Throat J. 2005;84(7):426–30.
11 Wang Y, Jin L, Liu S-X, Fan K, Qin M-L, Yu S-Q. Role of nasal saline irrigation in the treatment of allergic rhinitis in children and adults: A systematic analysis. Allergol Immunopathol (Madr). 2020;48(4):360–67. 10.1016/j.aller.2020.01.002
12 Hermelingmeier KE, Weber RK, Hellmich M, Heubach CP, Mösges R. Nasal irrigation as an adjunctive treatment in allergic rhinitis: A systematic review and meta-analysis. Am J Rhinol Allergy. 2012;26(5):e119–25. 10.2500/ajra.2012.26.3787
13 Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: A revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. 10.1136/bmj.l4898
14 Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al., editors. Cochrane handbook for systematic reviews of interventions version 6.3. [cited 2022 Feb). Cochrane, 2022. Available from: www.training.cochrane.org/handbook
15 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ. 2021;372:n71 10.1136/bmj.n71
16 Sansila K, Eiamprapai P, Sawangjit R. Effects of self-prepared hypertonic nasal saline irrigation in allergic rhinitis: A randomized controlled trial. Asian Pac J Allergy Immunol. 2020;38(3):200–7. 10.12932/AP-090618-0331
17 Singh R, Galagali JR, Kumar S, Bahurupi Y, Chandrachood M. Comparative study of intranasal hypertonic seawater saline versus intranasal normal saline in allergic rhinitis. Int J Otorhinolaryngol Head Neck Surg. 2017;3(1):104–7. 10.18203/issn.2454-5929.ijohns20164810
18 Garavello W, Somigliana E, Acaia B, Gaini L, Pignataro L, Gaini RM. Nasal lavage in pregnant women with seasonal allergic rhinitis: A randomized study. Int Arch Allergy Immunol. 2010;151(2):137–41. 10.1159/000236003
19 Di Berardino F, Zanetti D, D’Amato G. Nasal rinsing with an atomized spray improves mucociliary clearance and clinical symptoms during peak grass pollen season. Am J Rhinol Allergy. 2017;31(1):40–3. 10.2500/ajra.2016.30.4383
20 Satdhabudha A, Poachanukoon O. Efficacy of buffered hypertonic saline nasal irrigation in children with symptomatic allergic rhinitis: A randomized double-blind study. Int J Pediatr Otorhinolaryngol. 2012;76(4):583–8. 10.1016/j.ijporl.2012.01.022
21 Malizia V, Fasola S, Ferrante G, Cilluffo G, Montalbano L, Landi M, et al. Efficacy of buffered hypertonic saline nasal irrigation for nasal symptoms in children with seasonal allergic rhinitis: A randomized controlled trial. Int Arch Allergy Immunol. 2017;174(2):97–103. 10.1159/000481093
22 Rattanamaneewong K, Chinratanapisit S, Piromrat K, Thambamrung N. Efficacy of hypertonic saline irrigation for nasal symptoms in children with perennial allergic rhinitis: A randomized double-blind study. J Med Assoc Thai. 2021;104:1570–7.
23 Marchisio P, Varricchio A, Baggi E, Bianchini S, Capasso ME, Torretta S, et al. Hypertonic saline is more effective than normal saline in seasonal allergic rhinitis in children. Int J Immunopathol Pharmacol. 2012;25(3):721–30. 10.1186/1824-7288-40-47
24 Garavello W, Romagnoli M, Sordo L, Gaini RM, Di Berardino C, Angrisano A. Hypersaline nasal irrigation in children with symptomatic seasonal allergic rhinitis: A randomized study. Pediatr Allergy Immunol. 2003;14(2):140–3. 10.1034/j.1399-3038.2003.00021.x
25 König K, Klemens C, Eder K, San Nicoló M, Becker S, Kramer MF, et al. Cytokine profiles in nasal fluid of patients with seasonal or persistent allergic rhinitis. Allergy Asthma Clin Immunol. 2015;11:26. 10.1186/s13223-015-0093-x
26 Small P, Keith PK, Kim H. Allergic rhinitis. Allergy Asthma Clin Immunol. 2018;14(Suppl 2):51. 10.1186/s13223-018-0280-7
27 Pawankar R, Hayashi M, Yamanishi S, Igarashi, T. The paradigm of cytokine networks in allergic airway inflammation. Curr Opin Allergy Clin Immunol. 2015;15:41–8. 10.1097/ACI.0000000000000129
28 Scadding, G. Cytokine profiles in allergic rhinitis. Curr Allergy Asthma Rep. 2014;14:435. 10.1007/s11882-014-0435-7
29 Barham HP, Harvey RJ. Nasal saline irrigation: Therapeutic or homeopathic. Braz J Otorhinolaryngol. 2015;81:457–58. 10.1016/j.bjorl.2015.07.002
30 Bonnomet A, Luczka E, Coraux C, de Gabory L. Non-diluted seawater enhances nasal ciliary beat frequency and wound repair speed compared to diluted seawater and normal saline. Int Forum Allergy Rhinol. 2016;6:1062–68. 10.1002/alr.21782
31 Georgitis JW. Nasal hyperthermia and simple irrigation for perennial rhinitis. Changes in inflammatory mediators. Chest. 1994;106:1487–92. 10.1378/chest.106.5.1487
32 Chen J-R, Jin L, Li X-Y. The effectiveness of nasal saline irrigation (seawater) in treatment of allergic rhinitis in children. Int J Pediatr Otorhinolaryngol. 2014;78:1115–18. 10.1016/j.ijporl.2014.04.026
33 Gallant JN, Basem JI, Turner JH, Shannon CN, Virgin FW. Nasal saline irrigation in pediatric rhinosinusitis: A systematic review. Int J Pediatr Otorhinolaryngol. 2018;108:155–62. 10.1016/j.ijporl.2018.03.001
34 Rabago D, Zgierska A. Saline nasal irrigation for upper respiratory conditions. Am Fam Physician. 2009;80(10):1117–19.
35 Klimek L, Bachert C, Pfaar O, Becker S, Bieber T, Brehler R, et al. ARIA guideline 2019: Treatment of allergic rhinitis in the German health system. Allergol Select. 2019;3(1):22–50. 10.5414/ALX02120E
36 Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025. [cited 2025 May]. Available from: www.ginasthma.org
37 Ridolo E, Barone A, Nicoletta F, Paoletti G, Heffler E, Malvezzi L, et al. Intranasal corticosteroid and antihistamine combinations in the treatment of allergic rhinitis: The role of the novel formulation olopatadine/mometasone furoate. Expert Rev Clin Immunol. 2023;19(6):575–84. 10.1080/1744666X.2023.2200165
38 Fein MN, Fischer DA, O’Keefe AW, Sussman GL. CSACI position statement: Newer generation H1-antihistamines are safer than first-generation H1-antihistamines and should be the first-line antihistamines for the treatment of allergic rhinitis and urticaria. Allergy Asthma Clin Immunol. 2019;15(1):61. 10.1186/s13223-019-0375-9